The Oral Motor Institute

ORAL MOTOR TECHNIQUES ARE NOT NEW

Oral Motor Institute

Volume No. 1, Monograph No. 1, 25 September 2007

ORAL MOTOR TECHNIQUES ARE NOT NEW

by Pam Marshalla, M.A., CCC-SLP

Peer Review: Diane Bahr, MS, CCC-SLP, NCTMB, CIMI
There were no blind reviewers of this monograph.

ABSTRACT

Oral motor techniques are not new. According to Van Riper, techniques to facilitate jaw, lip and tongue movement, position and sensitivity for phoneme production have been around for centuries (Van Riper, 1954, p. 236). The timeline of modern publications offered in this paper reveals that every decade since 1912 has produced at least one major work that: (1) included a discussion of speech as a function of sensation and movement, or (2) prescribed the use of oral sensory, movement, and positioning techniques in articulation therapy. References for this material were gleaned from the articulation, phonology, and motor speech literature published from 1912 until the present. Other than one reference, this material was drawn from standard, often classic, textbooks that were read widely by professionals and used broadly in courses for students in the speech, language, and hearing sciences.

Pre-1900

According to Van Riper, “For centuries, speech correctionists have used diagrams, applicators, and instruments to ensure appropriate tongue, jaw, and lip placement. [These] phonetic placement methods are indispensable tools in the speech correctionist’s kit. … Every available device should be used to make the student understand clearly what positions of tongue, jaw, and lips are to be assumed. … If these devices and instruments have any real value, it seems to be that of vivifying the movements of the tongue and of providing a large number of varying tongue positions, from which the correct one may finally emerge” (Van Riper, 1954, pp. 236-8).

1912

Stuttering and Lisping, by E. W. Scripture, contained specific phoneme-by-phoneme lip and tongue facilitation techniques. To elicit a midline groove for /s/, for example, Scripture wrote: “One cure consists [of] inserting a probe, an applicator, a toothpick, or a pencil just over the middle of the tongue and pressing it down as the person begins to speak a word beginning with ‘s’. … He cannot close the passage completely and instead of saying ‘t’ he is forced to say ‘s.’ This catches his ear, and he notices the difference in sound. Constant repetition enables him to train his tongue in the new way” (Scripture, 1912, pp. 132-133). Scripture also wrote about training articulation in clients with “higher degrees of indistinctness” (p. 159). He recommended a four-part program consisting of “tongue gymnastics,” “respiration exercises,” “articulation exercises,” “careful drill in pronouncing words,” and “training of the intellect” (pp. 160-161).

1928

Robert Stetson, the first giant in speech science, released Motor Phonetics in 1928 and again in 1951. He defined motor phonetics as “the study of the skilled movements involved in the process of handling articulatory signals” (Stetson, 1951, p. 6). Stetson announced, “Every utterance is a movement” (p. 4). “A phonetic change is a mechanical change” (p. 6). “Speech is rather a set of movements made audible than a set of sounds produced by movements” (p. 33). “Consonants are not mere noises floating in the stream of sound. They are auxiliary movements” (p. 33). According to one of Stetson’s students, “Stetson knew more about anatomy, physiology and bone structure than anyone I have ever known. … He had no peer in the realm of skilled movements or in his insight into an individual problem with skilled movement. … He would encourage me to train the patient in the correct movements and not worry about the ‘functional’ etiology” (Hartson, 1988, p. 6).

1929

Richard Borden and Alvin Busse, co-directors at the New York University Speech Clinics, published Speech Correction, a wonderful little volume about articulation therapy. These authors used the new palatography research as their foundation for discussion of oral position for consonant and vowel production. “No one should attempt the work of speech correction without first learning how the human speech mechanism is built and how it functions” (Borden and Busse, 1929, p. 1). These authors discussed the use of a number of instruments that had been developed to facilitate correct tongue position for consonants: the “Fricator,” “Fraenum Fork,” “S-Concentrator,” “Ladator,” and “Ruvator” (pp. 183-186).

1931

Lee Edward Travis, in Speech Pathology, differentiated between organic and functional (non-organic and non-structural) speech deficits. In his section on functional articulation disorders, Travis wrote: “The articulatory case frequently shows inferior ability in controlling the lips, tongue, jaw and diaphragm in voluntary rhythmical movements not involved in speech. This would imply, as does the speech defect itself, that he possesses poor control of these structures in speech” (Travis, 1931, p. 223).

1937

Robert West, et al., added to the discussion of articulation therapy. The authors explained, “The general training of children with … defective sounds needs to be conducted along two lines: auditory training to sharpen discriminatory power and recognition of sounds, and muscular agility and control to develop skill in the adjustment of the articulators” (West et al., 1947, p. 472).

1938

Sara M. Stinchfield and Edna Hill Young first described their system of jaw, lip and tongue facilitation techniques for phoneme production in Children with Delayed or Defective Speech: Motor-Kinesthetic Factors in their Training. The program was re-published in 1955 under the title Moto-Kinesthetic Speech Training by Edna Hill Young and Sara Stinchfield Hawk. The authors described their technique as “the guidance and direction of speech muscles” (Young & Hawk, 1955, p. 12). For example, stimulation of /l/ begins: “The first step in the stimulation of /l/ is for the teacher to move the jaw slightly downward. … The teacher uses the thumb and finger of the other hand, on the upper jaw, at points from three-fourth of an inch to an inch apart, equidistant from the mid-line, to press steadily inward. This stimulation is directed to the tongue to induce it to move forward, not toward one point, but to broaden itself, fitting it to the curve of the dental ridge” (p. 45). In 1979, Hawk and Young’s techniques were modernized, expanded, and illustrated in Speech Facilitation: Extraoral and Intraoral Stimulation Technique for Improvement of Articulation Skills by Gwenyth Vaughn and Ruth Millburn Clark.

1939

Charles Van Riper, considered by many to be the father of traditional articulation therapy, published his first edition of Speech Correction: Principles and Methods in which he described many jaw, lip, and tongue facilitation techniques. The many editions of this book have made it the largest-selling speech therapy book of all time. In the 1953 edition and speaking of clients with articulation deficit, Van Riper wrote: “Their tongues do not move with the speed and precision demanded by good speech. They can assume only the simplest tongue positions. Therefore, they raise the front or middle of the tongue instead of the back, and protrude it rather than lift it. It is difficult for them to curl the tip or groove the tongue. Tongue exercises are useful and necessary for these cases” (Van Riper, 1953, p. 216). These lines are followed by five pages of tongue facilitation techniques for the skills of protruding, retracting, curling, and grooving the tongue.

1940

Grant Fairbanks created voice and articulation practice material for adults who wanted to correct their own speech. In his Voice and Articulation Drillbook, Fairbanks remarked about the use of prolongation to aid adjustments to oral position while monitoring the auditory signal. In the introduction, Fairbanks wrote, “When articulating a sound in isolation it is valuable to start with prolonged examples, since you can listen carefully, make the necessary adjustments and perceive the position of your articulators” (Fairbanks, 1940, p. xxi).

1954

Grant Fairbanks proposed that speech was a closed loop system that could both produce and monitor its own activities. Although he placed primary emphasis on the auditory system (“Sensor 1”) for monitoring on-going speech, he wrote that tactile (“Sensor 2”) and proprioceptive (“Sensor 3”) receptors are integral to a person’s understanding of his own speech movements, especially in the creation of new movements for new sounds. “Sensor 2 and Sensor 3 supply data about the mechanical operation of the [speech production mechanism]” (Fairbanks, 1954, p. 136). In other words, the tactile and proprioceptive mechanisms are the sensory receptor systems that allow us to perceive our own respiration, phonation, resonation, and articulation (oral – jaw, lip, tongue) movements.

1957

The anxiously awaited Handbook of Speech Pathology, edited by Lee Edward Travis, was published in 1957. The second edition was published in 1971 and was entitled Handbook of Speech Pathology and Audiology. These handbooks were the first organized attempts to pull together into one manual “the ground plan … of various areas of specialization” (Travis, 1971, p. v). Margaret Hall Powers wrote two chapters devoted to functional articulation disorders. In her section entitled, “General Oral Inaccuracy,” she wrote about children whose speech was “careless,” “lazy,” “sluggish,” “indistinct,” “confused,” “mutilated,” “distorted,” or “unintelligible” with no known cause (Powers, 1971, p. 845). “In cases of general oral inaccuracy … movements are approximate rather than precise, broad rather than small surfaces are sometimes contacted, and contacts are made at the wrong place. In some cases movements are fairly accurate but are slow, weak, or underenergized, so that, though contacts are made, they are not tight or firm” (p. 845). “Although strong auditory stimulation is still the core of a therapeutic program for most clinicians … they make use of other sensory channels as well. The subject is given visual cues to the correct production of a sound. … He is also helped to identify kinesthetic cues and uses these both for discovering the way to produce a sound and for monitoring later productions of the sound” (pp. 893-894).

1964

Eugene T. McDonald blasted onto the scene with his “co-articulation” approach to evaluation and treatment of articulation disorder. It was entitled Articulation Testing and Treatment: A Sensory-Motor Approach. McDonald wrote, “the first objective [of treatment] is to heighten the child’s responsiveness to the patterns of auditory, proprioceptive, and tactile sensations associated with the overlapping, ballistic movements of articulation” (McDonald, 1964, p. 138). “Obviously, the more complex or precise the function demanded of the motor system, the more discriminative must be the sensory functions. … Only by an integration of finely discriminated auditory, proprioceptive, and tactile stimuli can the precise ballistic, overlapping movements of mature, normal articulation be developed from the gross motor behavior of an infant” (p. 92).

1968

Willard R. Zemlin released Speech and Hearing Science, a textbook that, for several decades, became perhaps the most widely used anatomy and physiology text for speech and hearing undergraduates. He wrote, “Articulation is the ultimate motor gesture in the speech process” (Zemlin, 1981, p. 347). Not one to mince words or to treat any subject lightly, Zemlin was adamant that a thorough understanding of anatomy and physiology was necessary to understand articulation diagnosis and therapy. His text gave us many hints about these relationships. For example, “Although jaw movement is very slight during the production of normal speech, inadequate, inappropriate, or sluggish movements may result in severe articulatory defects” (p. 324).

1975

Frederick Darley, Arnold Aronson, and Joe Brown, released their groundbreaking text, Motor Speech Disorders. The authors presented eleven chapters on the diagnosis of apraxia and dysarthria. In the single chapter devoted to therapy techniques, the authors wrote about the need for oral sensory and motor stimulation in the treatment of motor speech disorders. On the subject of apraxia they wrote: “The usual auditory information sufficient for correct production of a target phoneme … is insufficient for the apraxic patient. His skill in producing the target phoneme appears to depend upon multiple sources of information – visual, tactile, and kinesthetic as well as auditory. Multimodality stimulation together with heightened awareness of all types of sensory feedback is necessary for optimum performance” (Darley, Aronson & Brown, 1975, pp. 279-280). In regard to dysarthria, the authors described the need to slow rate of speech, emphasize syllables, and exaggerate consonants. Then they stated: “In instances of severe involvement, however, movement may be so limited that differentiation of the various vowels and consonants is next to impossible. One can try in such a case to help the patient concentrate his energies first on activities preliminary to speech production, such as lowering and elevating the mandible continuously, alternating pursing and retracting the lips, moving the tongue in and out and from side to side, and combinations of these” (pp. 273-274).

1980

Rolland J. Van Hattum wrote Communication Disorders: An Introduction, a text widely used for introductory students of speech-language-hearing. In his chapter on disorders of articulation, Van Hattum penned, “Clearly, when a speaker produces a sound that is an inaccurate acoustic representation of the intended sound, it is because the movements employed were inappropriate. This observation raises questions about why, and in what way, the movements are inappropriate. Whatever the answer to these questions, learning to produce the misarticulated sound correctly involves learning new patterns of articulatory movements. Techniques directed to developing or modifying motor behavior must be an integral part of any approach to remediating articulatory disorders” (Van Hattum, 1980, p. 172).

1982

Weckler and Crary presented their “Multifocal Intervention Program” for children with developmental apraxia of speech to the American Speech-Language-Hearing Association Convention in Toronto. It was then written up in Crary, 1993, referenced here. The first phase of this three-part program involved “a series of oral motor phonetic drills” to improve independent lingual movement during speech by using a bite block. Crary writes, “Using a bite block to stabilize the mandible … may help to increase independent lingual movement and result in improved oral articulation for speech” (Crary, 1993, p. 224).

1983

W. B. Saunders Company published Articulation by Marvin Hanson. Although less well-known than the other works cited in this time line, Hanson’s book nicely combines research with plenty of “how-to” advice that often is tactile and proprioceptive in nature. “In most cases,” Hanson wrote, “emphasis on the auditory cues would predominate over the other senses, but it would not be unusual during the teaching of a sound to ask the child to listen, watch, feel, and touch” (Hanson, 1983, p. 148).

1983

Thieme-Stratton published a series entitled Current Therapy of Communication Disorders edited by William H. Perkins. In Dysarthria and Apraxia, Robert Blakely contributed a chapter called “Treatment of Developmental Apraxia of Speech.” Embedded within his 11-point treatment outline, Blakely discusses tactile facilitation techniques. To stimulate tongue-back elevation for production of /k/ and /g/, for example, Blakely wrote, “During exhalation of air … or during oral phonation, I push the tongue posteriorly with a tongue stick until the dorsum makes contact with the soft palate, then I lower the tongue immediately (withdraw the stick slightly)” (Blakely, 1983, pp. 31-32).

1984

University Park Press published Treating Articulation Disorders: For Clinicians by Clinicians, the second in their clinical series edited by Harris Winitz. This volume was dedicated to Charles Van Riper and contained a compilation of authors. It was written, in part, as a response to some attempts in the early 1980’s to replace the term articulation disorders with the term phonological disorders. In the preface to the volume, Winitz discussed the difference between apraxia and dysarthria: “Traditionally, the disorder of apraxia has been identified as a breakdown in motor programming, and dysarthria as a breakdown in motor control” (Winitz, 1984, p. xii). In chapter three, “Consideration of Motor-Sensory targets and a Problem in Perception,” Gloria Borden discusses various motor approaches: “Speech pathologists in France, called orthophonistes, carry around with them a tool kit with all sorts and shapes of oral probes for pushing the tongue around and for increasing awareness of tactile sensation in the mouth” (Borden, 1984, p. 57). Borden summarizes, “Recent research in the area of feedback during normal speech production points to the special problems in making people aware of motor-sensory targets and puts special demands upon the resourcefulness of the speech pathologist” (p. 57).

1991

James Paul Dworkin wrote Motor Speech Disorders: A Treatment Guide, an intensely detailed volume that took speech therapy for apraxia and dysarthria to new clinical heights. Dworkin details hundreds of jaw, lip, and tongue movement facilitation techniques for apraxia and dysarthria and discusses their use in the overall plan of remediation. For example, on dysarthria he stated: “Usually the treatment package includes techniques that are designed to promote (1) oral motor development in those whose dysarthria is of a congenital origin; (2) adequate body and orofacial postures; (3) integration of primitive and higher-level oral reflexes; (4) reductions or increases in orofacial muscle tone; (5) increases in orofacial muscle strength; and (6) improvement in the range, speed, timing, and/or coordination of orofacial muscle contractions and movements” (Dworkin, 1991, p. 27).

1992

Samuel Fletcher wrote Articulation: A Physiological Approach, a groundbreaking book overlooked by many, probably because it is extremely detailed and a very slow read. Fletcher described patterns in the development of oral motor skill learning using terminology from the motor literature. For example, he pens: “The emergence of stability and mobility functions is an essential part of speech skill development. … Speech skill building starts with learning to stabilize the jaw and anchor the tongue along the outer, lateral margins of the palate” (Fletcher, 1992, p. 13).

1995

Joseph R. Duffy’s Motor Speech Disorders: Substrates, Differential Diagnosis, and Management helped us take a broad view of movement and its relationship to speech: “Examination of the oral mechanism at rest and during nonspeech activities provides confirmatory evidence and information about the size, strength, symmetry, range, tone, steadiness, speed, and accuracy of orofacial structures and movements (Duffy, 1995, p. 93). These observations “are primarily visual and tactile” (p. 69) and are made “at rest, during sustained postures, during movement, and [during] reflexes” (p.69).

1997

Malcolm McNeil edited Clinical Management of Sensorimotor Speech Disorders, a book that “reflects the work of individuals whose diverse research and clinical contributions capture the range of sensorimotor speech disorders and methods for studying them” (McNeil, 1997, p. ix). Anita Van der Merwe’s poses the theoretical framework for the book: “Most researchers today agree that sensory information or input is an integral part of movement control and coordination. … Auditory, tactile, and proprioceptive feedback arise as consequences of speech production” (Van der Merwe, 1997, p. 3).

1999

Anthony Caruso and Edythe Strand wrote Clinical Management of Motor Speech Disorders in Children, a book that integrated old and new ideas about apraxia and dysarthria in children. The text opens by directing us to the heart of the matter: “Most of us, when we hear the word speech, think of a series of sounds. In this chapter, we want to encourage you to think about movement” (Caruso & Strand, 1999, p. 1). “In its most basic form, speech production results from movements of the lips, tongue, jaw, velum, vocal folds, and respiratory system” (p. 8). They explain, “one of the most important aspects of normal speech motor control concerns the moment-to-moment contribution of sensory (afferent) information to the multiple interactive pathways involved in movement planning, programming, and execution” (p. 11). On childhood dysarthria they state: “Children [like adults] who exhibit dysarthria have difficulty with movements of the muscles used in respiration, phonation, resonance, and articulation, in both speech and non-speech movement” (p. 13). On childhood apraxia they write: “It is our view that the term developmental apraxia of speech (DAOS) is a motor level of impairment. Specifically, we posit that the speech characteristics of these children are due to disruption of sensorimotor planning or sensorimotor programming” (pp. 16-17).

2000

Jacqueline Bauman-Waengler wrote an excellent modern textbook on articulation and phonology published by Pro•Ed and used today in many articulation/phonology courses throughout the United States. In the 2004 edition, in a chapter entitled “Therapy for Phonetic Errors,” she mentioned the waning treatment of motor-based approaches to articulation and gave her view about leaving them behind: “Any contemporary view of treatment needs to stress what is current, what is new. Thus, due to their noncontemporary roots, one might hesitate to take traditional-motor approaches seriously. … Should a traditional phonetic approach still be used? The answer to this is yes” (Bauman-Waengler, 2000, p. 206).

2007

Wayne Second, et al., published a comprehensive practical book of techniques for phoneme elicitation that “is designed to provide the clinician with a quick, easy-to-use array of techniques for quickly evoking any phoneme targeted for remediation” (Secord, 2007, p. v). Dedicated to Charles Van Riper, it contains a wide variety of sensory and movement techniques for phoneme elicitation. To facilitate improved sensory awareness of the tip-to-alveolus contact necessary for /n/, for example, the authors write, “Place some … flavored food on a cotton swab and touch the ‘bump’ or ‘hill’ behind the upper central incisors. Ask the client to remove the food with the tip of his tongue” (p. 77).

CONCLUSION

Our timeline reveals three important facts: (1) Viewing speech as movement is not a new idea; (2) Treating articulation disorders as a problem of oral sensation, movement or position is not a new idea; and (3) Designing articulation therapy techniques to facilitate improved oral sensation, movement or position is not a new idea. Since the beginning of the speech-language therapy profession, it has been recognized that a problem in oral sensation, movement or position can and does contribute to disordered articulation. Paraphrasing Stetson, Speech IS Movement. Therefore, the remediation of speech errors by necessity involves adjusting speech sensation, movement, and position. The facilitation of improved oral sensation, movement, and position is integral to everything we do in articulation therapy. Articulation therapy is the process of adjusting the movements of respiration, phonation, resonation, and articulation to help clients achieve correct place, manner, and voicing. As Fletcher stated, “The ultimate goal of articulatory intervention is to change motor performance” (Fletcher, 1992, p. 219).

A TOPICAL BIBLIOGRAPHY ON ORAL MOTOR ASSESSMENT AND TREATMENT

Oral Motor Institute

Volume No. 2, Monograph No. 1, 16 January 2008

A TOPICAL BIBLIOGRAPHY ON ORAL MOTOR ASSESSMENT AND TREATMENT

TO HELP ADDRESS THE CURRENT CONTROVERSY REGARDING ORAL MOTOR RESEARCH

By Diane Bahr, MS, CCC-SLP, NCTMB, CIMI

Peer Reviewers: Leslie Faye Davis, MS, CCC-SLP; Daymon Gilbert, M Ed, CCC-SLP; Jennifer Gray, MS, CCC-SLP; Dave Hammer, MA, CCC-SLP; Mary Kennedy, EdD, CCC-SLP; Pam Marshalla, MA, CCC-SLP; Donna Ridley, M Ed, CCC-SLP; Daniela Rodrigues, MA, CCC-SLP. There were no blind reviewers of this monograph.

ABSTRACT and DESCRIPTION OF PROBLEM

In 2002, Duchan wrote an article for The ASHA Leader regarding the history of speech-language pathology and why it is important. Knowing the history of a field is an integral part of understanding the field. Some within the field of speech-language pathology seem to have forgotten the rich supply of oral motor research that exists. This is of great concern, since students and young professionals in the field are frequently not exposed to this information. In recent years some graduate students, recent graduates, and working professionals have stated: (1) oral motor treatment does not work, (2) there is no research on oral motor treatment, and (3) ASHA does not support oral motor treatment. Such statements require serious investigation.

The purpose of this paper is to provide a rich sample of journal literature on the topic of oral motor assessment and treatment, discuss the trends within the literature, and suggest further research needed in the area. A topical bibliography containing articles from journals and selected papers (many with peer review) on oral motor assessment and treatment and related topics resulted from the study. Items were placed within the categories of the topical bibliography based on apparent relatedness to the topic. Some bibliography items were listed under more than one topic. The topical bibliography will assist speech-language pathologists, occupational therapists, and others in understanding the current state of oral motor literature and future research needs.

Key Words: oral motor, oral-motor, oromotor, oro-motor

Method

In order to find the history of oral motor research, a survey of the many articles written on oral motor assessment and treatment was conducted. A previous ASHA (American Speech-Language-Hearing Association) “Building Blocks Module” on oral motor, feeding, swallowing, and respiratory-phonatory assessment and treatment served as a starting point for this study (1990). After that, numerous other resources (books and journal articles) on feeding, motor speech, and related topics were used.

A search was also conducted using PubMed, a service of the National Library of Medicine and the National Institutes of Health. The terms “oral motor,” “oral-motor,” “oro-motor,” and “oromotor” were used in the search. As of November 7, 2007, PubMed had 4409 citations with the term “oral motor,” 398 citations with the term “oral-motor,” 124 citations with the term “oromotor,” and seven citations with the term “oro-motor.”

The subtopic areas for the survey were chosen based on definitions of “oral motor” from David W. Hammer, MA, CCC-SLP and Pamela Marshala, MA, CCC-SLP. According to Hammer (2007) the term “oral motor” is defined as “having to do with movements and placements of the oral structures such as the tongue, lips, palate, and teeth.” In his work with apraxia of speech in children, Hammer defines his oral motor strategies as “speech therapy… techniques which draw the child’s attention and effort to the oral musculature/articulators while simultaneously engaging the child in speech production practice.” According to Marshalla (2004, p. 10), “oral-motor therapy … can be defined as the process of facilitating improved oral (jaw, lip, tongue) movements.” Based on these definitions, the following areas were included in the survey of the literature on oral motor assessment and treatment:

Oral Motor Development
Oral Motor Function
Respiration (as it relates to oral motor function)
Oral Motor Disorders (pediatric)
Oral Motor Disorders (adult)
Sensory Awareness and Discrimination/Sensory-Motor Facilitation
Feeding, Eating, and Drinking (pediatric)
Feeding, Eating, and Drinking (adult)
Oral Activities and Exercises (related to oral motor function)
Myofunctional Therapy
Swallowing (pediatric – oral phase)
Swallowing (adult – oral phase)
Motor Speech (pediatric)
Motor Speech (adult)

The definitions by Hammer (2007) and Marshalla (2004) along with the topics listed here may help the field of speech-language pathology develop a “working” or “operational” definition of the term “oral motor.” See the Discussion section of this article for some suggestions on how to approach this task.

Results

The results of the survey are listed in an extensive Appendix after the Discussion and Reference sections of the article.

DISCUSSION

In reviewing the journal articles found in the Appendix, the terms “oral motor” and “oral-motor” were used most frequently, while the terms “oromotor” and “oro-motor” were found less often. Some form of the term “oral motor” appeared in the 1980s in the journal literature as a way of discussing mouth movement related to feeding and motor speech (Alexander, 1987; Morris, 1989). It has been used since that time to discuss development, function, and disorders related to mouth movement. The term was found frequently in the literature on feeding and swallowing; although, it also appeared in literature on motor speech. For example, a recent technical report from ASHA (2007) entitled Childhood Apraxia of Speech: Ad Hoc Committee on Apraxia of Speech in Children used the term “Oral-Motor Development” as a subtopic under the topic of “Motor Control.”

There is an overwhelming amount of research in the journal literature related to the topic of oral motor assessment and treatment. A significant number of articles were found for every subtopic selected. In fact, there were so many articles related to the topic or subtopics that the author decided to continue the search at a later date to develop future articles.

It is interesting to note that many of the articles were published outside of the field of speech-language pathology. There were numerous articles published in the fields of medicine, dentistry, psychology, nutrition, and occupational therapy. Another survey of the literature could take a closer look at other fields conducting research and contributions made.

The current claims that oral motor treatment does not work, that there is no research on oral motor treatment, and that ASHA does not support oral motor treatment, seem to be unfounded based on the survey of the literature. Perhaps the field of speech-language pathology needs to look at the origins of such claims and the theoretical and clinical data provided for their perpetuation. The following hypotheses might be tested to help reveal the bases of these claims:

The field is focused on language and not speech or feeding.
Most of the recent studies in the field have been related to language and not the motor aspects of speech or feeding.
Recently, there have been far fewer studies on all motor related disorders in the field. This includes voice, fluency, motor speech, and the oral phase of swallowing.
The field does not have enough PhDs, and many university faculty members are not studying the motor aspects of speech and feeding.
While ASHA has projects like NOMS (National Outcomes Measurement System), very few clinicians are participating in clinical research.

In a brief survey of 117 articles from the American Journal of Speech-Language Pathology (AJSLP) from February 2004 until August 2007, there were eight articles related to motor speech, five articles related to phonology, 14 articles related to fluency, and four related to voice. According to the 2008 ASHA Marketing Planner, 78 percent of speech-language pathologists treat articulation and phonological disorders, 64 percent treat motor speech disorders, 50 percent treat fluency disorders, 30 percent treat dysphagia, 11 percent treat myofunctional disorders, and 31 percent treat voice and resonance disorders. These statistics reveal that speech-language pathologists treat a large numbers of clients with motor disorders. Colleagues in the fields of occupational therapy and physical therapy receive a motor-based training program in order to work with motor disorders in the body. This does not seem to be occurring in the field of speech-language pathology at this time.

It is understandable that the field of speech-language pathology has moved toward the study of language. The study of language is a relatively recent addition to the field. A “History of ASHA Membership and Certification Requirements” shows the addition of language assessment and treatment requirements in graduate programs beginning in 1965 (The ASHA Leader Online, 2007). This has been a vast undertaking. According to the 2008 ASHA Marketing Planner, 47 percent of speech-language pathologists treat individuals with specific language impairment.

University training programs in speech-language pathology understandably struggle to teach all that students need to know as the field has continued to expand over time. However, it is a concern that graduate students may not be systematically learning from the wealth of existing oral motor information. The research itself is scattered (i.e., many different journals, many different fields). The exceptions are dysphagia and orofacial myology, which have their own journals and special interest groups.According to Annual Counts of ASHA Membership and Affiliation (Year-end 2006), only four percent of the membership and affiliates had a PhD and only one percent had another type of doctorate. Ninety-three percent of the membership and affiliates have Master’s degrees. Regarding primary employment function, 81 percent of the membership and affiliates were clinical service providers and only one percent were researchers. These statistics do not bode well for those within the field who call for research to support applied treatment techniques.

Recommendations to resolve the concerns discussed in this paper follow. Consider:

A survey of graduate students and recent graduates of university program as well as other practicing clinicians to determine their understanding and knowledge of oral motor assessment and treatment. This survey would target areas based on a complete definition of oral motor treatment, “beyond non-speech oral exercise only” (e.g., Hodge, Salonka, & Kollias, 2005; Lof & Watson, 2004, 2008).
The formation of an ASHA Ad Hoc Committee to define the role of the speech-language pathologist and the knowledge and skills needed by the speech-language pathologist in the variety of areas that encompass oral motor assessment and treatment (See ASHA documents on orofacial myofunctional disorders, dysphagia, and childhood apraxia of speech listed in reference section). It is suggested that an Ad Hoc Committee include both researchers and working clinicians with both PhD and Master’s levels of education.
The development of graduate level and continuing education courses and curriculums based on the vast amount of oral motor literature that currently exists.
A survey of university faculty willing to conduct research on oral motor topics (e.g., feeding and motor speech).
ASHA support in setting up clinical research with interested clinicians (e.g., NOMS).
The establishment of teams of researchers and working clinicians to complete needed peer-reviewed efficacy research on the use of oral motor treatment.

REFERENCES

Alexander, R. (1987). Oral-motor treatment for infants and young children with cerebral palsy. Seminars in Speech and Language, 8(1). 87-100.
American Speech-Language-Hearing Association. (1990). Issues in oral motor, feeding, swallowing, and respiratory-phonatory assessment and intervention. [A Building Blocks Module].
American Speech-Language-Hearing Association. (1990). Skills needed by speech-language pathologists providing services to dysphagic patients/clients, Asha, 32 (Suppl. 2), 7-12.
American Speech-Language-Hearing Association. (1991). The role of the speech-language pathologist in management of oral myofunctional disorders, Asha, 33 (Suppl. 5), 7.
American Speech-Language-Hearing Association. (1993). Orofacial myofunctional disorders: Knowledge and skills. Asha, 35, (Suppl. 10), 21-23.
American Speech-Language-Hearing Association. (Year-end 2006). Annual Counts of the ASHA Membership and Affiliation. [ASHA’s Surveys and Information Team].
American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report].
American Speech-Language-Hearing Association. (2007). History of ASHA membership and certification requirements. The ASHA Leader Online.
American Speech-Language-Hearing Association. (2007). 2008 ASHA Marketing Planner.
Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston: Allyn and Bacon.
Duchan, J. F. (2002). What do you know about the history of speech-language pathology? And why is it important? The ASHA Leader, 7(23), 4-5, 29.
Groher, M. E. (Ed.). (1997). Dysphagia: Diagnosis and management, (3rd ed). Boston: Butterworth-Heinemann.
Hammer, D. (2007). Childhood apraxia of speech: New perspectives on assessment and treatment. Las Vegas, NV: The Childhood Apraxia of Speech Association (workshop).
Hodge, M., Salonka, R., & Kollias, S. (2005, November). Use of Nonspeech oral-motor exercises in children’s speech therapy. San Diego, CA: Annual meeting of the American Speech-Language-Hearing Association.
Lof, G. L., & Watson, M. (2004, November). Speech-language pathologist’s use of nonspeech oral-motor drills: National survey results. Philadelphia, PA: Poster presented at annual meeting of the American Speech-Language-Hearing Association.
Lof, G. L., & Watson, M. (2008). A nationwide survey of non-speech oral motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing in Schools (in press).
Marshalla, P. (2004). Oral-Motor techniques in articulation & phonological therapy. Mill Creek, WA: Marshalla Speech and Language.
Morris, S. E. (1989). Development of oral-motor skills in the neurologically impaired child receiving non-oral feedings. Dysphagia, 3(3). 135-154.
Oetter, P., Richer, E. W., & Frick, S. M. (1995). M.O.R.E.: Integrating the mouth with sensory and postural functions (2nd ed.). Hugo, MN: PDP Press.
PubMed. A service of the National Library of Medicine and the National Institutes of Health.
Robin, D. A., Yorkston, K. M., & Beukelman, D. R. (Eds.). (1996). Disorders of motor speech: Assessment, treatment, and clinical characterization. Baltimore: Paul H. Brookes Publishing Co.
Rosenfeld-Johnson, S. (2005). Assessment and treatment of the jaw: Putting it all together: Sensory, feeding, and speech. United States: Talk Tools.

APPENDIX

ORAL MOTOR DEVELOPMENT

Alexander, R. (1987). Oral-motor treatment for infants and young children with cerebral palsy. Seminars in Speech and Language, 8(1). 87-100.
Anderson, D. (1963). Development of function in mastication. Journal of Dental Research Supplement, 42, 381-384.
Anderson, G., & Vidyasagar, D. (1979). Development of sucking in premature infants from 1 to 7 days post birth. Birth Defects: Original Article Series, 15(7), 145-171.
Ansel, B. M., Windsor, J., & Stark, R. E. (1992). Oral volitional movements in children: An approach to assessment. Seminars in Speech and Language, 13(1), 1-13.
Archambault, M., Millen, K., & Gisel, E. (1991). Effect of bite size on eating development in normal children 6 months to 2 years of age. Physical & Occupational Therapy in Pediatrics, 10(4), 29-47.
Ashmead, D. H., Reilly, B. M., & Litpsitt, L. P. (1980). Neonates heart-rate, sucking rhythm, and sucking amplitude as a function of sweet taste. Journal of Experimental Child Psychology, 29, 264.
Bahr, D. C. (2003). Typical versus atypical oral motor function in the pediatric population: Beyond the checklist. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) American Speech-Language-Hearing Association Division 13, 12(1), 4-12.
Bartlett, D. (1997). Primitive reflexes and early motor development. Journal of Development and Behavioral Pediatrics, 18, 143-150.
Blass, E. M., & Teicher, M. H. (1980). Suckling. Science, 210, 15.
Bosma, J. F. (1985). Postnatal ontogeny of performances of the pharynx, larynx, and mouth. The American Review of Respiratory Disease, 131, S10.
Bosma, J. F. (1986). Development of feeding. The Journal of Clinical Nutrition, 5, 210.
Boysson-Bardies, B. D., & Vihman, M. M. (1991). Adaptation to language: Evidence from babbling and first words in four languages. Language, 67, 297-319.
Braun, M. A., & Palmer, M. M. (1986). A pilot study of oral-motor dysfunction in “at-risk” infants. Physical & Occupational Therapy in Pediatrics, 5 (4), 13-25.
Bu’Lock, F., Woolridge, M., & Baum, J. (1990). Development of co-ordination of sucking, swallowing, and breathing: Ultrasound study of term and preterm infants. Developmental Medicine and Child Neurology, 32, 669-678.
Burns, Y., Rogers, Y., Neil, M., Brazier, K., Croker, A., Behnke, L., & Tudehope, D. (1987). Development of oral function in pre-term infants. Physiotherapy Practice, 3, 168-178.
Cobo-Lewis, A. B., Oller, K. D., Lynch, M. P., Levine, S. L. (1996). Relations of motor and vocal milestones in typically developing infants and infants with Down syndrome. American Journal of Mental Retardation, 100(5), 456-467.
Crook, C. K., & Lipsitt, L. P. (1976). Neonatal nutritive sucking: Effects of taste stimulation upon sucking rhythm and heart rate. Child Development, 47, 518-522.
Colley, J. R. T., & Creamer, B. (1958). Suckling and swallowing in infants. British Medical Journal, 12, 422.
Daniels, H., Devileger, H., Minami, T., Eggermont, E., & Casaer, P (1990). Infant feeding and cardiorespiratory maturation, Neuropediatrics, 21(1), 9-10.
Davis, B., & MacNeilage, P. (1995). The articulatory basis of babbling. Journal of Speech and Hearing Research, 38, 1199-1211.
Davis-McFarland, E. (2000). Language and oral-motor development and disorders in infants and young toddlers with human immunodeficiency virus. Seminars in Speech and Language, 21(1), 19-36.
Ellison, S. L., Vidyasagar, D., & Anderson, G. C. (1979). Sucking in the newborn infant during the first hour of life. Journal of Nurse-Midwifery, 24, 18-25.
Erenberg, A., Smith, W. L., Nowak, A. J., et al. (1986). Evaluation of sucking in the breast-fed infant by ultrasonography. Pediatric Research, 20, 409a.
Field, T. (1990). Alleviating stress in newborn infants in the intensive care unit. Clinics in Perinatology, 17(1), 1-9.
Field, T. (1995). Massage therapy for infants and children. Journal of Developmental Behavioral Pediatrics, 16(2), 105-111.
Field, T. (1998). Massage therapy effects. American Psychology, 53(12), 1270-1281.
Fletcher, S. (1970). Processes and maturation of mastication and deglutition. ASHA Reports, 5, 92-105.
Gisel, E. G. (1988). Chewing cycles in 2- to 8-year-old normal children : A developmental profile, The American Journal of Occupational Therapy, 42, 40.
Gisel, E. G. (1988). Development of oral side preference during chewing and its relation to hand preference in normal 2- to 8-year-old children. The American Journal of Occupational Therapy, 42, 378.
Gisel, E. G. (1991). Effect of food texture on development of chewing in children 6 months to 2 years of age. Developmental Medicine and Child Neurology, 33, 69.
Green, J. R., Moore, C. A., Ruark, J. L., Rodda, P. R., Morvee, W. T., & Van Witzenburg, M. J. (1997). Development of chewing in children from 12 to 48 months: Longitudinal study of EMG patterns. Journal of Neurophysiology, 77, 2704-2716.
Green, J. R., Moore, C. A., Higashikawa, M., & Steeve, R. W. (2000). The sequential development of jaw and lip control for speech. Journal of Speech, Language, and Hearing Research, 45, 66-79.
Green, J. R., Moore, C. A., & Reilly, K. J. (2002). The physiologic development of speech motor control: Lip and jaw coordination. Journal of Speech, Language, and Hearing Research, 43, 239-255.
Hannam, A., & McMillan, A. (1994). Internal organization of human jaw muscles. Critical Review in Oral Biology and Medicine, 5, 55-89.
Hanson, M., & Cohen, M. (1973). Effects of form and function on swallowing and the developing dentition. American Journal of Orthodontics, 64, 63-82.
Illingworth, R. S., & Lister, J. (1964). The critical or sensitive period, with special reference to certain feeding problems in infants and children. The Journal of Pediatrics, 65(6), 839-848.
Iverson, J. M., Hall, A. J., Nickel, L., & Wozniak, R. H. (2007). The relationship between reduplicated babble onset and laterality in infant rhythmic arm movements. Brain and Language, 101(3), 198-207.
Jain, L., Sivieri, E., Abbasi, S., & Bhutani, V. K. (1987). Energetics and mechanics of nutritive sucking in the preterm and term neonate. Journal of Pediatrics, 111, 894-898.
Lawrence, R. (Ed.). (1987). Breastfeeding. Clinics in Perinatology, 14(1).
Lau, C., & Schanler, R. J. (1996). Oral motor function in the neonate. Neonatal Gastroenterology, 23(2), 161-178.
Maller, O, & Turner, R. E. (1973). Taste in acceptance of sugars in human infants. Journal of Comparative Physiology, 84, 496-501.
Marshalla, P. R. (1985). The role of reflexes in oral-motor learning: Techniques for improved articulation. Seminars in Speech and Language, 6(4), 317-336.
Matthew, O. P., & Bhatia, J. (1989). Sucking and breathing patterns during breast- and bottle-feeding in term neonates. American Journal of Disease in Children, 143, 588-592.
Mizuno, K., & Ueda, A. (2001). Development of sucking behavior in infants who have not been fed for 2 months after birth. Pediatrics International, 43(3). 251-255.
Moore, C. A., & Ruark, J. L. (1996). Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research, 39, 1034-1047.
Morris, S. E. (1985). Developmental implications for the management of feeding problems in neurologically impaired infants. Seminars in Speech and Language, 6(4), 293-315.
Morris, S. E. (1989). Development of oral-motor skills in the neurologically impaired child receiving non-oral feedings. Dysphagia, 3(3). 135-154.
Ogg, M. A. (1975). Oral-pharyngeal development and evaluation. Physical Therapy, 55, 235-241.
Oller, D. (1978). Infant vocalization and the development of speech. Allied Health and Behavioral Sciences, 1(4), 532-549.
Oller, D. K., & Eilers, R. E. (1988). The role of audition in infant babbling. Child Development, 59, 441-446.
Oller, D. K., Eilers, R. E., Neal, R., & Schwartz, H. (1999). Precursors to speech in infancy: The prediction of speech and language disorders. Journal of Communication Disorders, 32, 223-245.
Oller, D., Wieman, L., Doyle, W., & Ross, C. (1975). Infant babbling and speech. Journal of Child Language, 3, 1-11.
Page, D. C. (1999). The new dental-medical renaissance: Medically efficacious functional jaw orthopedics. The Functional Orthodontist: A Journal of Functional Jaw Orthopedics, 16(1), 16-25.
Reilly, S., Skuse, D., Mathisen, M. & Wolke, D. (1995). The objective rating of oral-motor functions during feeding. Dysphagia, 10, 177-191.
Robbins, J., & Klee, T. (1987). Clinical assessment of orophayngeal motor development in young children. Journal of Speech and Hearing Disorders, 52, 271-277.
Ruark, J. L., & Moore, C. A. (1997). Coordination of lip muscle activity by 2-year-old children during speech and nonspeech tasks. Journal of Speech, Language, and Hearing Research, 40, 1373-1385.
Rybski, D. A., Almli, R. C., & Gisel, E. G. (1984). Sucking behaviours of normal 3-day-old female neonates during a 24-hour period. Developmental psychobiology, 17, 70.
Rybski, D. A., & Gisel, E. G. (1984). Optimal and sub-optimal feeding behaviors of neonates. Physical & Occupational Therapy in Pediatrics, 4, 37.
Sameroff, A. J. (1968). The components of sucking in the human newborn. Journal of Experimental Child Psychology, 6, 607-623.
Sarnat, H. B. (1978). Olfactory reflexes in the newborn infant. The Journal of Pediatrics, 92, 624.
Schaal, B. (1988). Olfaction in infants and children in developmental and functional perspectives. Chemical Senses, 13, 145.
Shapiro, B. L., Redman, R. S., Gorlin, R. J. (1963). Measurements of normal and reportedly malformed palatal vaults: I. Normal adult measurements. Journal of Dental Research, 42, 1039.
Schwartz, J., Niman, C., & Gisel, E. (1984). Tongue movements in normal preschool children during eating. American Journal of Occupational Therapy, 38 (2), 87-93.
Selley, W. G., Ellis, R. E., Flack, F. C., & Brooks, W. A. (1990). Coordination of sucking, swallowing, and breathing in the newborn: Its relationship to infant feeding and normal development. The British Journal of Disorders of Communication, 25(3), 311-327.
Smith, A., Weber, C. M., Newton, J., & Denny, M. (1991). Developmental and age-related changes in reflexes of the human jaw-closing system. Electroencephalography and Clinical Neurophysiology, 81, 118-128.
Sochaniwskyj, A., Koheil, R., Baablich, K., Milner, M., & Kenny, D. (1986). Oral motor functioning, frequency of swallowing, and drooling in normal children and in children with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 67, 866-874.
Stark, R. (1978). Features of infant sounds: The emergence of cooing. Journal of Child Language, 5, 1-12.
Stolovitz, P., & Gisel, E. G. (1991). Circumoral movements in response to three different food textures in children six months to two years of age. Dysphagia, 6, 17.
Sullivan, R. M., Taborski-Barba, S., Mendoza, R., Itano, A., Leon, M., Cotman, C.W., Payne, T. F., & Lott, I. (1991). Olfactory classical conditioning in neonates. Pediatrics, 87(4), 511-518.
Tucker, J. A. (1985). Perspectives on the development of the air and food passages. American Review of Respiratory Diseases, 131, S7-S9.
Walsh, B., & Smith, A. (2002). Articulatory movements in adolescents: Evidence of the protracted development of speech motor control processes. Journal of Speech, Language, and Hearing Research, 45, 1119-1133.
Weber, F. M., Woolridge, W., & Baum, J. D. (1986). An ultrasonographic study of the organization of sucking and swallowing by newborn infants. Developmental Medicine and Child Neurology, 28, 19-24.
Williams, P., & Stackhouse, J. (1998). Diadochokinetic skills: Normal and atypical performance in children aged 3-5 years. International Journal of Language and Communication Disorders, 33 (Suppl.), 481-486.
Williams, P., & Stackhouse, J. (2000). Rate, accuracy, and consistency: Diadochokinetic performance of young normally developing children. Clinical Linguistics and Phonetics, 14, 267-293.
Wolff, P. H. (1968). The serial organization of sucking in the young infant. Pediatrics, 42, 943-955.
Ziev, M. S. R. (1999). Earliest intervention: Speech-Language pathology services in the neonatal intensive care unit. Asha, 41(3), 32-36.

ORAL MOTOR FUNCTION

Ansel, B. M., Windsor, J., & Stark, R. E. (1992). Oral volitional movements in children: An approach to assessment. Seminars in Speech and Language, 13(1), 1-13.
Bahr, D. C. (2003). Typical versus atypical oral motor function in the pediatric population: Beyond the checklist. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) American Speech-Language-Hearing Association Division 13, 12(1), 4-12.
Barlow, S. M., & Abbs. J. H. (1983). Force transducers for the evaluation of labial, lingual, and mandibular function in dysarthria, Journal of Speech and Hearing Research, 26, 616-621.
Bateson, E., & Ostry, D. (1995). An analysis of the dimensionality of jaw movement in speech. Journal of Phonetics, 23, 101-117.
Beckman, D., Neal, C., Phirsichbaum, J., Stratton, L., Taylor, V., & Ratusnik, D. (2004). Range of movement and strength in oral motor therapy: A retrospective study. Florida Journal of Communication Disorders, 21, 7-14.
Bisch, E. M., Logemann, J. A., Rademaker, A. W., Kahrilas, P. J., & Lazarus, C. L. (1994). Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia resulting from neurologic impairment and normal subjects. Journal of Speech and Hearing Research, 37(5), 1041-1059.
Bosma, J. F., Hepburn, L. G. Josell, S. D., & Baker, K. (1990). Ultrasound demonstration of tongue motions during suckle feeding. Developmental Medicine and Child Neurology, 32(3), 223-229.
Clark, G. T., & Carter, M. C. (1985). Electromyographic study of human jaw closing muscle endurance, fatigue, and recovery at various isometric force levels. Archives of Oral Biology, 30, 563-569.
Clark, H. M., Robin, D. A., McCullagh, G., & Schmidt, R. A. (2001). Motor control in children and adults during a non-speech oral task. Journal of Speech, Language, and Hearing Research, 44, 1015-1025.
Edwards, J. (1985). Contextual effects on lingual-mandibular coordination. Journal of the Acoustical Society of America, 78, 1944-1948.
Ekberg, O., & Nylander, G. (1982). Cineradiography of the pharyngeal stage of deglutition in 150 individuals without dysphagia. British Journal of Radiology, 55, 253-257.
Forrest, K., Weismer, M., & Turner, G. S. (1989). Kinematic, acoustic, and perceptual analyses of connected speech produced by parkinsonian and normal geriatric adults. Journal of the Acoustical Society of America, 85, 2608-2622.
Fucile, S., Wright, P. M., Chan, I., Yee, S., Langlais, M., & Gisel, E. G. (1998). Functional oral-motor skills: Do they change with age? Dysphagia, 13, 195-201.
Gay, T. (1974). Jaw movements during speech: A cinefluorographic investigation. Haskins Laboratories. Status Report on Speech Research, 39140, 219-229.
Gracco, V. L. (1994). Some organizational characteristics of speech movement control. Journal of Speech, Language, and Hearing Research, 37, 4-27.
Gracco, V. L., & Abbs, J. H. (1986). Variant and invariant characteristics of speech movements. Experimental Brain Research, 65, 156-166.
Gracco, V. L., & Lofqvist, A. (1994). Speech motor coordination and control: Evidence from lip, jaw, and laryngeal movements. Journal of Neuroscience, 14, 6585-6597.
Hannam, A., & McMillan, A. (1994). Internal organization of human jaw muscles. Critical Review in Oral Biology and Medicine, 5, 55-89.
Hertrich, I., & Ackermann, H. (2000). Lip-jaw and tongue-jaw coordination during rate-controlled syllable repetitions. Journal of the Acoustical Society of America, 107, 2236-2247.
Hiyama, S., Iwamoto, S., Ono, R., Ishiwata, Y. & Kuroda, T. (2000). Genioglossus muscle activity during rhythmic open-close jaw movements. Journal of Oral Rehabilitation, 27(8), 664-670.
Hughes, O. M., & Abbs, J. H. (1976). Labial-mandibular coordination in the production of speech: Implication for the operation of motor equivalence. Phonetica, 33, 199-221.
Jean, A. (1984). Brainstem organization of the swallowing network. Brain Behavior, 25, 109-116.
Junge, D., & Clark, G. T. (1993). Electromyographic turns analysis of sustained contraction in human masseter muscles at various isometric force levels. Archives of Oral Biology, 38, 583-588.
Kelso, J. A., Tuller, B., Vatikiotis-Bateson, E., & Fowler, C. A. (1984). Functionally specific articulatory cooperation following jaw perturbations during speech: Evidence for coordinative structures. International Journal of Experimental Psychology: Human Perception and Performance, 10, 812-832.
Kennedy, J., & Kent, R. (1985). Anatomy and physiology of deglutition and related functions. Seminars in Speech and Language, 6(4). 257-273.
Kent, R. D. (2000). Research on speech motor control and its disorders: A review and prospective. Journal of Communication Disorders, 33, 391-428.
Kohno, S., Matsuyama, T., Medina, R. U., & Arai, Y.(2001). Functional-rhythmical coupling of head and mandibular movements. Journal of Oral Rehabilitation, 28(2), 161-167.
Larson, C. (1985). Neurophysiology of speech and swallowing. Seminars in Speech and Language, 6(4), 275-291.
Lobbezoo, F., Trulsson, M., Jacobs, R., Svensson, P., Caden, S. W., & Van Steenberqhe, D. (2002). Topical review: Modulation of trigeminal sensory input in humans: Mechanisms and clinical implications. Journal of Orofacial Pain, 16(1). 9-21.
Marshalla, P. R. (1985). The role of reflexes in oral-motor learning: Techniques for improved articulation. Seminars in Speech and Language, 6(4), 317-336.
McLeod, S., & Searl, J. (2006). Adaptation to an electropalatograph palate: Acoustic, impressionistic, and perceptual data. America Journal of Speech-Language Pathology, 15(2), 192-206.
Meyer, P. G. (2000). Tongue, lip, and jaw differentiation and its relationship to orofacial myofunctional treatment. International Journal of Orofacial Myology, 26, 44-52.
Miles, T. S., Flavel, S. C., & Nordstrom, M. A. (2004). Control of human mandibular posture during locomotion. The Journal of Physiology, 554(1), 216-226.
Miller, A. J. (1972). Significance of sensory inflow to the swallowing reflex. Brain Research, 43, 147-159.
Miller, A. J. (1982). Deglutition, Physiological Reviews, 63, 129.
Miyaoka, S, Hirano, H., Miyaoka, Y, & Yamada, Y. (2004). Head movement associated with performance of mandibular tasks. Journal of Oral Rehabilitation, 31(9), 843-850.
Moore, C. A. (1993). Symmetry of mandibular muscle activity as an index of coordinative strategy. Journal of Speech and Hearing Research, 31, 670-680.
Moore, C. A., Smith A., & Ringel, R. L. (1988). Task-specific organization of activity in human jaw muscles. Journal of Speech and Hearing Research, 31, 670-680.
Ogawa, T., Ogawa, M., & Koyano, K. (2001). Different responses of masticatory movements after alteration of occlusal guidance related to individual movement pattern. Journal of Oral Rehabilitation, 28(9), 830-841.
Ong, D., & Stone, M. (1998). Three-dimensional vocal tract shapes in /r/ and /l/: A study of MRI, ultrasound, electropalatography, and acoustics. Phonoscope, 1, 1-13.
Ostry, D. J., & Flanagan, J. R. (1989). Human jaw movement in mastication and speech. Archives of Oral Biology, 34, 685-693.
Palmer, M. F., & Osborn, C. D. (1940). A study of tongue pressures of speech defective and normal speaking individuals. Journal of Speech Disorders, 52, 133-140.
Petrofsky, J. S., & Lind, A. R. (1975). Isometric strength, endurance, and the blood pressure and heart rate responses during isometric exercise in healthy men and women with special reference to age and body fat content. Pflugers Archive: European Journal of Physiology, 360, 49-61.
Scott, B. J., Mason, A. G., & Cadden, S. W. (2002). Voluntary and reflex control of the human temporalis muscle. Journal of Oral Rehabilitation, 29(7), 634-643.
Sgobbi De Faria, C. R., & Berzin, F. (1998). Electromyographic study of the temporalis, masseter, and suprahyoid muscles in the mandibular rest position. Journal of Oral Rehabilitation, 25(10). 776.
Shapiro, B. L., Redman, R. S., Gorlin, R. J. (1963). Measurements of normal and reportedly malformed palatal vaults: I. Normal adult measurements. Journal of Dental Research, 42, 1039.
Tamura, T., Kanayama, T., Yoshida, S., & Kawasake, T. (2003). Functional magnetic resonance imaging of human jaw movements. Journal of Oral Rehabilitation, 30(6), 614-622.
Till, J. A., & Goff, A. M. (1986, November). Task variables affecting temporal structure and respiratory patterns in speech, Asha, 28, 102.
Uchida, S., Inoue, H., & Maeda, T. (1999). Electromyographic study of the activity of jaw depressor muscles before initiation of opening movements. Journal of Oral Rehabilitation 26(6), 503-510.
Wang, M. Q., Yan, C. Y., & Yuan, Y. P. (2001). Is the superior belly of the lateral pterygoid primarily a stabilizer? An EMG study. Journal of Oral Rehabilitation, 28(6), 507-510.
Watanabe, K. (2000). The relationship between dentofacial morphology and the isometric jaw-opening and closing muscle function as evaluated by electromyography. Journal of Oral Rehabilitation, 27(7), 639-345.
Westbury, J. R., Lindstrom, M. J., & McClean, M. D. (2002). Tongues and lips without jaws: A comparison of methods for decoupling speech movements. International Journal of Speech, Language, and Hearing Research, 45, 651-662.
Wood, L. M., Hughes, J., Hayes, K. C., & Wolfe, D. L. (1992). Reliability of labial closure force measurement in normal subjects and patients with CNS disorders. Journal of Speech and Hearing Research, 35, 252-258.
Woody, R. C., & Kiel, E. A. (1968). Swallowing syncope in a child. Pediatrics, 78, 507.

RESPIRATION

Bu’Lock, F., Woolridge, M., & Baum, J. (1990). Development of co-ordination of sucking, swallowing, and breathing: Ultrasound study of term and preterm infants. Developmental Medicine and Child Neurology, 32, 669-678.
Carlo, W., Beoglos, A., Siner, B, & Martin, R. (1989). Neck and body position effects on pulmonary mechanics in infants. Pediatrics, 84(4), 670-674
Crelin, E. (1976). Development of the upper respiratory system. Clinical Symposia, 28(3).
Daniels, H., Devileger, H., Minami, T., Eggermont, E., & Casaer, P (1990). Infant feeding and cardiorespiratory maturation. Neuropediatrics, 21(1), 9-10.
Davis, L. (1987). Respiration and phonation in cerebral palsy: A developmental model. Seminars in Speech and Language, 8(1), 101-106.
Gunn, T., & Tonkin, S. (1989). Upper airway measurements during inspiration and expiration in infants. Pediatrics, 84(1). 73-77.
Heldt, G. P. (1988). Effect of gavage feeding on the mechanics of lung, chest wall, and diaphragm of preterm infants. Pediatric Research, 24, 55.
Matthew, O. P., & Bhatia, J. (1989). Sucking and breathing patterns during breast- and bottle-feeding in term neonates. American Journal of Disease in Children, 143, 588-592.
Matthews, C. L., (1994). Supporting suck-swallow-breath coordination during nipple feeding. American Journal of Occupational Therapy, 48(6). 561-562.
Moore, C. A., Caulfield, T. J., & Green J. R. (2001). Relative kinematics of the rib cage and abdomen during speech and nonspeech behaviors of 15-month-old children. Journal of Speech, Language, and Hearing Research, 44, 80-94.
Mortola, J., Fisher, J., Smith, B., Fox, G., & Weeks, S. (1982). Dynamics of breathing in infants. Journal of Applied Physiology, 52, 1209-1215.
Paludetto, A. R., Robertson, S. S., & Martin, R. J. (1986). Interaction between non-nutritive sucking and respiration in preterm infants. Biology of the Neonate, 49, 198.
Polgar, G., & Weng, T. (1979). The functional development of the respiratory system. American Review of Respiratory Disease, 120, 625-695.
Prechi, H., Fargel, J., Weinmann, H., & Bakker, H. (1979). Postures, motility and respiration of low-risk pre-term infants. Developmental Medicine and Child Neurology, 21, 3-27.
Selley, W. G., Ellis, R. E., Flack, F. C., & Brooks, W. A. (1990). Coordination of sucking, swallowing, and breathing in the newborn: Its relationship to infant feeding and normal development. The British Journal of Disorders of Communication, 25(3), 311-327.
Solomon, N. P., & Hixon, T. J. (1993). Speech breathing in Parkinson’s disease. Journal of Speech and Hearing Research, 36, 294-310.
Stern, L. (Ed.). (1987). The respiratory system in the newborn. Clinics in Perinatology, 14(3).
Till, J. A., & Goff, A. M. (1986, November). Task variables affecting temporal structure and respiratory patterns in speech, Asha, 28, 102.
Tzelepis, G. E., McCool, F. D., Friedman, J. H., & Hoppin, F. G., Jr. (1988). Respiratory muscle dysfunction in Parkinson’s disease. American Review of Respiratory Disease, 138, 266-271.
Tucker, J. A. (1985). Perspectives on the development of the air and food passages. American Review of Respiratory Diseases, 131, S7-S9.
Wilson, S. L., Thach, B. T., Brouillette, R. T., Abu-Osba, Y. K. (1981). Coordination of breathing and swallowing. Journal of Applied Physiology, 50(4), 851-858.

ORAL MOTOR DISORDERS (PEDIATRIC)

Adler-Bock, M., Bernhardt, B. M., Gick, B., & Bacsfalvi, P. (2007). The use of ultrasound in remediation of North American English /r/ in 2 Adolescents. American Journal of Speech-Language Pathology, 16(2), 128-139.
Alexander, R. (1987). Oral-motor treatment for infants and young children with cerebral palsy. Seminars in Speech and Language, 8,(1). 87-100.
Alper, B. S., & Manno, C. J. (1996). Dysphagia in infants and children with oral-motor deficits: Assessment and management. Seminars in Speech and Language, 17, 283-309.
Anderson, G., & Vidyasagar, D. (1979). Development of sucking in premature infants from 1 to 7 days post birth. Birth Defects: Original Article Series, 15(7), 145-171.
Ardron, G. M., Harker, P., & Kemp, F. H. (1972). Tongue size in Down’s syndrome. Journal of Mental Deficiency Research, 16, 160-166.
Axelrod, R. B., & Pearson, J. (1984). Congenital sensory neuropathies: Diagnostic distinction from familial dysautonomia. American Journal of Diseases of Children, 138, 947.
Bahr, D. C. (2003). Typical versus atypical oral motor function in the pediatric population: Beyond the checklist. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) American Speech-Language-Hearing Association Division 13, 12(1), 4-12.
Barry, R. M. (1995). A comparative study of the relationship between dysarthria and verbal dyspraxia in adults and children. Clinical Linguistics and Phonetics, 9, 311-312.
Barry, R. M. (1995). The relationship between dysarthria and verbal dyspraxia in children: A comparative study using profiling and instrumental analyses. Clinical Linguisics and Phonetics, 9, 277-309.
Bashina, V. M., Simashkova, N. V., Grachev, V. V., & Gorbachevskaya, N. L. (2002). Speech and motor disturbances in Rett syndrome. Neuroscience and Behavioral Physiology, 32, 323-327.
Bashir, A., Graham-Jones, F., & Bostwick, R. (1984). A touch cue method of therapy for developmental verbal apraxia. Seminars in Speech and Language, 5, 127-138.
Bazyk, S. (1990). Factors associated with the transition to oral feeding in infants fed by nasogastric tubes. The American Journal of Occupational Therapy, 44(12), 1070-1078.
Belton, E., Salmond, C. H., Watkins, K. E., Vargha-Khadem, F., & Gadian, D. G. (2003). Bilateral brain abnormalities associated with dominantly inherited verbal orofacial dyspraxia. Human Brain Mapping, 18, 194-200.
Beratis, S., Kolb, R., Sperling, E., & Stein, R. E. (1981). Development of a child with long-lasting deprivation of oral feeding. Journal of the American Academy of Child Psychiatry, 20(1), 53-64.
Bernbaum, J. C., Pereira, G. R., Watkins, J. B., & Peckham, G. J. (1983). Nonnutritive sucking during gavage feeding enhances growth and maturation in premature infants. Pediatrics, 71(1), 41-45.
Bernstein, I. L. (1978). Learned taste aversions in children receiving chemotherapy. Science, 200, 1302.
Borea, G., Magi, M., Mingarelli, R., Zamboni, C. (1990). The oral cavity in Down syndrome. The Journal of Pedodontics, 14, 139-140.
Boysson-Bardies, B. D., Sagart, L., & Bacri, N. (1981). Phonetic analysis of late babbling: A case study of a French child. Journal of Child Language, 8, 511-524.
Braun, M. A., & Palmer, M. M. (1986). A pilot study of oral-motor dysfunction in “at-risk” infants. Physical & Occupational Therapy in Pediatrics, 5(4), 13-25.
Bu’Lock, F., Woolridge, M., & Baum, J. (1990). Development of co-ordination of sucking, swallowing, and breathing: Ultrasound study of term and preterm infants. Developmental Medicine and Child Neurology, 32, 669-678.
Burns, Y., Rogers, Y., Neil, M., Brazier, K., Croker, A., Behnke, L., & Tudehope, D. (1987). Development of oral function in pre-term infants. Physiotherapy Practice, 3, 168-178.
Carlo, W., Beoglos, A., Siner, B, & Martin, R. (1989). Neck and body position effects on pulmonary mechanics in infants. Pediatrics, 84(4), 670-674
Carneol, S. O., Marks, S. M., & Weik, L. (1999). The speech-language pathologist: Key role in the diagnosis of Velocardiofacial syndrome. American Journal of Speech-Language Pathology, 8, 23-32.
Casaer, P., Daniels, H. , Devileger, H., DeCock, P., & Eggermont, E. (1982). Feeding behaviour in preterm neonates. Early Human Development, 7(4), 331-346.
Catto-Smith, A. G., Machida, H., Butzner, J. D., Gall, D. G., & Scott, R. B. (1991). The role of gastroesophageal reflux in pediatric dysphagia. Journal of Pediatric Gastroenterology and Nutrition, 12(2), 159-165.
Clawson, E. P., Palinski, K. S., & Elliott, C. A. (2006). Outcome on intensive oral motor and behavioural interventions for feeding difficulties in three children with Goldenhar syndrome. Pediatric Rehabilitation, 9(1), 65-75.
Cobo-Lewis, A. B., Oller, K. D., Lynch, M. P., Levine, S. L. (1996). Relations of motor and vocal milestones in typically developing infants and infants with Down syndrome. American Journal of Mental Retardation, 100(5), 456-467.
Crary, M. A. (1995). Clinical evaluation of developmental motor speech disorders. Seminars in Speech and Language, 16, 110-125.
Daniels, H. Casaer, P. Devileger, H. & Eggermont, E. (1986). Mechanisms of feeding efficiency in preterm infants. Journal of Pediatric Gastroenterology and Nutrition, 5(4), 593-596.
Davis, B., & Velleman, S. L. (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers. Infant-Toddler Intervention: The Transdisciplinary Journal, 10, 177-192.
Davis, L. (1987). Respiration and phonation in cerebral palsy: A developmental model. Seminars in Speech and Language, 8(1), 101-106.
Davis-McFarland, E. (2000). Language and oral-motor development and disorders in infants and young toddlers with human immunodeficiency virus. Seminars in Speech and Language, 21(1), 19-36.
Desai, S. S. (1997). Down syndrome: A review of the literature. Oral Surgery Oral Medicine Oral Pathology, 84, 279-285.
Dewey, D., Roy, E. A., Square-Storer, P. A., & Hayden, D. (1988). Limb and oral praxic abilities of children with verbal sequencing deficits. Developmental Medicine and Child Neurology, 30, 743-751.
Evans, P. R. (1954). Nuclear agenesis Mobius syndrome; The congenital facial diplegia syndrome. American Journal of Diseases of Children, 30, 247.
Evans, T. J., & Davies, D. P. (1977). Failure to thrive at the breast: An old problem revisited. Archives of Disease in Childhood, 52, 974.
Fee, M., Charney, E., & Robertson, W. (1988). Nutritional assessment of the young child with cerebral palsy. Infants and Young Children, 1(1). 33-40.
Field, T., Ignaroff, E., Stringer, S., Brennan, J., Greenberg, R., Widmayer, S., & Anderson, G. (1982). Nonnutritive sucking during tube feedings: Effects on preterm neonates in an intensive care unit. Pediatrics, 70(3), 381-384.
Fisher, S. E., Painter, M., & Milmoe, G. (1981). Swallowing disorders in infancy. Pediatric Clinics of North America, 28(4). 845-853.
Flipsen, P., Jr., Hammer, J. B., & Yost, K. M. (2005). Measuring severity of involvement in speech delay: Segmental and whole-word measures. American Journal of Speech-Language Pathology, 14(4). 298-312.
Frazier, J. B., & Friedman, B. (1996). Swallow function in children with Down syndrome: A retrospective study. Developmental Medicine and Child Neurology, 38, 695-703.
Frostad, N. A., Cleall, J. F., & Melosky, L. C., (1971). Craniofacial complex in the Trisomy 21 syndrome. Archives of Oral Biology, 16, 707-722.
Fucile, S., Gisel, E., & Lau, C. (2002). Oral stimulation accelerates the transition from tube to oral feeding in preterm infants. Journal of Pediatrics, 141(2), 230-236.
Gibbon, F., Stewart, F., Hardcastle, W. J., & Crampin, L. (1999). Widening access to eletropalatography for children with persistent sound system disorders. American Journal of Speech-Language Pathology, 8, 319-334.
Goldblatt, E., & Williams, D. (1986). “I an sniling!” Meobius syndrome inside and out. Journal of Child Neurology, 1, 71.
Gryboski, J. D. (1969). Suck and swallow in the premature infant. Pediatrics, 43, 96.
Hayasaki, H., Yamasaki, Y., Nishijima, N., Naruse, K.. & Nakata, M. (1998). Characteristics of protrusive and lateral excursions of the mandible in children with the primary dentition. Journal of Oral Rehabilitation, 25(4), 311-320.
Harris, S. R., & Purdy, A. H. (1987). Drooling and its management in cerebral palsy. Developmental Medicine and Child Neurology, 29, 805.
Heldt, G. P. (1988). Effect of gavage feeding on the mechanics of lung, chest wall, and diaphragm of preterm infants. Pediatric Research, 24, 55.
Illingsworth, R. (1969). Sucking and swallowing difficulties in infancy: Diagnostic problems of dysphagia. Archives of Disease in Childhood, 44, 655-665.
Jain, L. Sivieri, E., Abbasi, S., & Bhutani, V. K. (1987). Energetics and mechanics of nutritive sucking in the preterm and term neonate. Journal of Pediatrics, 111, 894-898.
Judd, P., Kenny, D., Koheil, R., Milner, M., & Moran, R. (1989). The multidisciplinary feeding profile: A statistically based protocol for assessment of dependent feeders. Dysphagia, 4(1). 29-34.
Kenny, D., Casas, M., & McPherson, K. (1989). Correlation of ultrasound imaging of oral swallow with ventilatory alterations in cerebral palsied and normal children: Preliminary observations. Dysphagia, 4(2), 112-117.
Kisling, E., (1966). Cranial morphology in Down’s syndrome: A comparative roentgenocephalometric study in adult males, Copenhagen, Denmark: Munksgaard.
Krick, J., & Van Duyn, M. (1984). The relationship between oral-motor involvement and growth: A pilot study in a pediatric population with cerebral palsy. Journal of the American Dietetic Association, 84(5), 555-559.
Kumin, L. (1996). Speech and language skills in children with Down syndrome. Mental Retardation and Developmental Disabilities Research Reviews, 2, 109-116.
Kumin, L., & Bahr, D. C. (1999). Patterns of feeding, eating, and drinking in young children with Down syndrome with oral motor concerns. Down Syndrome Quarterly, 4(2), 1-8.
Kumin, L., Von Hagel, K. C., & Bahr, D. C. (2001). An effective oral motor intervention protocol for infants and toddlers with low muscle tone. Infant-Toddler Intervention, 11(3-4), 181-200.
Lind, J., Wasz-Hockert, O., Vuorenkoski, V., & Valanne, E. (1965). The vocalization of a newborn brain-damaged child. Annales Paediatrica Fenniae, 11, 32-37.
Lauteslager, P. E., Vermeer, A., & Helders, P. J. (1998). Disturbances in the motor behaviour of children with Down’s syndrome: The need for a theoretical framework. Physiotherapy, 84(1), 6-13.
Leeuw, R. D., Colin, E. M., Dunnebier, E. A., & Mirmiran, M. (1991) Physiological effects of kangaroo care in very small preterm infants. Biology of the Neonate, 59(3), 149-155.
Logan, W. J., & Bosma, J. F. (1967). Oral and pharyngeal dysphagia in infants. Pediatric Clinics of North America, 14, 47.
Love, R. J., Hagerman, E. L., & Tiami, E. G. (1980). Speech performance, dysphagia, and oral reflexes in cerebral palsy. Journal of Speech and Hearing Disorders, 45, 59-75.
Maassen, B. (2002). Issues contrasting adult acquired versus developmental apraxia of speech. Seminars in Speech and Language, 23, 257-266.
Matthews, C. L., (1994). Supporting suck-swallow-breath coordination during nipple feeding. American Journal of Occupational Therapy, 48(6). 561-562.
McCoy, R., Kadowaki, C., Wilks, S., Engstrom, J. & Meier, P. (1988). Nursing management of breast feeding for preterm infants. The Journal of Perinatal & Neonatal Nursing, 2(1), 42-55.
Measel, C. P., & Anderson, G. C. (1980). Non-nutritive sucking during tube feeding: Effect on clinical course in premature infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 8, 265.
Meier, P. (1980). A program to support breast-feeding in the special care nursery. Perinatology/Neonatology, 4, 43.
Meier, P., & Anderson, G. C. (1987). Responses of small preterm infants to bottle and breast feeding. MCN. The American Journal of Maternal Child Nursing, 12, 97.
Meier, P., & Pugh, E. (1985). Breast feeding behavior in small preterm infant. MCN. The American Journal of Maternal Child Nursing, 10, 396.
Mizuno, K., & Ueda, A. (2001). Development of sucking behavior in infants who have not been fed for 2 months after birth. Pediatrics International, 43(3). 251-255.
Morris, S. E. (1985). Developmental implications for the management of feeding problems in neurologically impaired infants. Seminars in Speech and Language, 6(4), 293-315.
Morris, S. E. (1987). Therapy for the child with cerebral palsy: Interacting frameworks. Seminars in Speech and Language, 8(1), 71-86.
Morris, S. E. (1989). Development of oral-motor skills in the neurologically impaired child receiving non-oral feedings. Dysphagia, 3(3). 135-154.
Muir, N. Y., Allard, G. B., & Greenburg, C. (1999). Oral language development in a child with Floating-Harbor syndrome. Language, Speech, and Hearing Services in Schools, 30, 207-211.
Murdoch, B. E., Attard, M. D., Ozanne, A. E., & Stokes, P. D. (1995). Impaired tongue strength and endurance in developmental verbal dyspraxia: A physiological analysis. European Journal of Disorders of Communication, 30, 51-64.
Mysak, E. (Ed.). (1978). Communication disorders of the cerebral palsied: Assessment and treatment. Seminars in Speech and Language, 8(1).
Oller, D. K., Eilers, R. E., Neal, R., & Schwartz, H. (1999). Precursors to speech in infancy: The prediction of speech and language disorders. Journal of Communication Disorders, 32, 223-245.
Page, D. C. (1999). The new dental-medical renaissance: Medically efficacious functional jaw orthopedics. The Functional Orthodontist: A Journal of Functional Jaw Orthopedics, 16(1), 16-25.
Page, J., & Boucher, J. (1998). Motor impairments in children with autistic disorder. Child Language Teaching and Therapy, 14, 233-259.
Paludetto, A. R., Robertson, S. S., & Martin, R. J. (1986). Interaction between non-nutritive sucking and respiration in preterm infants. Biology of the Neonate, 49, 198.
Pannbacker, M. (2004). Velopharyngeal incompetence: The need for speech standards. American Journal of Speech-Language Pathology, 13(3). 195-201.
Patrick, J., & Gisel E. G. (1990). Nutrition for the feeding-impaired child. Journal of Neurologic Rehabilitation, 4, 115.
Prechi, H., Fargel, J., Weinmann, H., & Bakker, H. (1979). Postures, motility and respiration of low-risk pre-term infants. Developmental Medicine and Child Neurology, 21, 3-27.
Redman, R. S., Shapiro, B. L., & Gorlin, R. J., (1965). Measurement of normal and reportedly malformed palatal vaults: III. Down’s syndrome (Trisomy 21, Mongolism). Journal of Pediatrics, 67, 162-165.
Richmond, G, & Bell, J. C. (1983). Analysis of a treatment package to reduce a handmouthing stereotypy. Behavior Therapy, 14, 576-581.
Riski, J. E. (2007). Feeding the infant born with cleft lip/palate: A literature review. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) American Speech-Language-Hearing Association Division 13, 16(3), 12-17.
Robin, D. A. (1992). Developmental apraxia of speech: Just another motor problem. American Journal of Speech-Language Pathology, 1, 19-22.
Robin, P. (1931). Glossoptosis due to atresia and hypotrophy of the mandible. American Journal of Diseases of Children, 48, 541.
Robbins, J., & Klee, T. (1987). Clinical assessment of orophayngeal motor development in young children. Journal of Speech and Hearing Disorders, 52, 271-277.
Rocha, A. D., Moreira, M. E. L., Pimenta, H. P., Ramos, J. R. M , & Lucena, S. L. A. (2007). Randomized study of the efficacy of sensory-motor-oral stimulation and non-nutritive sucking in very low birthweight infants. Early Human Development, 83(6), 385-388.
Rosenbek, J., Hansen, R., Baughman, C. H., & Lemme, M. (1974). Treatment of developmental apraxia of speech: A case study. Language, Speech, and Hearing Services in Schools, 5, 13-22.
Roche, A. F., Roche, J. P., & Lewis, A. B. (1972). The cranial base in Trisomy 21. Journal of Mental Deficiency Research, 16, 7-20.
Rudolph, C. D. (1994). Feeding disorders in infants and children. The Journal of Pediatrics, 125, S116.
Shapiro, B. L., Gorlin, R. J., Redman, R. S., & Bruhl, H. H., (1967). The palate and Down’s syndrome. New England Journal of Medicine, 276, 460-463.
Shapiro, B. L., Redman, R. S., Gorlin, R. J. (1963). Measurements of normal and reportedly malformed palatal vaults: I. Normal adult measurements. Journal of Dental Research, 42, 1039.
Sivit, C. (1990). The role of the pediatric radiologist in the evaluation of oral and pharyngeal dysphagia. Journal of Neurologic Rehabilitation, 4, 103.
Smith, A., Weber, C. M., Newton, J., & Denny, M. (1991). Developmental and age-related changes in reflexes of the human jaw-closing system. Electroencephalography and Clinical Neurophysiology, 81, 118-128.
Sochaniwskyj, A., Koheil, R., Baablich, K., Milner, M., & Kenny, D. (1986). Oral motor functioning, frequency of swallowing, and drooling in normal children and in children with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 67, 866-874.
Spender, Q., Dennis, J., Stein, A., Cave, D., Percy, E., & Reilly, S. (1995). Impaired oral-motor function in children with Down’s syndrome: A study of three twin pairs. European Journal of Disorder of Communication, 30, 77-87.
Spender, Q., Stein, A., Dennis, J., Reilly, S., Percy, E., & Cave, D. (1996). An exploration of feeding difficulties in children with Down syndrome. Developmental Medicine and Child Neurology, 38, 681-694.
Stoel-Gammon, C. (1997). Phonological development in Down syndrome. Mental Retardation and Developmental Disabilities Research Reviews, 3, 300-306.
Strand, E. (1995). Treatment of motor speech disorders in children. Seminars in Speech and Language, 16, 126-139.
Sweeney, J. (Ed.). (1986). The high-risk neonate: Developmental therapy perspectives (Special Issue). Physical & Occupational Therapy in Pediatrics, 6 (3&4).
Takagi, Y, Irwin, J. V., & Bosma, J. F. (1966). Prone feeding of infants with Pierre Robin syndrome. The Cleft Palate Journal, 3, 232.
Thoonen, G., Maassen, B., Gabreels, F., & Schreuder, R. (1999). Validity of maximum performance tasks to diagnose motor speech disorders in children. Clinical Linguistics and Phonetics, 13, 1-23.
Verrastro, A. P., Stefani, F. M., Rodrigues, C. R., & Wanderly, M. T. (2006). Occlusal and orofacial myofunctional evaluation in children with primary dentition, anterior open bite and pacifier sucking habit. International Journal of Orofacial Myology, 32, 7-21.
Widstrom, A. M., Marchini, G., Matthiesen, A. S., Werner, S., Winberg, J., & Uvnas-Moberg, K. (1988). Non-nutritive sucking in tube fed preterm infants: Effects on gastric motility and gastric contents of somatostatin. Journal of Pediatric Gastroenterology and Nutrition, 7(4), 517-523.
Williams, P., & Stackhouse, J. (1998). Diadochokinetic skills: Normal and atypical performance in children aged 3-5 years. International Journal of Language and Communication Disorders, 33 (Suppl.), 481-486.
Yarrom, R., Sagher, U., Havivi, Y., Peled, I. J., Wexler, M. R. (1986). Myofibers in tongues of Down syndrome. Journal of Neurological Science, 73, 279-287.
Zeeman, S., Nowaczyk, M. J. M., Teshima, I., Roberts, W., Oram Cardy, J., Brian, J., et al. (2006). Speech and language impairment and oromotor dyspraxia due to deletion of 7q31 that involves FOXP2. American Journal of Human Genetics, 140(A), 509-514.
Ziev, M. S. R. (1999). Earliest intervention: Speech-Language pathology services in the neonatal intensive care unit. Asha, 41(3), 32-36.

ORAL MOTOR DISORDERS (ADULT)

Abbs, J. H., Hartman, D. E., & Vishwanat, B. (1987). Orofacial motor control impairment in Parkinson’s disease. Neurology, 37, 394-398.
Barry, R. M. (1995). A comparative study of the relationship between dysarthria and verbal dyspraxia in adults and children. Clinical Linguistics and Phonetics, 9, 311-312.
Bisch, E. M., Logemann, J. A., Rademaker, A. W., Kahrilas, P. J., & Lazarus, C. L. (1994). Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia resulting from neurologic impairment and normal subjects. Journal of Speech and Hearing Research, 37(5), 1041-1059.
Canter, G. J. (1965). Speech characteristics of patients with Parkinson’s disease: III. Articulation, diadochokinesis, and over-all speech adequacy. Journal of Speech and Hearing Disorders, 30, 217-224.
Connor, N. P., Ludlow, C. L., & Schulz, G. M. (1989). Stop consonant production in insolated and repeated syllables in Parkinson’s disease, Neuropsychologia, 27, 829-838.
Darley, F. L., Aronson, A. E., & Brown, J. R. (1969). Differential diagnostic patterns of dysarthria. Journal of Speech and Hearing Research, 12, 246-269.
Duffy, J. R., Peach, R. K., & Strand, E. A. (2007). Progressive apraxia of speech as a sign of motor neuron disease. American Journal of Speech-Language Pathology, 16(3). 198-208.
Dworkin, J. P. (1996). Bite block therapy of oromandibular dystonia. Journal of Medical Speech-Language Pathology, 4, 47-56.
Dworkin, J. P., & Aronson, A. E. (1986). Tongue strength and alternate motion rates in normal and dysarthric subjects. Journal of Communication Disorders, 19, 115-132.
Dworkin, J. P., Aronson, A. E., & Mulder, D. W. (1980). Tongue strength in normal subjects and dysarthric patients with amyotrophic lateral sclerosis. Journal of Speech and Hearing Research, 23, 828-837.
Enderby, P., & Crow, E. (1990). Long-term recovery patterns of severe dysarthria following head injury. British Journal of Disorders of Communication, 25, 341-354.
Forrest, K., Weismer, M., & Turner, G. S. (1989). Kinematic, acoustic, and perceptual analyses of connected speech produced by parkinsonian and normal geriatric adults. Journal of the Acoustical Society of America, 85, 2608-2622.
Fucile, S., Wright, P. M., Chan, I., Yee, S., Langlais, M., & Gisel, E. G. (1998). Functional oral-motor skills: Do they change with age? Dysphagia, 13, 195-201.
Gandevia, S. C. (1982). The perception of motor commands or effort during muscular paralysis, Brain, 105, 151-159.
Hill, A. J., Theodoros, D. G., Russell, T. G., Cahill, L. M., Ward, E. C., & Clark, K. M. (2006). An internet-based telerehabilitation system for the assessment of motor speech disorders: A pilot study. American Journal of Speech-Language Pathology, 15(1), 45-56.
Hustad, K. C. (2006). A closer look at transcription intelligibility for speakers with dysarthria: Evaluation of scoring paradigms and linguistic errors made by listeners. American Journal of Speech-Language Pathology, 15(3), 268-277.
Judd, P., Kenny, D., Koheil, R., Milner, M., & Moran, R. (1989). The multidisciplinary feeding profile: A statistically based protocol for assessment of dependent feeders. Dysphagia, 4(1). 29-34.
Keintz, C. K., Bunton, K., & Hoit, J. D. (2007). Influence of visual information on the intelligibility of dysarthric speech. American Journal of Speech-Language Pathology, 16(3), 222-234.
Koller, W., & Kase, S. (1986). Muscle strength testing in Parkinson’s disease, European Neurology, 25, 130-133.
Larsson , L., & Karlsson, J. (1978) Isometric and dynamic endurance as a function of age and skeletal muscle characteristics. Acta Physiologica Scandinavia, 104, 129-136.
Leung, K. C., Pow, E. H., McMillan, A. S., Wong, M. C., Li, L. S., & Ho, S. L. (2002). Oral perception and oral motor ability in edentulous patients with stroke and Parkinson’s disease. Journal of Oral Rehabilitation, 29(6), 497-503.
Liss, J. M., Krein-Jones, K., Wszolek, Z. K., & Caviness J. N. (2006). Speech characteristics of patients with pallido-ponto-nigral degeneration and their application to presymptomatic detection in at-risk relatives. American Journal of Speech-Language Pathology, 15(3), 226-235.
Logemann, J. A. (1985). The relationship of speech and swallowing in head and neck surgical patients. Seminars in Speech and Language, 6(4), 351-359.
Maassen, B. (2002). Issues contrasting adult acquired versus developmental apraxia of speech. Seminars in Speech and Language, 23, 257-266.
McHenry, M. A., Minton, J. T., Wilson, R. L., & Post, Y. V. (1994). Intelligibility and nonspeech orofacial strength and force control following traumatic brain injury. Journal of Speech and Hearing Research, 37, 1271-1283.
Morrison, E. B., Rigrodsky, S., & Mysak, E. D. (1970). Parkinson’s disease: Speech disorder and released infantile oroneuromotor activity. Journal of Speech and Hearing Research, 13, 655-666.
Murray, J. P. (1962). Deglutition in myasthenia gravis. The British Journal of Radiology, 35, 43.
Netsell, R., Daniel, B., & Celesia, G. G. (1975). Acceleration and weakness in parkinsonian dysarthria. Journal of Speech and Hearing Disorders, 40, 170-078.
Palmer, M. F., & Osborn, C. D. (1940). A study of tongue pressures of speech defective and normal speaking individuals. Journal of Speech Disorders, 52, 133-140.
Page, D. C. (1999). The new dental-medical renaissance: Medically efficacious functional jaw orthopedics. The Functional Orthodontist: A Journal of Functional Jaw Orthopedics, 16(1), 16-25.
Ramsey, W. O. (1986). Suckle facilitation of feeding in selected adult dysphagic persons. Dysphagia, 1, 7.
Ray, J. (2006). Orofacial myofunctional deficits in elderly individuals. International Journal of Orofacial Myology, 32, 22-31.
Robin, D. A., Goel, A., Somodi, L. B., & Luschei, E. S. (1992). Tongue strength and endurance: Relation to highly skilled movements. Journal of Speech and Hearing Research, 35, 1239-1245.
Robbins, J. (1985). Swallowing and speech problems in the neurologically impaired adult. Seminars in Speech and Language, 6(4), 337-350.
Robbins, J. (1992). The impact of oral motor dysfunction on swallowing: From beginning to end. Seminars in Speech and Language, 13(1), 55-69.
Robbins, J., Kays, S. A., Gangnon, R. E., Hind, J. A., Hewitt, A. L., Gentry, L., R., & Taylor, A. J. (2007). The effects of lingual exercise in stroke patients with dysphagia. Archives of Physical Medicine and Rehabilitation, 88(2), 150-158.
Rosenbek, J., Lemme, M., Ahern, M., Harris, E., & Wertz, T. (1973). A treatment for apraxia of speech in adults. Journal of Speech and Hearing Disorders, 38, 462-472.
Shapiro, B. L., Redman, R. S., Gorlin, R. J. (1963). Measurements of normal and reportedly malformed palatal vaults: I. Normal adult measurements. Journal of Dental Research, 42, 1039.
Smith, A., Weber, C. M., Newton, J., & Denny, M. (1991). Developmental and age-related changes in reflexes of the human jaw-closing system. Electroencephalography and Clinical Neurophysiology, 81, 118-128.
Strand, E. A., Miller, R. M., Yorkston, K. M., & Hillel, A. D. (1996). Management of oral-pharyngeal dysphagia symptoms in amyotrophic lateral sclerosis. Dysphagia, 11, 129.
Solomon, N. P., & Hixon, T. J. (1993). Speech breathing in Parkinson’s disease. Journal of Speech and Hearing Research, 36, 294-310.
Solomon, N. P., Lorell, C. M., Robin, D. A., Rodnitzky, R. L., & Luschei, E., S. (1995). Tongue strength and endurance in mild to moderate Parkinson’s disease. Journal of Medical Speech-Language Pathology, 3, 15-26.
Tzelepis, G. E., McCool, F. D., Friedman, J. H., & Hoppin, F. G., Jr. (1988). Respiratory muscle dysfunction in Parkinson’s disease. American Review of Respiratory Disease, 138, 266-271.
Wambaugh, J. L., Duffy, J. R., McNeil, M. R., Robin, D. A., & Rogers, M. A. (2006). Treatment guidelines for acquired apraxia of speech: A synthesis and evaluation of the evidence. Journal of Medical Speech-Language Pathology, 14, xv-xxxiii.
Wambaugh, J. L., Duffy, J. R., McNeil, M. R., Robin, D. A., & Rogers, M. A. (2006). Treatment guidelines for acquired apraxia of speech: Treatment descriptions and recommendations. Journal of Medical Speech-Language Pathology, 14, xxv-lxvii.
Weinberg, B., Christenson, R., Logan, W. Bosma, J., & Wornall, A. (1969). Severe hypoplasia of the tongue. The Journal of Speech and Hearing Disorders, 34(2), 157-168.
Wood, L. M., Hughes, J., Hayes, K. C., & Wolfe, D. L. (1992). Reliability of labial closure force measurement in normal subjects and patients with CNS disorders. Journal of Speech and Hearing Research, 35, 252-258.
Yanagawa, S., Shindo, M., & Yanagisawa, N. (1990). Muscular weakness in Parkinson’s disease. Advances in Neurology, 53, 259-269.

SENSORY AWARENESS AND DISCRIMINATION SENSORY-MOTOR FACILITATION

Anderson, G. C., Marks, E.A., & Wahlberg, V. (1986). Kangaroo care for premature infants. The American Journal of Nursing, 86, 807.
Alexander, R. (1987). Oral-motor treatment for infants and young children with cerebral palsy. Seminars in Speech and Language, 8(1). 87-100.
Ashmead, D. H., Reilly, B. M., & Litpsitt, L. P. (1980). Neonates heart-rate, sucking rhythm, and sucking amplitude as a function of sweet taste. Journal of Experimental Child Psychology, 29, 264.
Axelrod, R. B., & Pearson, J. (1984). Congenital sensory neuropathies: Diagnostic distinction from familial dysautonomia. American Journal of Diseases of Children, 138, 947.
Bashir, A., Graham-Jones, F., & Bostwick, R. (1984). A touch cue method of therapy for developmental verbal apraxia. Seminars in Speech and Language, 5, 127-138.
Beckman, D., Neal, C., Phirsichbaum, J., Stratton, L., Taylor, V., & Ratusnik, D. (2004). Range of movement and strength in oral motor therapy: A retrospective study. Florida Journal of Communication Disorders, 21, 7-14.
Beidler, L. M., & Smallman, R. L. (1965). Renewal of cells within taste buds. Journal of Cellular Biology, 27(2), 263-272.
Beratis, S., Kolb, R., Sperling, E., & Stein, R. E. (1981). Development of a child with long-lasting deprivation of oral feeding. Journal of the American Academy of Child Psychiatry, 20(1), 53-64.
Bernbaum, J. C., Pereira, G. R., Watkins, J. B., & Peckham, G. J. (1983). Nonnutritive sucking during gavage feeding enhances growth and maturation in premature infants. Pediatrics, 71(1), 41-45.
Bernstein, I. L. (1978). Learned taste aversions in children receiving chemotherapy. Science, 200, 1302.
Bisch, E. M., Logemann, J. A., Rademaker, A. W., Kahrilas, P. J., & Lazarus, C. L. (1994). Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia resulting from neurologic impairment and normal subjects. Journal of Speech and Hearing Research, 37(5), 1041-1059.
Bosma, J. (Ed.). (1973). Fourth symposium on oral sensation and perception. (NIH, DHEW Publication No. 73-546). Washington, D.C.: U.S. Government Printing Office.
Brown, G. E., Nordloh, S., & Donowitz, A. J. (1992). Systematic desensitization of oral hypersensitivity in a patient with a closed head injury. Dysphagia, 7, 138-141.
Crook, C. K., & Lipsitt, L. P. (1976). Neonatal nutritive sucking: Effects of taste stimulation upon sucking rhythm and heart rate. Child Development, 47, 518-522.
Field, T. (1990). Alleviating stress in newborn infants in the intensive care unit. Clinics in Perinatology, 17(1), 1-9.
Field, T. (1995). Massage therapy for infants and children. Journal of Developmental Behavioral Pediatrics, 16(2), 105-111.
Field, T. (1998). Massage therapy effects. American Psychology, 53(12), 1270-1281.
Fucile, S., Gisel, E., & Lau, C. (2002). Oral stimulation accelerates the transition from tube to oral feeding in preterm infants. Journal of Pediatrics, 141(2), 230-236.
Gandevia, S. C. (1982). The perception of motor commands or effort during muscular paralysis. Brain, 105, 151-159.
Gatchel, R. J. (1980). Effectiveness of two procedures for reducing dental fear: Group-administered desensitization and group education and discussion. Journal of the American Dental Association, 101, 634-637.
Gisel, E. G. (1991). Effect of food texture on development of chewing in children 6 months to 2 years of age. Developmental Medicine and Child Neurology, 33, 69.
Harris, S. R., & Purdy, A. H. (1987). Drooling and its management in cerebral palsy. Developmental Medicine and Child Neurology, 29, 805.
Hirano, K., Hirano, S., & Hayakawa, I. (2004). The role of oral sensorimotor function in masticatory ability. Journal of Oral Rehabilitation, 31(3), 199-205.
Klepac, R. K., Hauge, G., Dowling, J. (1982). Treatment of an overactive gag reflex: Two cases. Journal of Behavior Therapy and Experimental Psychiatry, 13, 141-144.
Kumin, L., Von Hagel, K. C., & Bahr, D. C. (2001). An effective oral motor intervention protocol for infants and toddlers with low muscle tone. Infant-Toddler Intervention, 11(3-4), 181-200.
Kuhn, C. M., Schanberg, S. M., Field, T., Symanski, R., Zimmerman, E., Scafidi, F., & Roberts, J. (1991). Tactile-kinesthetic stimulation effects on sympathetic and adrenocortical function in preterm infants. Journal of Pediatrics, 119(3), 434-440.
Lazzara, G. D., Lazarus, C., & Logemann, J. A. (1986). Impact of thermal stimulation on the triggering of the swallowing reflex, Dysphagia, 1, 73.
Leeuw, R. D., Colin, E. M., Dunnebier, E. A., & Mirmiran, M. (1991) Physiological effects of kangaroo care in very small preterm infants, Biology of the Neonate, 59(3), 149-155.
Leung, K. C., Pow, E. H., McMillan, A. S., Wong, M. C., Li, L. S., & Ho, S. L. (2002). Oral perception and oral motor ability in edentulous patients with stroke and Parkinson’s disease. Journal of Oral Rehabilitation, 29(6), 497-503.
Lobbezoo, F., Trulsson, M., Jacobs, R., Svensson, P., Caden, S. W., & van Steenberqhe, D. (2002). Topical review: Modulation of trigeminal sensory input in humans: Mechanisms and clinical implications. Journal of Orofacial Pain, 16(1). 9-21.
Logemann, J. A., Pauloski, B. R., Colangelo, L., Lazarus, C., Fujiu, M., & Kahrilas, P. J. (1995). Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia. Journal of Speech and Hearing Research, 38(3), 556-563.
Maller, O., & Turner, R. E. (1973). Taste in acceptance of sugars in human infants. Journal of Comparative Physiology, 84, 496-501.
Matthews, P. B. C. (1988). Proprioceptors and their contribution to somatosensory mapping: Complex messages require complex processing. Canadian Journal of Physiology and Pharmacology, 66, 430-438.
Melzack, R., Konrad, K. W., & Dubrovsky, B. (1969). Prolonged changes in central nervous system activity produced by somatic and reticular stimulation. Experimental Neurology, 25, 416-428.
Miller, A. J. (1972). Significance of sensory inflow to the swallowing reflex. Brain Research, 43, 147-159.
Ong, D., & Stone, M. (1998). Three-dimensional vocal tract shapes in /r/ and /l/: A study of MRI, ultrasound, electropalatography, and acoustics. Phonoscope, 1, 1-13.
Richmond, G, & Bell, J. C. (1983). Analysis of a treatment package to reduce a handmouthing stereotypy. Behavior Therapy, 14, 576-581.
Ringel, R. L., & Ewanowski, S. J. (1965). Oral perception. I. Two-point discrimination. Journal of Speech and Hearing Research, 8(4), 389-398.
Ringel, R. L., & Fletcher, H. M. (1967). Oral perception. 3. Texture discrimination. Journal of Speech and Hearing Research, 10(3), 642-649.
Rocha, A. D., Moreira, M. E. L., Pimenta, H. P., Ramos, J. R. M , & Lucena, S. L. A. (2007). Randomized study of the efficacy of sensory-motor-oral stimulation and non-nutritive sucking in very low birthweight infants. Early Human Development, 83(6), 385-388.
Rood, M. S. (1954). Neurophysiological reactions as a basis for physical therapy. Physical Therapy Review, 34, 444-449.
Rosenbek, J. C., Robbins, J., Fishback, B., & Levine, R. L. (1991). Effect of thermal application on dysphagia after stroke. Journal of Speech and Hearing Research, 34(6), 1257-1268.
Sarnat, H. B. (1978). Olfactory reflexes in the newborn infant. The Journal of Pediatrics, 92, 624.
Schaal, B. (1988). Olfaction in infants and children in developmental and functional perspectives. Chemical Senses, 13, 145.
Scheerer, C. R. (1992). Perspectives on an oral motor activity: The use of rubber tubing as a “chewy.” The American Journal of Occupational Therapy, 46, 344-352.
Sochaniwskyj, A., Koheil, R., Baablich, K., Milner, M., & Kenny, D. (1986). Oral motor functioning, frequency of swallowing, and drooling in normal children and in children with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 67, 866-874.
Stolovitz, P., & Gisel, E. G. (1991). Circumoral movements in response to three different food textures in children six months to two years of age. Dysphagia, 6, 17.
Sullivan, R. M., Taborski-Barba, S., Mendoza, R., Itano, A., Leon, M., Cotman, C.W., Payne, T. F., & Lott, I. (1991). Olfactory classical conditioning in neonates. Pediatrics, 87(4), 511-518.
Wheeden, A., Scafidi, F. A., Field, T., Ironson, G., Valdeon, C., & Bandstra, E. (1993). Massage effects on cocaine-exposed preterm neonates. Journal of Developmental Behavioral Pediatrics, 14(5), 318-322.

FEEDING/EATING/DRINKING (PEDIATRIC)

Alexander, R. (1987). Oral-motor treatment for infants and young children with cerebral palsy. Seminars in Speech and Language, 8(1). 87-100.
Anderson, D. (1963). Development of function in mastication. Journal of Dental Research Supplement, 42, 381-384.
Anderson, G. C., Marks, E.A., & Wahlberg, V. (1986). Kangaroo care for premature infants. The American Journal of Nursing, 86, 807.
Archambault, M., Millen, K., & Gisel, E. (1991). Effect of bite size on eating development in normal children 6 months to 2 years of age. Physical & Occupational Therapy in Pediatrics, 10(4), 29-47.
Ardran, G., & Kemp, F. (1970). Some important factors in the assessment of oropharyngeal function. Developmental Medicine and Child Neurology, 12, 158-166.
Ashmead, D. H., Reilly, B. M., & Litpsitt, L. P. (1980). Neonates heart-rate, sucking rhythm, and sucking amplitude as a function of sweet taste. Journal of Experimental Child Psychology, 29, 264.
Bazyk, S. (1990). Factors associated with the transition to oral feeding in infants fed by nasogastric tubes. The American Journal of Occupational Therapy, 44(12), 1070-1078.
Beidler, L. M., & Smallman, R. L. (1965). Renewal of cells within taste buds. Journal of Cellular Biology, 27(2), 263-272.
Beratis, S., Kolb, R., Sperling, E., & Stein, R. E. (1981). Development of a child with long-lasting deprivation of oral feeding. Journal of the American Academy of Child Psychiatry, 20(1), 53-64.
Bernbaum, J. C., Pereira, G. R., Watkins, J. B., & Peckham, G. J. (1983). Nonnutritive sucking during gavage feeding enhances growth and maturation in premature infants. Pediatrics, 71(1), 41-45.
Bernstein, I. L. (1978). Learned taste aversions in children receiving chemotherapy. Science, 200, 1302.
Blass, E. M., & Teicher, M. H. (1980). Suckling. Science, 210, 15.
Bosma, J. F. (1986). Development of feeding. The Journal of Clinical Nutrition, 5, 210.
Bosma, J. F., Hepburn, L. G. Josell, S. D., & Baker, K. (1990). Ultrasound demonstration of tongue motions during suckle feeding. Developmental Medicine and Child Neurology, 32(3), 223-229.
Braun, M. A., & Palmer, M. M. (1986). A pilot study of oral-motor dysfunction in “at-risk” infants. Physical & Occupational Therapy in Pediatrics, 5(4), 13-25.
Bu’Lock, F., Woolridge, M., & Baum, J. (1990). Development of co-ordination of sucking, swallowing, and breathing: Ultrasound study of term and preterm infants. Developmental Medicine and Child Neurology, 32, 669-678.
Burns, Y., Rogers, Y., Neil, M., Brazier, K., Croker, A., Behnke, L., & Tudehope, D. (1987). Development of oral function in pre-term infants. Physiotherapy Practice, 3, 168-178.
Casaer, P., Daniels, H. , Devileger, H., DeCock, P., & Eggermont, E. (1982). Feeding behaviour in preterm neonates. Early Human Development, 7(4), 331-346.
Clawson, E. P., Palinski, K. S., & Elliott, C. A. (2006). Outcome on intensive oral motor and behavioural interventions for feeding difficulties in three children with Goldenhar syndrome. Pediatric Rehabilitation, 9(1), 65-75.
Crook, C. K., & Lipsitt, L. P. (1976). Neonatal nutritive sucking: Effects of taste stimulation upon sucking rhythm and heart rate. Child Development, 47, 518-522.
Colley, J. R. T., & Creamer, B. (1958). Suckling and swallowing in infants. British Medical Journal, 12, 422.
Daniels, H. Casaer, P. Devileger, H. & Eggermont, E. (1986). Mechanisms of feeding efficiency in preterm infants. Journal of Pediatric Gastroenterology and Nutrition, 5(4), 593-596.
Ellison, S. L., Vidyasagar, D., & Anderson, G. C. (1979). Sucking in the newborn infant during the first hour of life. Journal of Nurse-Midwifery, 24, 18-25.
Erenberg, A., Smith, W. L., Nowak, A. J., et al. (1986). Evaluation of sucking in the breast-fed infant by ultrasonography. Pediatric Research, 20, 409a.
Evans, T. J., & Davies, D. P. (1977). Failure to thrive at the breast: An old problem revisited. Archives of Disease in Childhood, 52, 974.
Fee, M., Charney, E., & Robertson, W. (1988). Nutritional assessment of the young child with cerebral palsy. Infants and Young Children, 1(1). 33-40.
Field, T., Ignaroff, E., Stringer, S., Brennan, J., Greenberg, R., Widmayer, S., & Anderson, G. (1982). Nonnutritive sucking during tube feedings: Effects on preterm neonates in an intensive care unit. Pediatrics, 70(3), 381-384.
Fletcher, S. (1970). Processes and maturation of mastication and deglutition. ASHA Reports, 5, 92-105.
Fucile, S., Gisel, E., & Lau, C. (2002). Oral stimulation accelerates the transition from tube to oral feeding in preterm infants. Journal of Pediatrics, 141(2), 230-236.
Fucile, S., Wright, P. M., Chan, I., Yee, S., Langlais, M., & Gisel, E. G. (1998). Functional oral-motor skills: Do they change with age? Dysphagia, 13, 195-201.
Gisel, E. G. (1988). Chewing cycles in 2- to 8-year-old normal children : A developmental profile. The American Journal of Occupational Therapy, 42, 40.
Gisel, E. G. (1988). Development of oral side preference during chewing and its relation to hand preference in normal 2- to 8-year-old children. The American Journal of Occupational Therapy, 42, 378.
Gisel, E. G. (1991). Effect of food texture on development of chewing in children 6 months to 2 years of age. Developmental Medicine and Child Neurology, 33, 69.
Gisel, E. G., & Pollock, N. A. (1988). Eating skills: A review of current assessment practices. Occupational Therapy Journal Research, 8, 38.
Green, J. R., Moore, C. A., Ruark, J. L., Rodda, P. R., Morvee, W. T., & Van Witzenburg, M. J. (1997). Development of chewing in children from 12 to 48 months: Longitudinal study of EMG patterns. Journal of Neurophysiology, 77, 2704-2716.
Gryboski, J. D. (1969). Suck and swallow in the premature infant. Pediatrics, 43, 96.
Hanson, M., & Cohen, M. (1973). Effects of form and function on swallowing and the developing dentition. American Journal of Orthodontics, 64, 63-82.
Hirano, K., Hirano, S., & Hayakawa, I. (2004). The role of oral sensorimotor function in masticatory ability. Journal of Oral Rehabilitation, 31(3), 199-205.
Humphrey, R. (1991). Impact of feeding problems on the parent-infant relationship. Infants and Young Children, 3(3). 30-38.
Illingsworth, R. (1969). Sucking and swallowing difficulties in infancy: Diagnostic problems of dysphagia. Archives of Disease in Childhood, 44, 655-665.
Illingworth, R. S., & Lister, J. (1964). The critical or sensitive period, with special reference to certain feeding problems in infants and children. The Journal of Pediatrics, 65(6), 839-848.
Jain, L. Sivieri, E., Abbasi, S., & Bhutani, V. K. (1987). Energetics and mechanics of nutritive sucking in the preterm and term neonate. Journal of Pediatrics, 111, 894-898.
Judd, P., Kenny, D., Koheil, R., Milner, M., & Moran, R. (1989). The multidisciplinary feeding profile: A statistically based protocol for assessment of dependent feeders. Dysphagia, 4(1). 29-34.
Kennedy, J., & Kent, R. (1985). Anatomy and physiology of deglutition and related functions. Seminars in Speech and Language, 6(4). 257-273.
Kenny, D., Koheil, R., Greenberg, J., Reid, D., Milner, M., Moran, R., & Judd, P. (1989). Development of a multidisciplinary feeding profile for children who are dependent feeders. Dysphagia, 4(1), 16-28.
Kramer, S. S., & Eicher, P. M. (1993). The evaluation of pediatric feeding abnormalities. Dysphagia, 8, 215-224.
Krick, J., & Van Duyn, M. (1984). The relationship between oral-motor involvement and growth: A pilot study in a pediatric population with cerebral palsy. Journal of the American Dietetic Association, 84(5), 555-559.
Kumin, L., & Bahr, D. C. (1999). Patterns of feeding, eating, and drinking in young children with Down syndrome with oral motor concerns. Down Syndrome Quarterly, 4(2), 1-8.
Kumin, L., Von Hagel, K. C., & Bahr, D. C. (2001). An effective oral motor intervention protocol for infants and toddlers with low muscle tone. Infant-Toddler Intervention, 11(3-4), 181-200.
Lawrence, R. (Ed.). (1987). Breastfeeding. Clinics in Perinatology, 14(1).
Leeuw, R. D., Colin, E. M., Dunnebier, E. A., & Mirmiran, M. (1991) Physiological effects of kangaroo care in very small preterm infants, Biology of the Neonate, 59(3), 149-155.
Love, R. J., Hagerman, E. L., & Tiami, E. G. (1980). Speech performance, dysphagia, and oral reflexes in cerebral palsy. Journal of Speech and Hearing Disorders, 45, 59-75.
Maller, O., & Turner, R. E. (1973). Taste in acceptance of sugars in human infants. Journal of Comparative Physiology, 84, 496-501.
Matthew, O. P., & Bhatia, J. (1989). Sucking and breathing patterns during breast- and bottle-feeding in term neonates. American Journal of Disease in Children, 143, 588-592.
Matthews, C. L., (1994). Supporting suck-swallow-breath coordination during nipple feeding. American Journal of Occupational Therapy, 48(6). 561-562.
McCoy, R., Kadowaki, C., Wilks, S., Engstrom, J. & Meier, P. (1988). Nursing management of breast feeding for preterm infants. The Journal of Perinatal & Neonatal Nursing, 2(1), 42-55.
Measel, C. P., & Anderson, G. C. (1980). Non-nutritive sucking during tube feeding: Effect on clinical course in premature infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 8, 265.
Meier, P. (1980). A program to support breast-feeding in the special care nursery. Perinatology/Neonatology, 4, 43.
Meier, P., & Anderson, G. C. (1987). Responses of small preterm infants to bottle and breast feeding. MCN. The American Journal of Maternal Child Nursing, 12, 97.
Meier, P., & Pugh, E. (1985). Breast feeding behavior in small preterm infants. MCN. The American Journal of Maternal Child Nursing, 10, 396.
Mizuno, K., & Ueda, A. (2001). Development of sucking behavior in infants who have not been fed for 2 months after birth. Pediatrics International, 43(3). 251-255.
Morris, S. E. (1985). Developmental implications for the management of feeding problems in neurologically impaired infants. Seminars in Speech and Language, 6(4), 293-315.
Morris, S. E. (1987). Therapy for the child with cerebral palsy: Interacting frameworks. Seminars in Speech and Language, 8(1), 71-86.
Morris, S. E. (1989). Development of oral-motor skills in the neurologically impaired child receiving non-oral feedings. Dysphagia, 3(3). 135-154.
Moore, C. A., & Ruark, J. L. (1996). Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research, 39, 1034-1047.
Ogawa, T., Ogawa, M., & Koyano, K. (2001). Different responses of masticatory movements after alteration of occlusal guidance related to individual movement pattern. Journal of Oral Rehabilitation, 28(9), 830-841.
Ogg, M. A. (1975). Oral-pharyngeal development and evaluation. Physical Therapy, 55, 235-241.
Ostry, D. J., & Flanagan, J. R. (1989). Human jaw movement in mastication and speech. Archives of Oral Biology, 34, 685-693.
Paludetto, A. R., Robertson, S. S., & Martin, R. J. (1986). Interaction between non-nutritive sucking and respiration in preterm infants. Biology of the Neonate, 49, 198.
Patrick, J., & Gisel E. G. (1990). Nutrition for the feeding-impaired child. Journal of Neurologic Rehabilitation, 4, 115.
Reilly, S., Skuse, D., Mathisen, M. & Wolke, D. (1995). The objective rating of oral-motor functions during feeding. Dysphagia, 10, 177-191.
Riski, J. E. (2007). Feeding the infant born with cleft lip/palate: A literature review. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) American Speech-Language-Hearing Association Division 13, 16(3), 12-17.
Rocha, A. D., Moreira, M. E. L., Pimenta, H. P., Ramos, J. R. M , & Lucena, S. L. A. (2007). Randomized study of the efficacy of sensory-motor-oral stimulation and non-nutritive sucking in very low birthweight infants. Early Human Development, 83(6), 385-388.
Ruark J. L., & Moore, C. A. (1997). Coordination of lip muscle activity by 2-year-old children during speech and nonspeech tasks. Journal of Speech, Language, and Hearing Research, 40, 1373-1385.
Rudolph, C. D. (1994). Feeding disorders in infants and children. The Journal of Pediatrics, 125, S116.
Rybski, D. A., Almli, R. C., & Gisel, E. G. (1984). Sucking behaviours of normal 3-day-old female neonates during a 24-hour period. Developmental psychobiology, 17, 70.
Rybski, D. A. , & Gisel, E. G. (1984). Optimal and sub-optimal feeding behaviors of neonates. Physical & Occupational Therapy in Pediatrics, 4, 37.
Sameroff, A. J. (1968). The components of sucking in the human newborn. Journal of Experimental Child Psychology, 6, 607-623.
Schwartz, J., Niman, C., & Gisel, E. (1984). Tongue movements in normal preschool children during eating. American Journal of Occupational Therapy, 38(2), 87-93.
Selley, W. G., Ellis, R. E., Flack, F. C., & Brooks, W. A. (1990). Coordination of sucking, swallowing, and breathing in the newborn: Its relationship to infant feeding and normal development. The British Journal of Disorders of Communication, 2(3)5, 311-327.
Spender, Q., Dennis, J., Stein, A., Cave, D., Percy, E., & Reilly, S. (1995). Impaired oral-motor function in children with Down’s syndrome: A study of three twin pairs. European Journal of Disorder of Communication, 30, 77-87.
Spender, Q., Stein, A., Dennis, J., Reilly, S., Percy, E., & Cave, D. (1996). An exploration of feeding difficulties in children with Down syndrome. Developmental Medicine and Child Neurology, 38, 681-694.
Stolovitz, P., & Gisel, E. G. (1991). Circumoral movements in response to three different food textures in children six months to two years of age. Dysphagia, 6, 17.
Takagi, Y, Irwin, J. V., & Bosma, J. F. (1966). Prone feeding of infants with Pierre Robin syndrome. The Cleft Palate Journal, 3, 232.
Tuchman, D. N. (1989). Cough, choke, sputter: The evaluation of the child with dysfunctional swallowing. Dysphagia, 3, 111-116.
Tucker, J. A. (1985). Perspectives on the development of the air and food passages. American Review of Respiratory Diseases, 131, S7-S9.
Weber, F. M., Woolridge, W., & Baum, J. D. (1986). An ultrasonographic study of the organization of sucking and swallowing by newborn infants. Developmental Medicine and Child Neurology, 28, 19-24.
Widstrom, A. M., Marchini, G., Matthiesen, A. S., Werner, S., Winberg, J., & Uvnas-Moberg, K. (1988). Non-nutritive sucking in tube fed preterm infants: Effects on gastric motility and gastric contents of somatostatin. Journal of Pediatric Gastroenterology and Nutrition, 7(4), 517-523.
Wolff, P. H. (1968). The serial organization of sucking in the young infant. Pediatrics, 42, 943-955.
Ziev, M. S. R. (1999). Earliest intervention: Speech-Language pathology services in the neonatal intensive care unit. Asha, 41(3), 32-36.

FEEDING/EATING/DRINKING (ADULT)

Beidler, L. M., & Smallman, R. L. (1965). Renewal of cells within taste buds. Journal of Cellular Biology, 27(2), 263-272.
Hargrove, R. (1980). Feeding the severely dysphagic patient. Journal of Neurosurgical Nursing, 12(2), 102-107.
Hirano, K., Hirano, S., & Hayakawa, I. (2004). The role of oral sensorimotor function in masticatory ability. Journal of Oral Rehabilitation, 31(3), 199-205.
Judd, P., Kenny, D., Koheil, R., Milner, M., & Moran, R. (1989). The multidisciplinary feeding profile: A statistically based protocol for assessment of dependent feeders. Dysphagia, 4(1). 29-34.
Kennedy, J., & Kent, R. (1985). Anatomy and physiology of deglutition and related functions. Seminars in Speech and Language, 6(4). 257-273.
Miller, A. J. (1982). Deglutition. Physiological Reviews, 63, 129.
Murray, J. P. (1962). Deglutition in myasthenia gravis. The British Journal of Radiology, 35, 43.
Ogawa, T., Ogawa, M., & Koyano, K. (2001). Different responses of masticatory movements after alteration of occlusal guidance related to individual movement pattern. Journal of Oral Rehabilitation, 28(9), 830-841.
Ostry, D. J., & Flanagan, J. R. (1989). Human jaw movement in mastication and speech. Archives of Oral Biology, 34, 685-693.
Pelletier, C. A. (2004). What do certified nurse assistants actually know about dysphagia and feeding nursing home residents? American Journal of Speech-Language Pathology, 13(2), 99-113.
Ramsey, W. O. (1986). Suckle facilitation of feeding in selected adult dysphagic persons. Dysphagia, 1, 7.
Robbins, J. (1992). The impact of oral motor dysfunction on swallowing: From beginning to end. Seminars in Speech and Language, 13(1), 55-69.

ORAL ACTIVITIES/EXERCISES RELATED TO ORAL MOTOR FUNCTION

Ansel, B. M.,Windsor, J., & Stark, R. E. (1992). Oral volitional movements in children: An approach to assessment. Seminars in Speech and Language, 13(1), 1-13.
Barlow, S. M., & Abbs. J. H. (1983). Force transducers for the evaluation of labial, lingual, and mandibular function in dysarthria. Journal of Speech and Hearing Research, 26, 616-621.
Beckman, D., Neal, C., Phirsichbaum, J., Stratton, L., Taylor, V., & Ratusnik, D. (2004). Range of movement and strength in oral motor therapy: A retrospective study. Florida Journal of Communication Disorders, 21, 7-14.
Clark, G. T., & Carter, M. C. (1985). Electromyographic study of human jaw closing muscle endurance, fatigue, and recovery at various isometric force levels. Archives of Oral Biology, 30, 563-569.
Clark, H. M., Robin, D. A., McCullagh, G., & Schmidt, R. A. (2001). Motor control in children and adults during a non-speech oral task. Journal of Speech, Language, and Hearing Research, 44, 1015-1025.
Collumbine, H., Bibile, S. W., Wikramanayake, T. W., & Watson, R. S. (1950). Influence of age, sex, physique, and muscular development on physical fitness. Journal of Applied Physiology, 2, 488-511.
Dewey, D., Roy, E. A., Square-Storer, P. A., & Hayden, D. (1988). Limb and oral praxic abilities of children with verbal sequencing deficits. Developmental Medicine and Child Neurology, 30, 743-751.
Dworkin, J. P. (1996). Bite block therapy of oromandibular dystonia. Journal of Medical Speech-Language Pathology, 4, 47-56.
Dworkin, J. P., & Aronson, A. E. (1986). Tongue strength and alternate motion rates in normal and dysarthric subjects. Journal of Communication Disorders, 19, 115-132.
Dworkin, J. P., Aronson, A. E., & Mulder, D. W. (1980). Tongue strength in normal subjects and dysarthric patients with amyotrophic lateral sclerosis. Journal of Speech and Hearing Research, 23, 828-837.
Enoka, R. M., & Stuart, D. G. (1985). The contribution of neuroscience to exercise studies. Federation Proceedings, 44(7), 2279-2285.
Forrest, K. (2002). Are oral-motor exercises useful in the treatment of phonological/articulatory disorders? Seminars in Speech and Language, 23, 15-26.
Gandevia, S. C., (1982). The perception of motor commands or effort during muscular paralysis. Brain, 105, 151-159.
Hiyama, S., Iwamoto, S., Ono, R., Ishiwata, Y. & Kuroda, T. (2000). Genioglossus muscle activity during rhythmic open-close jaw movements. Journal of Oral Rehabilitation, 27(8), 664-670.
Iverson, J. M., Hall, A. J., Nickel, L., & Wozniak, R. H. (2007). The relationship between reduplicated babble onset and laterality in infant rhythmic arm movements. Brain and Language, 101(3), 198-207.
Junge, D., & Clark, G. T. (1993). Electromyographic turns analysis of sustained contraction in human masseter muscles at various isometric force levels. Archives of Oral Biology, 38, 583-588.
Kohno, S., Matsuyama, T., Medina, R. U., & Arai, Y.(2001). Functional-rhythmical coupling of head and mandibular movements. Journal of Oral Rehabilitation, 28(2), 161-167.
Koller, W., & Kase, S. (1986). Muscle strength testing in Parkinson’s disease. European Neurology, 25, 130-133.
Kumin, L., Von Hagel, K. C., & Bahr, D. C. (2001). An effective oral motor intervention protocol for infants and toddlers with low muscle tone. Infant-Toddler Intervention, 11(3-4), 181-200.v
Larsson , L., & Karlsson, J. (1978) Isometric and dynamic endurance as a function of age and skeletal muscle characteristics. Acta Physiologica Scandinavia, 104, 129-136.
McHenry, M. A., Minton, J. T., Wilson, R. L., & Post, Y. V. (1994). Intelligibility and nonspeech orofacial strength and force control following traumatic brain injury. Journal of Speech and Hearing Research, 37, 1271-1283.
Moore, C. A. (1993). Symmetry of mandibular muscle activity as an index of coordinative strategy. Journal of Speech and Hearing Research, 31, 670-680.
Moore, C. A., Caulfield, T. J., & Green J. R. (2001). Relative kinematics of the rib cage and abdomen during speech and nonspeech behaviors of 15-month-old children. Journal of Speech, Language, and Hearing Research, 44, 80-94.
Murdoch, B. E., Attard, M. D., Ozanne, A. E., & Stokes, P. D. (1995). Impaired tongue strength and endurance in developmental verbal dyspraxia: A physiological analysis. European Journal of Disorders of Communication, 30, 51-64.
Miyaoka, S, Hirano, H., Miyaoka, Y, & Yamada, Y. (2004). Head movement associated with performance of mandibular tasks. Journal of Oral Rehabilitation, 31(9), 843-850.
Netsell, R., Daniel, B., & Celesia, G. G. (1975). Acceleration and weakness in parkinsonian dysarthria. Journal of Speech and Hearing Disorders, 40, 170-078.
Palmer, M. F., & Osborn, C. D. (1940). A study of tongue pressures of speech defective and normal speaking individuals. Journal of Speech Disorders, 52, 133-140.
Petrofsky, J. S., & Lind, A. R. (1975). Isometric strength, endurance, and the blood pressure and heart rate responses during isometric exercise in healthy men and women with special reference to age and body fat content. Pflugers Archive: European Journal of Physiology, 360, 49-61.
Robin, D. A., Goel, A., Somodi, L. B., & Luschei, E. S. (1992). Tongue strength and endurance: Relation to highly skilled movements. Journal of Speech and Hearing Research, 35, 1239-1245.
Robbins, J., Gangnon, R. E., Theis, S. M, Kays, S. A., Hewitt, A. L., & Hind, J. A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53(9), 1483-1489.
Robbins, J., Kays, S. A., Gangnon, R. E., Hind, J. A., Hewitt, A. L., Gentry, L., R., & Taylor, A. J. (2007). The effects of lingual exercise in stroke patients with dysphagia. Archives of Physical Medicine and Rehabilitation, 88(2), 150-158.
Roy, R. R., Baldwin, K. M., & Edgerton, V. R. (1991). The plasticity of skeletal muscle: Effects of neuromuscular activity. Exercise and Sport Sciences Reviews, 19, 269-312.
Scheerer, C. R. (1992). Perspectives on an oral motor activity: The use of rubber tubing as a “chewy.” The American Journal of Occupational Therapy, 46, 344-352.
Scott, B. J., Mason, A. G., & Cadden, S. W. (2002). Voluntary and reflex control of the human temporalis muscle. Journal of Oral Rehabilitation, 29(7), 634-643.
Sgobbi De Faria, C. R., & Berzin, F. (1998). Electromyographic study of the temporalis, masseter, and suprahyoid muscles in the mandibular rest position. Journal of Oral Rehabilitation, 25(10). 776.
Solomon, N. P., Lorell, C. M., Robin, D. A., Rodnitzky, R. L., & Luschei, E., S. (1995). Tongue strength and endurance in mild to moderate Parkinson’s disease. Journal of Medical Speech-Language Pathology, 3, 15-26.
Tamura, T., Kanayama, T., Yoshida, S., & Kawasake, T. (2003). Functional magnetic resonance imaging of human jaw movements. Journal of Oral Rehabilitation, 30(6), 614-622.
Uchida, S., Inoue, H., & Maeda, T. (1999). Electromyographic study of the activity of jaw depressor muscles before initiation of opening movements. Journal of Oral Rehabilitation 26(6), 503-510.
Wang, M. Q., Yan, C. Y., & Yuan, Y. P. (2001). Is the superior belly of the lateral pterygoid primarily a stabilizer? An EMG study. Journal of Oral Rehabilitation, 28(6), 507-510.
Watanabe, K. (2000). The relationship between dentofacial morphology and the isometric jaw-opening and closing muscle function as evaluated by electromyography. Journal of Oral Rehabilitation, 27(7), 639-345.
Wood, L. M., Hughes, J., Hayes, K. C., & Wolfe, D. L. (1992). Reliability of labial closure force measurement in normal subjects and patients with CNS disorders. Journal of Speech and Hearing Research, 35, 252-258.
Yanagawa, S., Shindo, M., & Yanagisawa, N. (1990). Muscular weakness in Parkinson’s disease. Advances in Neurology, 53, 259-269.

MYOFUNCTIONAL THERAPY

NOTE: Many more references found in the International Journal of Orofacial Myology and some other journals.

Fletcher, S., Casteel, R., & Bradley, D. (1961). Tongue thrust swallow, speech articulation, and age. Journal of Speech and Hearing Disorders, 26, 219-225.
Graber, T. (1976). For want of T-L-C. International Journal of Oral Myology, 2, 7-12.
Hanson, M., & Cohen, M. (1973). Effects of form and function on swallowing and the developing dentition. American Journal of Orthodontics, 64, 63-82.
Hayasaki, H., Yamasaki, Y., Nishijima, N., Naruse, K.. & Nakata, M. (1998). Characteristics of protrusive and lateral excursions of the mandible in children with the primary dentition. Journal of Oral Rehabilitation, 25(4), 311-320.
Meyer, P. G. (2000). Tongue, lip, and jaw differentiation and its relationship to orofacial myofunctional treatment. International Journal of Orofacial Myology, 26, 44-52.
Miyaoka, S, Hirano, H., Miyaoka, Y, & Yamada, Y. (2004). Head movement associated with performance of mandibular tasks. Journal of Oral Rehabilitation, 31(9), 843-850.
Ogawa, T., Ogawa, M., & Koyano, K. (2001). Different responses of masticatory movements after alteration of occlusal guidance related to individual movement pattern. Journal of Oral Rehabilitation, 28(9), 830-841.
Page, D. C. (1999). The new dental-medical renaissance: Medically efficacious functional jaw orthopedics. The Functional Orthodontist: A Journal of Functional Jaw Orthopedics, 16(1), 16-25.
Paskay, L. C. (2006). Instrumentation and measurement procedures in orofacial myology. International Journal of Orofacial Myology, 32, 37-57.
Ray, J. (2006). Orofacial myofunctional deficits in elderly individuals. International Journal of Orofacial Myology, 32, 22-31.
Verrastro, A. P., Stefani, F. M., Rodrigues, C. R., & Wanderly, M. T. (2006). Occlusal and orofacial myofunctional evaluation in children with primary dentition, anterior open bite and pacifier sucking habit. International Journal of Orofacial Myology, 32, 7-21.

SWALLOWING (PEDIATRIC)

NOTE: See “Feeding” resources above for more information on the “Oral Phase” of swallowing. Also see Dysphagia journal and Perspectives on Swallowing and Swallowing Disorders (Dysphagia) American Speech-Language-Hearing Association Division 13.

Alper, B. S., & Manno, C. J. (1996). Dysphagia in infants and children with oral-motor deficits: Assessment and management. Seminars in Speech and Language, 17, 283-309.
Ardran, G., & Kemp, F. (1970). Some important factors in the assessment of oropharyngeal function. Developmental Medicine and Child Neurology, 12, 158-166.
Bu’Lock, F., Woolridge, M., & Baum, J. (1990). Development of co-ordination of sucking, swallowing, and breathing: Ultrasound study of term and preterm infants. Developmental Medicine and Child Neurology, 32, 669-678.
Catto-Smith, A. G., Machida, H., Butzner, J. D., Gall, D. G., & Scott, R. B. (1991). The role of gastroesophageal reflux in pediatric dysphagia. Journal of Pediatric Gastroenterology and Nutrition, 12(2), 159-165.
Dahlquist, L. M., & Blount, R. L. (1984). Teaching a six-year-old girt to swallow pills. Journal of Behavior Therapy and Experimental Psychiatry, 15, 171-173.
Fisher, S. E., Painter, M., & Milmoe, G. (1981). Swallowing disorders in infancy. Pediatric Clinics of North America, 28(4). 845-853.
Frazier, J. B., & Friedman, B. (1996). Swallow function in children with Down syndrome: A retrospective study. Developmental Medicine and Child Neurology, 38, 695-703.
Hanson, M., & Cohen, M. (1973). Effects of form and function on swallowing and the developing dentition. American Journal of Orthodontics, 64, 63-82.
Jean, A. (1984). Brainstem organization of the swallowing network. Brain Behavior, 25, 109-116.
Kenny, D., Casas, M., & McPherson, K. (1989). Correlation of ultrasound imaging of oral swallow with ventilatory alterations in cerebral palsied and normal children: Preliminary observations. Dysphagia, 4(2), 112-117.
Kramer, S. Special swallowing problems in children. (1985). Gastrointestinal Radiology, 10, 241-250.
Kramer, S. (Ed.). (1989). Proceedings of the pediatric presentation at the second dysphagia symposium, Johns Hopkins Hospital, March 10-11, 1988 [Special issue]. Dysphagia, 3(3).
Larson, C. (1985). Neurophysiology of speech and swallowing. Seminars in Speech and Language, 6(4), 275-291.
Logan, W. J., & Bosma, J. F. (1967). Oral and pharyngeal dysphagia in infants. Pediatric Clinics of North America, 14, 47.
Love, R. J., Hagerman, E. L., & Tiami, E. G. (1980). Speech performance, dysphagia, and oral reflexes in cerebral palsy. Journal of Speech and Hearing Disorders, 45, 59-75.
Miller, A. J. (1972). Significance of sensory inflow to the swallowing reflex. Brain Research, 43, 147-159.
Mizuno, K., & Ueda, A. (2001). Development of sucking behavior in infants who have not been fed for 2 months after birth. Pediatrics International, 43(3), 251-255.
Ogawa, T., Ogawa, M., & Koyano, K. (2001). Different responses of masticatory movements after alteration of occlusal guidance related to individual movement pattern. Journal of Oral Rehabilitation, 28(9), 830-841.
Ogg, M. A. (1975). Oral-pharyngeal development and evaluation. Physical Therapy, 55, 235-241.
Ostry, D. J., & Flanagan, J. R. (1989). Human jaw movement in mastication and speech. Archives of Oral Biology, 34, 685-693.
Robbins, J., & Klee, T. (1987). Clinical assessment of orophayngeal motor development in young children. Journal of Speech and Hearing Disorders, 52, 271-277.
Sivit, C. (1990). The role of the pediatric radiologist in the evaluation of oral and pharyngeal dysphagia. Journal of Neurologic Rehabilitation, 4, 103.
Sochaniwskyj, A., Koheil, R., Baablich, K., Milner, M., & Kenny, D. (1986). Oral motor functioning, frequency of swallowing, and drooling in normal children and in children with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 67, 866-874.
Tuchman, D. N. (1989). Cough, choke, sputter: The evaluation of the child with dysfunctional swallowing. Dysphagia, 3, 111-116.
Weber, F. M., Woolridge, W., & Baum, J. D. (1986). An ultrasonographic study of the organization of sucking and swallowing by newborn infants. Developmental Medicine and Child Neurology, 28, 19-24.
Woody, R. C., & Kiel, E. A. (1968). Swallowing syncope in a child. Pediatrics, 78, 507.

SWALLOWING (ADULT)

Bisch, E. M., Logemann, J. A., Rademaker, A. W., Kahrilas, P. J., & Lazarus, C. L. (1994). Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia resulting from neurologic impairment and normal subjects. Journal of Speech and Hearing Research, 37(5), 1041-1059.
Buchholz, D., Bosma, J., & Donner, M. (1985). Adaptation, compensation, and decompensation of the pharyngeal swallow. Gastrointestinal Radiology, 10, 235-239.
Castell, D., & Conner, M. (1987). Evaluation of dysphagia: A careful history is crucial. Dysphagia, 2(2), 65-71.
Fucile, S., Wright, P. M., Chan, I., Yee, S., Langlais, M., & Gisel, E. G. (1998). Functional oral-motor skills: Do they change with age? Dysphagia, 13, 195-201.
Hargrove, R. (1980). Feeding the severely dysphagic patient. Journal of Neurosurgical Nursing, 12(2), 102-107.
Jean, A. (1984). Brainstem organization of the swallowing network. Brain Behavior, 25, 109-116.
Kaplan, P. R., & Evans, I. M. (1978), A case of functional dysphagia treated on the model of fear of fear. Journal of Behavior Therapy and Experimental Psychiatry, 9, 71-72.
Kasprisin, A. Clumeck, H., & Nino-Murcia, M. (1989). The efficacy of rehabilitative management of dysphagia. Dysphagia, 4(1), 48-52.
Kennedy, J., & Kent, R. (1985). Anatomy and physiology of deglutition and related functions. Seminars in Speech and Language, 6(4). 257-273.
Larson, C. (1985). Neurophysiology of speech and swallowing. Seminars in Speech and Language, 6(4), 275-291.
Lazzara, G. D., Lazarus, C., & Logemann, J. A. (1986). Impact of thermal stimulation on the triggering of the swallowing reflex. Dysphagia, 1, 73.
Logemann, J. A. (1985). The relationship of speech and swallowing in head and neck surgical patients. Seminars in Speech and Language, 6(4), 351-359.
Logemann, J. A., Pauloski, B. R., Colangelo, L., Lazarus, C., Fujiu, M., & Kahrilas, P. J. (1995). Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia. Journal of Speech and Hearing Research, 38(3), 556-563.
McNally, R. J. (1986). Behavioral treatment of a choking phobia. Journal of Behavioral Therapy and Experimental Psychiatry, 17, 185-188.
Miller, A. J. (1972). Significance of sensory inflow to the swallowing reflex. Brain Research, 43, 147-159.
Ogawa, T., Ogawa, M., & Koyano, K. (2001). Different responses of masticatory movements after alteration of occlusal guidance related to individual movement pattern. Journal of Oral Rehabilitation, 28(9), 830-841.
Ostry, D. J., & Flanagan, J. R. (1989). Human jaw movement in mastication and speech. Archives of Oral Biology, 34, 685-693.
Pelletier, C. A. (2004). What do certified nurse assistants actually know about dysphagia and feeding nursing home residents? American Journal of Speech-Language Pathology, 13(2), 99-113.
Ramsey, W. O. (1986). Suckle facilitation of feeding in selected adult dysphagia patients. Dysphagia, 1, 7.
Robbins, J. (1985). Swallowing and speech problems in the neurologically impaired adult. Seminars in Speech and Language, 6(4), 337-350.
Robbins, J. (1992). The impact of oral motor dysfunction on swallowing: From beginning to end. Seminars in Speech and Language, 13(1), 55-69.
Robbins, J. (2002). The current state of clinical geriatric dysphagia research. Journal of Rehabilitation Research and Development, 39(4), vii-ix.
Robbins, J. (2006). New frontiers in dysphagia rehabilitation. Seminars in Speech and Language, 27(4), 217-218.
Robbins, J., Gangnon, R. E., Theis, S. M, Kays, S. A., Hewitt, A. L., & Hind, J. A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53(9), 1483-1489.
Robbins, J., Kays, S. A., Gangnon, R. E., Hind, J. A., Hewitt, A. L., Gentry, L., R., & Taylor, A. J. (2007). The effects of lingual exercise in stroke patients with dysphagia. Archives of Physical Medicine and Rehabilitation, 88(2), 150-158.
Rosenbek, J. C., Robbins, J., Fishback, B., & Levine, R. L. (1991). Effect of thermal application on dysphagia after stroke. Journal of Speech and Hearing Research, 34(6), 1257-1268.
Solyom, L., & Sookman, D. (1980). Fear of choking and its treatment. Canadian Journal of Psychiatry, 25, 30-34.
Strand, E. A., Miller, R. M., Yorkston, K. M., & Hillel, A. D. (1996). Management of oral-pharyngeal dysphagia symptoms in amyotrophic lateral sclerosis. Dysphagia, 11, 129.
Wilson, S. L., Thach, B. T., Brouillette, R. T., & Abu-Osba, Y. K. (1981). Coordination of breathing and swallowing. Journal of Applied Physiology, 50(4), 851-858.

MOTOR SPEECH (PEDIATRIC)

Adler-Bock, M., Bernhardt, B. M., Gick, B., & Bacsfalvi, P. (2007). The use of ultrasound in remediation of North American English /r/ in 2 Adolescents. American Journal of Speech-Language Pathology, 16(2), 128-139.
Alexander, R. (1987). Oral-motor treatment for infants and young children with cerebral palsy. Seminars in Speech and Language, 8(1). 87-100.
Barry, R. M. (1995). A comparative study of the relationship between dysarthria and verbal dyspraxia in adults and children. Clinical Linguistics and Phonetics, 9, 311-312.
Barry, R. M. (1995). The relationship between dysarthria and verbal dyspraxia in children: A comparative study using profiling and instrumental analyses. Clinical Linguisics and Phonetics, 9, 277-309.
Bashina, V. M., Simashkova, N. V., Grachev, V. V., & Gorbachevskaya, N. L. (2002). Speech and motor disturbances in Rett syndrome. Neuroscience and Behavioral Physiology, 32, 323-327.
Bashir, A., Graham-Jones, F., & Bostwick, R. (1984). A touch cue method of therapy for developmental verbal apraxia. Seminars in Speech and Language, 5, 127-138.
Bateson, E., & Ostry, D. (1995). An analysis of the dimensionality of jaw movement in speech. Journal of Phonetics, 23, 101-117.
Belton, E., Salmond, C. H., Watkins, K. E., Vargha-Khadem, F., & Gadian, D. G. (2003). Bilateral brain abnormalities associated with dominantly inherited verbal orofacial dyspraxia. Human Brain Mapping, 18, 194-200.
Boysson-Bardies, B. D., Sagart, L., & Bacri, N. (1981). Phonetic analysis of late babbling: A case study of a French child. Journal of Child Language, 8, 511-524.
Boysson-Bardies, B. D., & Vihman, M. M. (1991). Adaptation to language: Evidence from babbling and first words in four languages. Language, 67, 297-319.
Chumpelik (Hayden), D. (1984). The PROMPT system of therapy: Theoretical framework and applications for developmental apraxia of speech. Seminars in Speech and Language, 5, 139-156.
Cobo-Lewis, A. B., Oller, K. D., Lynch, M. P., Levine, S. L. (1996). Relations of motor and vocal milestones in typically developing infants and infants with Down syndrome. American Journal of Mental Retardation, 100(5), 456-467.
Conrad, B., & Schonle, P. (1979). Speech and respiration. Archives of Psychiatry and Neurological Services, 226, 251-268.
Crary, M. A. (1995). Clinical evaluation of developmental motor speech disorders. Seminars in Speech and Language, 16, 110-125.
Davis, B., & MacNeilage, P. (1995). The articulatory basis of babbling. Journal of Speech and Hearing Research, 38, 1199-1211.
Davis, B., & Velleman, S. L. (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers. Infant-Toddler Intervention: The Transdisciplinary Journal, 10, 177-192.
Davis, L. (1987). Respiration and phonation in cerebral palsy: A developmental model. Seminars in Speech and Language, 8(1), 101-106.
Dewey, D., Roy, E. A., Square-Storer, P. A., & Hayden, D. (1988). Limb and oral praxic abilities of children with verbal sequencing deficits. Developmental Medicine and Child Neurology, 30, 743-751.
Edwards, J. (1985). Contextual effects on lingual-mandibular coordination. Journal of the Acoustical Society of America, 78, 1944-1948.
Flipsen, P., Jr., Hammer, J. B., & Yost, K. M. (2005). Measuring severity of involvement in speech delay: Segmental and whole-word measures. American Journal of Speech-Language Pathology, 14(4), 298-312.
Forrest, K. (2002). Are oral-motor exercises useful in the treatment of phonological/articulatory disorders? Seminars in Speech and Language, 23, 15-26.
Gay, T. (1974). Jaw movements during speech: A cinefluorographic investigation. Haskins Laboratories. Status Report on Speech Research, 39140, 219-229.
Gibbon, F., Stewart, F., Hardcastle, W. J., & Crampin, L. (1999). Widening access to eletropalatography for children with perisistent sound system disorders. American Journal of Speech-Language Pathology, 8, 319-334.
Gracco, V. L. (1994). Some organizational characteristics of speech movement control. Journal of Speech, Language, and Hearing Research, 37, 4-27.
Gracco, V. L., & Abbs, J. H. (1986). Variant and invariant characteristics of speech movements. Experimental Brain Research, 65, 156-166.
Gracco, V. L., & Lofqvist, A. (1994). Speech motor coordination and control: Evidence from lip, jaw, and laryngeal movements. Journal of Neuroscience, 14, 6585-6597.
Green, J. R., Moore, C. A., Higashikawa, M., & Steeve, R. W. (2000). The sequential development of jaw and lip control for speech. Journal of Speech, Language, and Hearing Research, 45, 66-79.
Green, J. R., Moore, C. A., & Reilly, K. J. (2002). The physiologic development of speech motor control: Lip and jaw coordination. Journal of Speech, Language, and Hearing Research, 43, 239-255.
Hayden, D. A., & Square, P. A. (1994). Motor speech treatment hierarchy: A systems approach. Clinics in Communication Disorders, 4, 151-161.
Hertrich, I., & Ackermann, H. (2000). Lip-jaw and tongue-jaw coordination during rate-controlled syllable repetitions. Journal of the Acoustical Society of America, 107, 2236-2247.
Hughes, O. M., & Abbs, J. H. (1976). Labial-mandibular coordination in the production of speech: Implication for the operation of motor equivalence. Phonetica, 33, 199-221.
Iverson, J. M., Hall, A. J., Nickel, L., & Wozniak, R. H. (2007). The relationship between reduplicated babble onset and laterality in infant rhythmic arm movements. Brain and Language, 101(3), 198-207.
Kelso, J. A., Tuller, B., Vatikiotis-Bateson, E., & Fowler, C. A. (1984). Functionally specific articulatory cooperation following jaw perturbations during speech: Evidence for coordinative structures. International Journal of Experimental Psychology: Human Perception and Performance, 10, 812-832.
Kent, R. D. (2000). Research on speech motor control and its disorders: A review and prospective. Journal of Communication Disorders, 33, 391-428.
Kent, R. D., Netsell, R., Osberger, M. J., & Hustedde, C. G. (1987). Phonetic development in twins who differ in auditory function. Journal of Speech and Hearing Disorders, 52, 64-75.
Kumin, L. (1996). Speech and language skills in children with Down syndrome. Mental Retardation and Developmental Disabilities Research Reviews, 2, 109-116. Larson, C. (1985). Neurophysiology of speech and swallowing. Seminars in Speech and Language, 6(4), 275-291.
Lind, J., Wasz-Hockert, O., Vuorenkoski, V., & Valanne, E. (1965). The vocalization of a newborn brain-damaged child. Annales Paediatrica Fenniae, 11, 32-37.
Love, R. J., Hagerman, E. L., & Tiami, E. G. (1980). Speech performance, dysphagia, and oral reflexes in cerebral palsy. Journal of Speech and Hearing Disorders, 45, 59-75.
Maassen, B. (2002). Issues contrasting adult acquired versus developmental apraxia of speech. Seminars in Speech and Language, 23, 257-266.
Marshalla, P. R. (1985). The role of reflexes in oral-motor learning: Techniques for improved articulation. Seminars in Speech and Language, 6(4), 317-336.
Moore, C. A. (1993). Symmetry of mandibular muscle activity as an index of coordinative strategy. Journal of Speech and Hearing Research, 31, 670-680.
Moore, C. A., Caulfield, T. J., & Green J. R. (2001). Relative kinematics of the rib cage and abdomen during speech and nonspeech behaviors of 15-month-old children. Journal of Speech, Language, and Hearing Research, 44, 80-94.
Moore, C. A., & Ruark, J. L. (1996). Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research, 39, 1034-1047.
Muir, N. Y., Allard, G. B., & Greenburg, C. (1999). Oral language development in a child with Floating-Harbor syndrome. Language, Speech, and Hearing Services in Schools, 30, 207-211.
Murdoch, B. E., Attard, M. D., Ozanne, A. E., & Stokes, P. D. (1995). Impaired tongue strength and endurance in developmental verbal dyspraxia: A physiological analysis. European Journal of Disorders of Communication, 30, 51-64.
Mysak, E. (Ed.). (1978). Communication disorders of the cerebral palsied: Assessment and treatment. Seminars in Speech and Language, 8(1).
Oller, D. (1978). Infant vocalization and the development of speech. Allied Health and Behavioral Sciences, 1(4), 532-549.
Oller, D. K., & Eilers, R. E. (1988). The role of audition in infant babbling. Child Development, 59, 441-446.
Oller, D. K., Eilers, R. E., Neal, R., & Schwartz, H. (1999). Precursors to speech in infancy: The prediction of speech and language disorders. Journal of Communication Disorders, 32, 223-245.
Oller, D., Wieman, L., Doyle, W., & Ross, C. (1975). Infant babbling and speech. Journal of Child Language, 3, 1-11.
Ong, D., & Stone, M. (1998). Three-dimensional vocal tract shapes in /r/ and /l/: A study of MRI, ultrasound, electropalatography, and acoustics. Phonoscope, 1, 1-13.
Ostry, D. J., & Flanagan, J. R. (1989). Human jaw movement in mastication and speech. Archives of Oral Biology, 34, 685-693.
Pannbacker, M. (2004). Velopharyngeal incompetence: The need for speech standards. American Journal of Speech-Language Pathology, 13(3). 195-201.
Robin, D. A. (1992). Developmental apraxia of speech: Just another motor problem. American Journal of Speech-Language Pathology, 1, 19-22.
Rosenbek, J., Hansen, R., Baughman, C. H., & Lemme, M. (1974). Treatment of developmental apraxia of speech: A case study. Language, Speech, and Hearing Services in Schools, 5, 13-22.
Ruark J. L., & Moore, C. A. (1997). Coordination of lip muscle activity by 2-year-old children during speech and nonspeech tasks. Journal of Speech, Language, and Hearing Research, 40, 1373-1385.
Rvachew, S., Slawinski, E. G., Williams, M., & Green C. L. (1996). Formant frequencies of vowels produced by infants with and without early otitis media. Canadian Acoustics/Acoustique Canadienne, 24, 19-28.
Stark, R. (1978). Features of infant sounds: The emergence of cooing. Journal of Child Language, 5, 1-12.
Stoel-Gammon, C. (1997). Phonological development in Down syndrome. Mental Retardation and Developmental Disabilities Research Reviews, 3, 300-306.
Strand, E. (1995). Treatment of motor speech disorders in children. Seminars in Speech and Language, 16, 126-139.
Thoonen, G., Maassen, B., Gabreels, F., & Schreuder, R. (1999). Validity of maximum performance tasks to diagnose motor speech disorders in children. Clinical Linguistics and Phonetics, 13, 1-23.
Walsh, B., & Smith, A. (2002). Articulatory movements in adolescents: Evidence of the protracted development of speech motor control processes. Journal of Speech, Language, and Hearing Research, 45, 1119-1133.
Westbury, J. R., Lindstrom, M. J., & McClean, M. D. (2002). Tongues and lips without jaws: A comparison of methods for decoupling speech movements. International Journal of Speech, Language, and Hearing Research, 45, 651-662.
Williams, P., & Stackhouse, J. (1998). Diadochokinetic skills: Normal and atypical performance in children aged 3-5 years. International Journal of Language and Communication Disorders, 33 (Suppl.), 481-486.
Williams, P., & Stackhouse, J. (2000). Rate, accuracy, and consistency: Diadochokinetic performance of young normally developing children. Clinical Linguistics and Phonetics, 14, 267-293.
Zeeman, S., Nowaczyk, M. J. M., Teshima, I., Roberts, W., Oram Cardy, J., Brian, J., et al. (2006). Speech and language impairment and oromotor dyspraxia due to deletion of 7q31 that involves FOXP2. American Journal of Human Genetics, 140(A), 509-514.

MOTOR SPEECH (ADULT)

Barry, R. M. (1995). A comparative study of the relationship between dysarthria and verbal dyspraxia in adults and children. Clinical Linguistics and Phonetics, 9, 311-312.
Bateson, E., & Ostry, D. (1995). An analysis of the dimensionality of jaw movement in speech. Journal of Phonetics, 23, 101-117.
Brown, J. R., Darley, F. L., & Aronson, A. E. (1970). Ataxic dysarthria. International Journal of Neurology, 7, 302-318.
Canter, G. J. (1965). Speech characteristics of patients with Parkinson’s disease: III. Articulation, diadochokinesis, and over-all speech adequacy. Journal of Speech and Hearing Disorders, 30, 217-224.
Connor, N. P., Ludlow, C. L., & Schulz, G. M. (1989). Stop consonant production in insolated and repeated syllables in Parkinson’s disease. Neuropsychologia, 27, 829-838.
Conrad, B., & Schonle, P. (1979). Speech and respiration. Archives of Psychiatry and Neurological Services, 226, 251-268.
Darley, F. L., Aronson, A. E., & Brown, J. R. (1969). Differential diagnostic patterns of dysarthria. Journal of Speech and Hearing Research, 12, 246-269.
Duffy, J. R., Peach, R. K., & Strand, E. A. (2007). Progressive apraxia of speech as a sign of motor neuron disease. American Journal of Speech-Language Pathology, 16(3). 198-208.
Dworkin, J. P., & Aronson, A. E. (1986). Tongue strength and alternate motion rates in normal and dysarthric subjects. Journal of Communication Disorders, 19, 115-132.
Dworkin, J. P., Aronson, A. E., & Mulder, D. W. (1980). Tongue strength in normal subjects and dysarthric patients with amyotrophic lateral sclerosis. Journal of Speech and Hearing Research, 23, 828-837.
Edwards, J. (1985). Contextual effects on lingual-mandibular coordination. Journal of the Acoustical Society of America, 78, 1944-1948.
Enderby, P., & Crow, E. (1990). Long-term recovery patterns of severe dysarthria following head injury. British Journal of Disorders of Communication, 25, 341-354.
Forrest, K., Weismer, M., & Turner, G. S. (1989). Kinematic, acoustic, and perceptual analyses of connected speech produced by parkinsonian and normal geriatric adults. Journal of the Acoustical Society of America, 85, 2608-2622.
Gay, T. (1974). Jaw movements during speech: A cinefluorographic investigation. Haskins Laboratories. Status Report on Speech Research, 39140, 219-229.
Gracco, V. L. (1994). Some organizational characteristics of speech movement control. Journal of Speech, Language, and Hearing Research, 37, 4-27.
Gracco, V. L., & Abbs, J. H. (1986). Variant and invariant characteristics of speech movements. Experimental Brain Research, 65, 156-166.
Gracco, V. L., & Lofqvist, A. (1994). Speech motor coordination and control: Evidence from lip, jaw, and laryngeal movements. Journal of Neuroscience, 14, 6585-6597.
Hertrich, I., & Ackermann, H. (2000). Lip-jaw and tongue-jaw coordination during rate-controlled syllable repetitions. Journal of the Acoustical Society of America, 107, 2236-2247.
Hill, A. J., Theodoros, D. G., Russell, T. G., Cahill, L. M., Ward, E. C., & Clark, K. M. (2006). An internet-based telerehabilitation system for the assessment of motor speech disorders: A pilot study. American Journal of Speech-Language Pathology, 15(1), 45-56.
Hughes, O. M., & Abbs, J. H. (1976). Labial-mandibular coordination in the production of speech: Implication for the operation of motor equivalence. Phonetica, 33, 199-221.
Hustad, K. C. (2006). A closer look at transcription intelligibility for speakers with dysarthria: Evaluation of scoring paradigms and linguistic errors made by listeners. American Journal of Speech-Language Pathology, 15(3), 268-277.
Keintz, C. K., Bunton, K., & Hoit, J. D. (2007). Influence of visual information on the intelligibility of dysarthric speech. American Journal of Speech-Language Pathology, 16(3), 222-234.
Kelso, J. A., Tuller, B., Vatikiotis-Bateson, E., & Fowler, C. A. (1984). Functionally specific articulatory cooperation following jaw perturbations during speech: Evidence for coordinative structures. International Journal of Experimental Psychology: Human Perception and Performance, 10, 812-832.
Kent, R. D. (2000). Research on speech motor control and its disorders: A review and prospective. Journal of Communication Disorders, 33, 391-428.
Ong, D., & Stone, M. (1998). Three-dimensional vocal tract shapes in /r/ and /l/: A study of MRI, ultrasound, electropalatography, and acoustics. Phonoscope, 1, 1-13.
Orlikoff, R. F. (1992). The use of instrumental measures in the assessment and treatment of motor speech disorders. Seminars in Speech and Language, 13(1), 25-38.
Ostry, D. J., & Flanagan, J. R. (1989). Human jaw movement in mastication and speech. Archives of Oral Biology, 34, 685-693.
Larson, C. (1985). Neurophysiology of speech and swallowing. Seminars in Speech and Language, 6(4), 275-291.
Liss, J. M., Krein-Jones, K., Wszolek, Z. K., & Caviness J. N. (2006). Speech characteristics of patients with pallido-ponto-nigral degeneration and their application to presymptomatic detection in at-risk relatives. American Journal of Speech-Language Pathology, 15(3), 226-235.
Logemann, J. A. (1985). The relationship of speech and swallowing in head and neck surgical patients. Seminars in Speech and Language, 6(4), 351-359.
Maassen, B. (2002). Issues contrasting adult acquired versus developmental apraxia of speech. Seminars in Speech and Language, 23, 257-266.
McHenry, M. A., Minton, J. T., Wilson, R. L., & Post, Y. V. (1994). Intelligibility and nonspeech orofacial strength and force control following traumatic brain injury. Journal of Speech and Hearing Research, 37, 1271-1283.
McLeod, S., & Searl, J. (2006). Adaptation to an electropalatograph palate: Acoustic, impressionistic, and perceptual data. America Journal of Speech-Language Pathology, 15(2), 192-206.
Moore, C. A. (1993). Symmetry of mandibular muscle activity as an index of coordinative strategy. Journal of Speech and Hearing Research, 31, 670-680.
Morrison, E. B., Rigrodsky, S., & Mysak, E. D. (1970). Parkinson’s disease: Speech disorder and released infantile oroneuromotor activity. Journal of Speech and Hearing Research, 13, 655-666.
Netsell, R., Daniel, B., & Celesia, G. G. (1975). Acceleration and weakness in parkinsonian dysarthria. Journal of Speech and Hearing Disorders, 40, 170-078.
Palmer, M. F., & Osborn, C. D. (1940). A study of tongue pressures of speech defective and normal speaking individuals. Journal of Speech Disorders, 52, 133-140.
Peterson, S. E., Fox, P. T., Posner, M. I., Mintun, M., & Raichle, M. E. (1988). Positron emission tomography studies of the cortical anatomy of single word processing. Nature, 331, 585-589.
Ringel, R. L., & Ewanowski, S. J. (1965). Oral perception. I. Two-point discrimination. Journal of Speech and Hearing Research, 8(4), 389-398.
Ringel, R. L., & Fletcher, H. M. (1967). Oral perception. 3. Texture discrimination. Journal of Speech and Hearing Research, 10(3), 642-649.
Robbins, J. (1985). Swallowing and speech problems in the neurologically impaired adult. Seminars in Speech and Language, 6(4), 337-350.
Rosenbek, J., Lemme, M., Ahern, M., Harris, E., & Wertz, T. (1973). A treatment for apraxia of speech in adults. Journal of Speech and Hearing Disorders, 38, 462-472.
Solomon, N. P., & Hixon, T. J. (1993). Speech breathing in Parkinson’s disease. Journal of Speech and Hearing Research, 36, 294-310.
Till, J. A., & Goff, A. M. (1986, November). Task variables affecting temporal structure and respiratory patterns in speech. Asha, 28, 102.
Wambaugh, J. L., Duffy, J. R., McNeil, M. R., Robin, D. A., & Rogers, M. A. (2006). Treatment guidelines for acquired apraxia of speech: A synthesis and evaluation of the evidence. Journal of Medical Speech-Language Pathology, 14, xv-xxxiii.
Wambaugh, J. L., Duffy, J. R., McNeil, M. R., Robin, D. A., & Rogers, M. A. (2006). Treatment guidelines for acquired apraxia of speech: Treatment descriptions and recommendations. Journal of Medical Speech-Language Pathology, 14, xxv-lxvii.
Westbury, J. R., Lindstrom, M. J., & McClean, M. D. (2002). Tongues and lips without jaws: A comparison of methods for decoupling speech movements. International Journal of Speech, Language, and Hearing Research, 45, 651-662.

This is a working draft.

Please cite this article as:

Bahr, D. (2008). A Topical Bibliography on Oral Motor Assessment and Treatment. Oral Motor Institute, 2(1). Available from www.oralmotorinstitute.org.

ORAL MOTOR TREATMENT vs. NON-SPEECH ORAL MOTOR EXERCISES

Oral Motor Institute
Volume 2, Monograph No. 2, 9 April 2008

ORAL MOTOR TREATMENT vs. NON-SPEECH ORAL MOTOR EXERCISES

HISTORICAL CLINICAL EVIDENCE OF “TWENTY-TWO FUNDAMENTAL METHODS”

By Pam Marshalla, MA, CCC-SLP

Peer Reviewers: Diane Chapman Bahr, M.S.; James Paul Dworkin, Ph.D.; Samuel Fletcher, Ph.D.; Daymon Gilbert, M.Ed.; Jennifer Gray, M.S.; Raymond Kent, Ph.D.; Suzanne Evans Morris, Ph.D.; Donna Ridley, M.Ed.; Sara Rosenfeld-Johnson, M.S.; Pat Taylor, M. Ed.. There were no blind reviewers of this monograph.

Re-prints: This monograph was reprinted in its entirety in the workshop manual Feeding and Pre-Speech Issues: The Mild and Moderately Involved Child by Suzanne Evans Morris, Ph.D.

This monograph was used in a coursework pack for fall and winter 2008 school term by University Readers. The monograph has been reprinted with the permission of the OMI.

INTRODUCTION

Some speech-language pathologists promote “oral motor treatment” for articulation and/or feeding therapy, while others insist that there is no evidence to support the use of “non-speech oral-motor exercises” (NS-OME) in articulation therapy (Banatoi, 2007, Lof & Watson, 2004, 2008, and Hodge & Salonka & Kollias, 2005). Are these professionals discussing the same thing? Therapy is a process of treatment comprised of techniques. Speech-language therapy includes many treatment techniques including those designed to facilitate improved oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) skills. But several questions arise today: What is oral motor treatment? Is “exercise” the extent of it? Who has advocated these methods? What role have oral motor techniques played in the history of speech-language therapy? Why has the term “oral motor” caused such a firestorm in the profession? Are advocates of “oral motor therapy” attempting to substitute it for articulation or phonological therapy? What does “wagging the tongue” have to do with speech? Why are some practicing speech-language pathologists clamoring for these methods? The current pressing need for scientific investigation of these techniques requires a thorough historical review.

Purpose

The purpose of this literature review was to seek out and report on techniques designed to facilitate improved oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) skills as they have been discussed in clinical speech-language-hearing publications throughout the history of the profession.

Method

A set of 84 textbooks, clinical guidebooks, and conference proceedings were reviewed for their oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques (Appendix A). Publications were selected from the following six treatment areas: articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor therapy. Three introductory communication sciences texts, and one speech-language guide for parents, also were included in this set. These publications spanned the years 1912 through 2007 and were written in English. Distribution of texts by topic is presented in Table 1.

RESULTS

Many interesting findings were made as a result of this literature review:

Jaw, lip, and tongue facilitation techniques were discussed, described, or recommended in 95.24% (80/84) of the publications reviewed.
There were uncounted hundreds of jaw, lip, and tongue facilitation techniques scattered throughout these publications.
Jaw, lip, and tongue facilitation techniques ranged from the simple to the sophisticated. On one end of this spectrum were simple techniques in which speech-language pathologists merely modeled jaw, lip, or tongue position. On the other end were procedures designed to influence neuromuscular processes (e.g., to influence muscle tone, stimulate oral reflexes, normalize oral tactile sensitivity, and so forth).
Authors represented all educational levels from practicing clinicians, with bachelor’s and master’s degrees, to full professors. These authors worked in schools, hospitals, private clinics, research facilities, and universities. Eight of these authors served as presidents of the American Speech-Language-Hearing Association (ASHA) (Appendix B).
The term “oral motor” did not appear in any of this literature until 1978. The first publication using the term “oral motor” from this collection was a 1978 publication of the proceedings of a four-day conference held in 1977. The conference was entitled “Oral-motor Function and Dysfunction in Children.” (Wilson, 1978).
1. The conference focused on feeding development, disorders, assessment and treatment, and there was one section on speech.
2. The conference was multi-disciplinary and included presentations on structure, function and neural control of the oral and pharyngeal mechanism.
3. The panel included Suzanne Evans Morris, Ph.D., Suzann Campbell, Ph.D., Joan Werner, Ph.D., James Bosma, M.D., Constance Evans, M.A.C.T., Sandra Radka, M.A.C.T., and Janet Wilson, L.P.T.
Publications on ARTICULATION from the first half of the century (1912-1956) openly advocated oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques, and contained advice about their selective application. They contained two types of methods:
1. Detailed methods designed to stimulate the movements and positions of the jaw, lips, and tongue for the production of specific phonemes. These methods were organized phoneme-by-phoneme and were intended for clients ready to work on one phoneme at a time. These methods became known as the “Stimulus Approach”, the “Phonetic Placement Approach,” “Motokinesthetics,” and the “Integral Stimulation Approach” (For a summary, see Newman, Creaghead, & Secord, 1985, pp.128-129).
2. Jaw, lip, and tongue warm-up activities designed to prepare the oral mechanism for speech sound movements. These methods were recommended for working with young children, older children with cognitive impairment or motor disability, and others who, for whatever reason, were not ready to work on one phoneme at a time.
Publications on ARTICULATION from the second half of the century (1960-2007) continued to contain information about oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. They generally represented one of three categories:
1. Broad-based speech textbooks that introduced both articulation and phonology. These textbooks contained general introductory and cautionary information about the application of these methods for the production of phonemes (e.g., Bernthal & Bankson, 1981 and 2004, and Bauman-Waengler, 2004).
2. Clinical guides that contained specific oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques designed to solve specific articulation problems (e.g., frontal lisp, lateral lip, persistent /r/ distortion) (e.g., Marshalla, 2004 and 2007).
3. Clinical guides that contained specific oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques while addressing a cross section of phonemes (e.g., Bleile, 2006, and Rosenfeld-Johnson, 2001).
Publications on ARTICULATION throughout the whole century (1912-2007) utilized a wide variety of terms and descriptive phrases to identify their oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. For example:
1. “Tongue gymnastics” (Scripture, 1912, p. 160).
2. “Maxillary, labial, lingual and velar gymnastics” (Borden & Busse, 1925, p. 159).
3. “Exercises for weak or relaxed muscles” (Travis, 1931, p. 208).
4. “Strengthening and stereotyping the motor patterns” (Kantner & West, 1933, p. 350).
5. “Exercises for gaining control of the speech mechanism” (Nemoy & Davis, 1937, p. 36).
6. “Visual, tactile, and kinesthetic approaches” (Anderson, (1953, p. 147).
7. “Improving the speed and precision of the articulatory musculature” (Van Riper, 1954, p. 216).
8. “Tongue exercises” (Van Riper, 1954, p. 216).
9. “Definite stimulation to speech muscles” (Young & Hawk, 1955, p. 12).
10. “Strengthening the visual-tactile cues” (Berry & Eisenson, 1956, p. 138).
11. “Increasing the flexibility of the articulators” (Berry & Eisenson, 1956, p. 139).
12. “Sensory-motor procedures” (McDonald, 1964, p. 135).
13. “Direct manipulation” (Winitz, 1975, p. 71).
14. “Extraoral and intraoral stimulation technique” (Vaughn & Clark, 1979, p. 3).
15. “Various approaches … along the sensory-motor continuum” (Hanson, 1983, p. 152).
16. “Motor practice” (Ruscello, 1984, p. 130).
17. “Motor sensory targets” (Borden, 1984, p. 51).
18. “Physiological approach” (Fletcher, 1992, p. iii).
19. “Oral motor techniques” (Marshalla, 1992, p. 1).
20. “Oral motor exercises for speech clarity” (Rosenfeld-Johnson, 2001, p. i).
21. “Tongue and lip awareness activities” (Bauman-Waengler, 2004, p. 225).
22. “Oral-motor activities”, “oral-motor training”, and “oral-motor instructional activities” (Bernthal & Bankson, 2004, p. 333-335).
23. “Touch cues” (Bleile, 2006, p. 8).
24. “Methods and techniques that can be used when the client cannot produce a target sound at all” (Secord et al, 2007, p. 3).
Publications on MOTOR SPEECH (including cerebral palsy) spanned the years 1964-1999. They contained a wide variety of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques organized by:
1. Body part (e.g., techniques to facilitate movement and position of the upper lip, lower lip, tongue tip, tongue back, tongue sides, head, neck, and so forth).
2. Sensory and motor process (e.g., techniques to vivify oral movement, improve muscle tone, normalize tactile sensitivity, dissociate movements, stimulate reflex responses, and so forth).
Publications on MOTOR SPEECH disorders, including cerebral palsy, identified their oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques by a wide variety of functional phrases. For example:
1. “Improving the function of the jaw, lips, and tongue” (McDonald & Chance, 1964, p. 124).
2. “Activities preliminary to speech production” (Darley, Aronson & Brown, 1975, p. 274).
3. “Neurospeech therapy” (Mysak, 1980, p. 183).
4. “Articulation subsystem exercises” (Dworkin, 1991, p.191).
5. “Muscle training” (Love, 1992, p. 152).
6. “Improving sensory and motor functions within physiologic processes” (Brookshire, 1992, p. 259).
7. “Mechanical positioning of the patient’s articulators” (Brookshire, 1992, p. 279).
8. “Oral motor phonetic drills” (Crary, 1993, p. 223).
9. “Motor programming approaches” (Hall, Jordan, & Robin, 1993, p. 123).
10. “Increasing physiologic support” by following “principles of motor learning” (Duffy, 1995, p. 381).
11. “Motor approach” relying heavily upon “principles of motor learning” (Yorkson, Beukelman, Strand, & Bell, 1999, pp. 552-553).
Publications on FEEDING, DYSPHAGIA, and OROFACIAL MYOLOGY spanned the years 1978 through 2000. They were replete with a wide variety of oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques organized by:
1. Body part (e.g., techniques to facilitate movement and position of the upper lip, lower lip, tongue tip, tongue back, tongue sides, head, neck, and so forth).
2. Sensory and motor process (e.g., techniques to improve muscle tone, normalize tactile sensitivity, dissociate movements, stimulate reflex responses, and so forth).
3. Eating and swallowing skill (e.g., techniques to facilitate chewing, sucking, swallowing, transferring food, creating a bolus, and so forth).
Publications on FEEDING, DYSPHAGIA, and OROFACIAL MYOLOGY utilized various terms to describe these methods. For example:
1. “Sensory stimulation to evoke movement [and] external control of involuntary, abnormal movement” (Campbell, 1978, p. 1).
2. “Myofunctional therapy” (Garliner, 1981, p. 3)
3. “Oral motor control exercises” (Logemann, 1983, p. 133).
4. “Lip and facial exercises” (Groher, 1984, p. 137).
5. “Myotherapy” (Hanson & Barrett, 1988, p. 231).
6. “Oral motor treatment” (Arvedson & Brodsky, 1993, p. 327).
7. “Therapeutic exercises” (Tuchman & Walter, 1994, p. 109).
8. “Treatment strategies and activities … for improving oral motor skills” (Morris & Klein, 2000, p. 402).
Publications on PHONOLOGY contained very few specific jaw, lip, and tongue facilitation techniques. However:
1. Most of these texts discussed a client’s “stimulability” or his “readiness” for phoneme production (i.e., the client’s ability to move and position the jaw, lips, and tongue correctly for production of a target phoneme given an auditory and visual model as well as a verbal description).
2. Several discussed or recommended the use of tactile cues to facilitate correct production of phonemes.
3. A few of these publications seemed to have confused or blended the terms “phonetics” and “phonology”, essentially replacing the prior with the latter (for a brief discussion, see, Winitz, 1984, pp. xi-xiv). They contained techniques to position the jaw, lips, and tongue.
4. One publication recognized the movement aspect of distinctive features: “Distinctive features are sets of consistent motoric gestures” (Blache, 1982, p. 62).
Publications that covered BOTH ARTICULATION AND PHONOLOGY TOGETHER IN ONE VOLUME were published from 1981 through 2004. They contained information about oral motor techniques related to phoneme production; however, they also contained cautions about the use of these methods (e.g., see Bauman-Waengler, 2004, p. 225, and Bernthal & Bankson, 2004, pp. 333-335).
Publications with the term “ORAL MOTOR” in the title spanned the years 1978 through 2004. They were replete with oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. The terms “oral motor treatment” and “oral motor therapy” were used throughout these publications. When the term “exercise” was used, it was used to represent a wide variety of methods (e.g., Gangale, 1993, and Rosenfeld-Johnson, 2001).
All three INTRODUCTORY speech-language-hearing TEXTBOOKS discussed oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques as one option in articulation therapy. These remarks were brief, general, and in line with the overall introductory nature of the texts.
The single PARENT GUIDE contained several suggestions for oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. These were brief, cursory, and playful.
Publications in ALL TREATMENT AREAS EXCEPT PHONOLOGY contained simple methods such as “wagging the tongue”. Such activities were never recommended, in any of this literature, as a direct path to phoneme production or feeding/swallowing skill. Instead, such methods were suggested to facilitate overall oral sensory processing and movement skill for later phoneme production and later or simultaneous feeding/swallowing training. These methods were recommended to:
1. Facilitate a client’s attention and orientation to the oral mechanism at a gross level.
2. Help the client begin to move the oral mechanism in gross movement patterns.
3. Achieve other neuromuscular ends (e.g., increase tonus, increase range of tongue motion, differentiate tongue from jaw or lip movements, facilitate midline integration of oral movement, normalize oral tactile sensitivity).
NONE OF THESE PUBLICATIONS used the term “non-speech oral-motor exercises” to identify oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques.
NONE OF THESE PUBLICATIONS advocated that oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) treatment be used as a replacement for any aspect of articulation or phonological therapy. In fact, the opposite is true. Every publication concerned with speech production discussed the use of these methods within a complete program of speech management, a program that includes stimulation of auditory awareness and discrimination, cognition, attention, memory, and other basic skills. None advocated that “non-speech oral motor exercises” be used instead of articulation or phonological procedures.
HISTORICAL READING (starting in 1912 and reading year-by-year until 2007) revealed that the basis for understanding movement development, assessment, and disorders has become increasingly more sophisticated throughout the century.
THE SAME TYPES of oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques overlapped in ALL treatment areas. Careful analysis of these procedures revealed that they could be organized into at least 22 distinctive types or “Fundamental Methods” listed here and defined later in this publication:
1. Assist oral movements
2. Associate oral movements
3. Contrast oral movements
4. Cue oral movements
5. Describe oral movements
6. Develop sensory awareness and discrimination for oral movements
7. Direct oral movements
8. Dissociate oral movements
9. Exaggerate oral movements
10. Increase or decrease muscle tone for oral movements
11. Increase range of motion for oral movements
12. Inhibit oral movements
13. Maintain oral positions
14. Mark the target of oral movements
15. Model oral movements or positions
16. Normalize tactile sensitivity for oral movements
17. Practice oral movements
18. Resist oral movements
19. Speed up or slow down oral movements
20. Stabilize oral movements
21. Stimulate reflexive oral movements
22. Vivify oral movements

DISCUSSION

The results of this literature review revealed that oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques have had substantial representation throughout the field of speech-language pathology from 1912 through 2007. These methods were described, discussed or recommended, in part or in whole, in 95.24% of reviewed textbooks, clinical guidebooks and conference proceedings in the areas of articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor, as well as introductory texts and one parent guide reviewed. Speech-language pathologists at all educational levels, from bachelor’s level clinicians through full professors and ASHA presidents, have contributed to the discourse on methods to improve oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) skills.

The Term “Oral Motor”

Forty-three functional phrases were used to refer to oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques throughout the century. From “tongue gymnastics”, in 1912, through “methods and techniques that can be used when the client cannot produce a target sound at all”, in 2007, these descriptive phrases each reflected the authors’ style and circumstance. The term “oral motor” did not appear in these publications until 1978, and then it was used in relation to both feeding and speech in children with neuromuscular disorders (Wilson, 1978). The term “oral motor” was used for the first time in an articulation therapy publication in 1992 (Marshalla, 1992). Both “oral motor therapy” and “oral motor treatment” seem to be two of many identifiers of these methods.

The Term “Non-speech oral-motor exercises”

The term “non-speech oral motor exercises” (NS-OME) was never used in any of these publications. This literature review did not make clear why the term NS-OME has been adopted recently by some writers (Banatoi, 2007, Lof &Watson, 2004, 2008, and Hodge & Salonka & Kollias, 2005). Perhaps “exercise” has been chosen because Van Riper used it. Van Riper has been called the “father” of traditional articulation therapy, and his basic therapy text was reprinted more than any other on the list. Van Riper used the term “exercise” to represent the wide variety of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques he discussed. A few newer publications also used the term “exercise”, and they too used the term to refer to a wide variety of methods (e.g., Rosenfeld-Johnson, 2001, 2005).

Cure-all

None of these publications suggested that oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques are a cure-all for speech production problems. Nor did any of these authors suggest that these methods be used as a replacement for traditional articulation or phonological therapy. Every publication that addressed the topic of articulation therapy clearly described the use of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques within the context of a full program of articulation and/or phonology.

“Wagging the Tongue”

Simple methods, such as “wagging the tongue, sticking out the tongue, and puckering the lips” (Banotai, 2007, p. 8), were discovered throughout all this literature, but none of these publications recommended them as a direct path to phoneme production. Instead, non-task specific activities such as these were recommended for three basic reasons: (1) to facilitate gross oral awareness of the oral mechanism, (2) to vivify oral movements, or (3) to achieve some other neuromuscular end. For example, “wagging the tongue” was suggested to orient a client to his mouth, to help a client discover that he had a tongue, to increase tone in the tongue, to increase range of motion of the tongue, to facilitate midline integration of oral movements, and to differentiate tongue movements from lip and/or jaw movements.

A lack of organization, and perhaps a misunderstanding of purpose, intent, vocabulary, and history, seems to have lead to the current confusion between the term “non-speech oral-motor exercises” and the classic perspective of “oral motor treatment” or “oral motor therapy” represented in this literature reviewed. Somehow the view has evolved recently that oral motor treatment consists of non-task specific techniques such as “wagging the tongue”. There seems to be the new belief that simplistic activities such as these have been advocated so that articulation errors, and perhaps feeding problems, will magically disappear. This relatively recent view is not congruent with what actually is written in the literature reviewed. None of the authors who wrote this extensive body of literature made such a claim. None claimed that non-specific oral motor tasks would result in phoneme correction.

The present literature review has revealed that the writers of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques always have referenced a deep understanding of the way phonemes are produced. There has never been anything “non-speech” about these exercises. None of these publications used the term “non-speech oral-motor exercises”. This suggests that the term NS-OME is unrelated to these widely published historical accounts. The term “exercise” is found by itself in these publications, but it is used in the generic sense meaning “activity”, and it refers to a wide variety of facilitation techniques, from limited ones like “wagging the tongue”, to far-reaching ones like those used to normalize oral tactile sensitivity or to improve muscular tone.

Disorganization

Perhaps oral motor treatment has become controversial due to the disorganized nature of some of this material. Consider the following list of techniques to stimulate the lip and facial muscles in a program of dysphagia management:

“Broad smiling … Tight frowning … Alternating lip pursing and retracting … Practice producing words and sounds: u, m, b, p, w … Resistive sucking on a pinched straw … Blowing up cheeks with mouth tightly closed … Blowing exercises … Hard sucking on frozen popsicle … Pursing lips around button tied on a string” (Asher, 1984, p. 137).

A list such as this is typical of the way this material is presented in many of the publications studied. The techniques are presented as good ideas, suggestions to try, and things that have proven useful clinically. Laundry lists like these lend themselves to random picking and choosing if there is no discussion about why to select one method over another, and if there are no controlled studies on any of them. The neurophysiological basis for the techniques often is disregarded. No controls weaken their potential application in other clinical settings.

Perspective

Another cause of confusion may stem from a lack of perspective. Many of the same methods appear in one publication after another across every treatment area throughout the entire century. However professionals who specialize in only one or two of these treatment areas might not realize that the same ideas and techniques course through all this literature. Only two authors (Marshalla, 1992, and Bahr, 2001) have taken a bird’s eye view of all of these treatment areas (articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor) to discuss the overlapping nature of these methods. They have begun to gather these methods into a comprehensive whole for discussion.

Phonology

Publications that discussed phonology as a single topic contained very few recommendations for oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. This might suggest an underlying philosophy that children who are studied for their phonological problems do not demonstrate the types of oral control problems present in clients with muscle function delay or disorder. However, tactile cueing to teach distinctive features of targets was discussed by Hodson and Paden (1983), and several other phonology publications cited their work. “The child needs to learn what the phoneme ‘feels like’ as well as what it sounds like. … We use tactual cues as supplements when first presenting the new target. … Tactual cues are simply ways in which the child can, through feeling, gain additional information about the image of the target” (Hodson & Paden, 1983, p. 59). Hodson and Paden recommended the Motokinesthetic cueing system (Young & Hawk, 1955), and they suggested, “The imaginative speech-language pathologist will devise many additions to this list [of tactual cueing techniques] when prompted by the needs of the child” (Hodson & Paden, 1983, p. 51). Clearly these authors recognize the need to help clients learn how to move and position the jaw, lips and tongue correctly for phoneme production. “We place great emphasis on cueing the child for correct production of the target pattern” (Hodson & Paden, 1983, p. 47). The authors’ background in phonetics and traditional articulation therapy comes through.

Stimulability

It is also notable that a standard practice in phonology seems to be one of choosing sounds “for which the child is stimulable” (Lowe, 1994, p. 178). “If a child is stimulable, he or she produces a sound in error, but following a model of the sound the child can correctly imitate or repeat the sound” (Elbert & Gierut, 1986, p. 98). Does this not suggest that a stimulable sound is one in which the client has already gained, or is about to gain, sensory and motor control? This is an argument that has arisen in the phonology literature itself (referenced in Elbert & Gierut, 1986, p. 98). Careful analysis of any distinctive feature clearly indicates that certain movements are required to achieve that feature. For example, a phoneme can be [+Back] only if some part of the back of the oral mechanism moves. Only one phonology publication broached this topic (Blache, 1982, p. 62).

Acceptance

There seems to be little argument regarding the use of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques in feeding, dysphagia, motor speech, and orofacial myology. These publications contain hundreds of methods to facilitate jaw, lip, and tongue function, and there has been little outcry about it despite a similar lack of research.

Articulation

Today’s real argument about oral motor techniques seems to be directed toward articulation therapy (Banatoi, 2007, Lof & Watson, 2004, 2008, and Hodge & Salonka & Kollias, 2005). This relatively recent view seems to be that there is no proof that techniques to help clients move their articulators has been effective in articulation therapy. However, articulation therapy, by its very nature, is a process of adjusting jaw, lip, and tongue movement and position for phoneme production. “Speech production is a highly precise and practiced motor skill” (Kent, 1980, p. 38). “The SLP who is interested in correcting misarticulation should never lose sight of the fact that articulation is, among other things, a motor act” (Van Hattum, 1980, p. 168).

Some clients with articulation errors are able to make adjustments to jaw, lip, and tongue movement and position after simply receiving a visual and auditory model along with a verbal description – a process one might call “Show and Tell” therapy. These clients are easy to manage, and they progress swiftly. Other clients, however, move very slowly through the stages of articulation treatment, and they seem to require the use of specific tactile and proprioceptive input to achieve target jaw, lip, and tongue movements and positions. These clients cannot seem to get their jaw, lips, or tongue to move and position well enough to produce target phonemes when given only visual and auditory information. For example, consider clients in unsuccessful long-term articulation therapy for a bi-lateral lisp or a distorted /r/. These clients clearly need an articulation program that is embedded with techniques to facilitate jaw, lip, and tongue function specific to the production of their misarticulated phonemes. “The ultimate goal of articulatory intervention is to change motor performance” (Fletcher, 1992, p. 219). The historical record, written by so many authors over so many years, substantiates this claim. Articulation therapy is highly stylized movement therapy even when auditory stimulation is the main focus of the treatment.

Movement Basics Lacking

Techniques to facilitate improvements in jaw, lip and tongue function in feeding or speech therapy are, by their very nature, movement techniques. Yet speech professionals, not movement professionals, have formulated the methods reported in the speech literature. The result is that the articulation, phonology, motor speech, feeding, dysphagia, and oral motor literature contains literally hundreds of methods to facilitate oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) skills, but these techniques are not integrated into a comprehensive body of knowledge that crosses all discipline areas. Nor have many of these methods undergone the rigorous controlled study now viewed as so important.

Fundamental Methods

The recurring and overlapping nature of these techniques scattered throughout this literature suggests that there are methods of facilitating improved oral function that are fundamental to all of these treatment areas. When grouped, the oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques advocated throughout these publications can be arranged into 22 basic types. These types are discussed with examples in “Proposal” below.

Clamoring for Information

This literature review gives us perhaps some insight as to why practicing speech-language pathologists are clamoring for information about oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques for articulation therapy. That has to do with the content of articulation therapy textbooks themselves and speech-language curriculums.

Some articulation textbooks are replete with specific oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques. They contain page after page of very specific detail about facilitating the movements required for specific phonemes [e.g., Nemoy and Davis (1925), Young and Hawk (1955), Hanson (1981), and Secord et al (2007)]. Other articulation textbooks contain general discussions with sample techniques for facilitating oral movement for speech sound production [e.g., Weiss, Lillywhite & Gordon (1980), Bernthal & Bankson (2004), and Creaghead, Newman, & Secord (1989)]. Still others contain only a few ideas about facilitating oral movement, and these limited ideas are scattered here and there throughout the text [e.g., Flowers (2003)]. An individual speech-language pathology student who is being trained in these matters is exposed to the particular viewpoint of the textbook used and the personal clinical experience of the teaching or supervising professor. Some speech-language pathologists get comprehensive training in these matters, and others do not.

Despite sometimes limited training, most speech-language pathologist’s have caseloads that contain clients with articulatory errors. Professional speech-language pathologists must know how to address every phoneme that might be in error because they treat clients with a wide variety of articulation errors. They need to know how to facilitate improved jaw, lip, and tongue function for phoneme production regardless of the fact that not all the data is in. Many speech-language pathologists also must provide feeding therapy, another process in which they may have received little or no training. Professional speech-language pathologists often are forced to figure these things out for themselves, and many have turned to the arena of continuing education for help. They also have looked to independent book publishers for clinical guides that contain “how to” information. Continuing education programs, and non-traditional clinical guides, offer the techniques therapists need to face the articulation and feeding problems of today’s diverse populations. These seminars and books on oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques are provided by speech-language pathologists who have decades of experience in these matters. These programs and publications are filling the gaps that many articulation textbooks and university programs leave behind.

Evidence-based Practice

The drive for evidence-based practice has caused some to question the use of oral motor techniques in articulation therapy. Yet, those (Hodge, Salonka, & Kollias, 2005; Lof, & Watson, 2004 & 2008) who question these techniques have looked only at one very small aspect of oral motor treatment, the “non-speech oral motor exercise”, a concept not described anywhere in the publications we reviewed. This limited view has brought about a damaging misunderstanding within the field of speech-language pathology. It has equated “non-speech oral-motor exercises” with the broad range of oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques described throughout one hundred years of speech-language pathology. It has forced many of the older, but clinically sound, techniques out of textbooks and university classes, and it has limited the introduction of new techniques that have not undergone rigorous scientific investigation. All oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques seem to have been lumped into one small category called “non-speech oral motor exercises”, an idea that appears to have very little to do with the methods described in the literature studied for this extensive review. As a result, the broad range of methods that have developed throughout the century are now being treated as old-fashioned, unproven, and, in some cases, suspicious or dangerous.

However, evidence should come from the scientific laboratory and from clinical practice. Dollaghan (2007) has defined evidence-based practice as, “the conscientious, explicit, and judicious integration of 1) best available external evidence from systematic research, 2) best available evidence internal to clinical practice, and 3) best available evidence concerning the preferences of a fully informed patient” (Dollaghan, 2007, p. 2). A lack of external laboratory evidence does not mean there is a lack of internal clinical evidence. The historical record of techniques, described by the authors of the literature studied for this review, supplies us with a cornucopia of evidence internal to clinical practice. To disavow oral motor treatment completely is to discard the 100 years of internal clinical evidence that has lead practicing speech-language pathologists to where they are today. “Lack of data does not mean that we should do nothing. Using the limited data that are available, along with an analysis of the motor tasks, we can assemble thoughtful paradigms for clinical application” (Kent, 2008). We have more decades of clinical trial-and-error evidence in matters of jaw, lip, and tongue function than we have in any other aspect of speech-language pathology. Instead of throwing out these methods, we should be treasuring and further refining this information to the level of knowledge expected at this point in our profession. What we need now are clinicians and researchers willing to investigate specific techniques in controlled studies in order to begin to provide us with the external evidence we need for the future.

RESEARCH NEEDS

A number of research needs, and advice for advancing into such research, have arisen as a result of this literature review.

Movement and Articulation

Research on oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques should NOT be limited to “non-speech oral-motor exercises”. Careful reading of the historical literature has revealed that there are at least 22 specific types of oral (jaw, lip, and tongue) motor (sensory, motor, and positioning) techniques that currently are under employment in the clinical arena (see details below). Each one of these ideas will make for an excellent series of research projects. A wide variety of questions could be asked. For example: What impact does resistance have on tongue tip, tongue back, or tongue side elevation for production of stop consonants? How does tapping the center of the tongue influence the creation of a midline groove for production of sibilants in clients with bi-lateral lisp? What impact do procedures to stabilize the jaw have on clients with a frontal lisp? How do techniques to influence oral tactile awareness and discrimination influence production of /r/ in clients who have failed in traditional therapy? Do clients with lateral lisps demonstrate differences in oral-tactile sensitivity?

Type of Stimulation

Future research projects need to be very specific about the type of stimulation methods employed, and care should be taken not to confuse methods. For example, studies should not compare methods of “cueing movements” with techniques to “stimulate oral reflexes”. That would be comparing apples to oranges. Research projects should be designed to isolate individual facilitation techniques, and to compare them within and across population groups. Isolating techniques may prove to be a difficult process because often there is overlap. But studying isolated techniques will yield better data about what truly is effective in treatment.

Developmental Data on Speech Movement

Another great need within this area of study is for developmental data. Publications on feeding reported month-by-month development in oral movement skill. But the body of literature studied for this report revealed no such developmental data in regard to speech movements. We do not know, for example, when children are able to lift the tongue-tip to the alveolar ridge during production of speech. Can children elevate the tongue-tip at 12 months when using /d/ on first words? At two years after having reached the two-word stage? At ten months during babbling? At four months during cooing?

We also need to know what makes the immature production of phonemes different from mature productions. For example, the articulation literature clearly treats /l/ as a later-developing phoneme, and explains that young children produce /l/ with some distortion. We do not know, however, what a child does during his immature production of /l/ that makes it different from a mature one. Is he moving his jaw, lips, or tongue differently? If so, how? What is the immature oral movement pattern? How is it different from a mature oral movement pattern utilized in production of /l/?

Data on Incorrect Oral Movement Patterns

We also need to know what oral movements cause phoneme distortion. What oral movements make a distorted /r/ different from a correct one? What tongue movements make a bilateral /s/ different from an /s/ produced with midline air stream? What are the oral movement patterns of the client with severe speech distortion in the absence of neuromuscular disease? Fletcher’s palatometer studies (1992) describe the equipment and procedures that might be used for these investigations.

Movement and Phonology

Research is also needed to investigate the underlying relationships between phonological patterns and movement, for it is at the level of distinctive features where phonetics, phonology, and oral motor converge. Many questions could be asked: What are the movements necessary to achieve each distinctive feature? What movements are necessary to make a phoneme [+Back], [+Front], [+Strident], and so forth? How do specific sensory and movement problems interfere with the acquisition of distinctive features? How does low muscle tone, for example, interfere with the production of final consonants, consonant clusters, or syllables? What percentage of clients who Back phonemes have a diagnosis of oral tactile hypersensitivity? How does low muscle tone interfere with jaw stability and the production of stridency?

PROPOSAL

twenty-two fundamental methods

It is proposed that the study of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques will be served by analyzing existing treatment techniques from many areas, by defining vocabulary, and by sorting this material into “fundamental methods” based on sensory and movement treatment procedures, i.e., grouping according to the type of sensory and movement technique being employed, not the body part, phoneme, or feeding skill being facilitated.

The following format describing 22 Fundamental Methods is proposed. It was formulated after studying the 84 publications used for our review. Each technique is described and examples from the literature are given. It is hoped that this format will be helpful in several ways: 1) in the process of organizing the past century of clinical insights, 2) in the design of future research studies, and 3) in the planning of treatment sessions for individual clients. It is also hoped that this material will enlighten the profession about the broad scope of oral motor treatment that has been described in the articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor literature from 1912 until the present day.

1. Assist Oral Movements

To assist is to “help (someone), typically by doing a share of the work” (Jewell & Abate, 2001, p. 96). “[Manipulation] may be necessary to place the organs in the starting position for the sound to be made” (Nemoy & Davis, 1937, p. 36). Assistance can be “passive positioning or manipulation” (Hardy, 1983, p. 170), or it can be active. Active assistance requires that “the therapist, with a small degree of effort from the child, moves the body part through the desired pattern of movement” (McDonald & Chance, 1964, p. 65). Speech-language pathologists use their own hands, fingers and other tools to assist clients in their attempts to achieve specific jaw, lip, and tongue movements and positions. Techniques to assist oral movements appeared in many of our researched texts. Examples:

To assist tongue back elevation for /r/: “A flat stick or a small rod … may be put under the tongue to push it back and up” (Scripture, 1912, p. 148).
To assist lower lip elevation for /f/: “The trainer [uses the fingers and] moves the lower lip upward until it comes in contact with the curved edge of the upper teeth” (Hawk and Young, 1955, p. 16).
To assist tongue tip elevation for lingua-alveolar phonemes: “Sometimes it is helpful to use a tongue depressor or a rounded stick to bring the tongue into the desired position” (Berry & Eisenson, 1956, p. 42).
To assist jaw movement in swallowing: “Occasionally, the clinician may assist the patient’s attempts at jaw movement by placing external pressure on the mandible in the desired direction of movement … If any pain occurs, the exercise should be discontinued” (Logemann, 1983, p. 142).
To assist jaw lowering for /ɑ/: “Pull down the chin with your index finger” (Kaufman, 2006, p. 14).
To assist correct tongue placement for /θ/: (1.) “Instruct the student, ‘Please stick out your tongue.’ (2.) Once the tongue is out, gently close the student’s mouth. If the tongue is sticking out too far, gently push it back with a tongue depressor” (Bleile, 2006, p. 23).

2. Associate Oral Movements

To associate is to “connect (something) with something else because they occur together or one produces another” (Jewell & Abate, 2001, p. 97). Speech-language pathologists use the movements and positions of one phoneme to teach the movements and positions of other phonemes. This has been called “sound modification” (Secord et al, 2007, p. 5). It has also been called “successive approximations” and “shaping” (Bernthal & Bankson, 2004, p. 302). The client who can benefit from this method obviously must be able to achieve the target position of the first phoneme before it can be used to teach the second. “The clinician instructs the client to produce a known sound and then to adjust the articulators in certain ways as he continues to produce the known sound. Each articultory adjustment is a movement that comes closer to the position necessary for the target sound. This method is often used with non-speech sounds, such as coughing to elicit a /k/” (Secord et al, 2007, Pp. 5-6). Examples:

Associating tongue-back elevation for /ŋ/ with tongue tongue-back elevation for /g/: “The pupil [is] induced through imitation of /ŋ/ to prolong /ŋ/ at first and then to complete the sound with a sudden expulsion of the voice” (Nemoy & Davis, 1937, p. 116).
Associating lingua-alveolar position for /t/ with lingua-alveolar position for /s/: “Make [t] … Make [t] with strong aspiration on the release … Prolong the strongly aspirated release … Remove the tip of the tongue slowly during the release from the alveolar ridge to make a [ts] cluster … Prolong the [s] part of the [ts] cluster in words like oats … Practice prolonging the last portion of the [ts] production … Practice ‘sneaking up quietly’ on the [s] (delete /t/) … Produce [s]” (Bernthal & Bankson, 2004, p. 302).
Associating tongue-tip protrusion for /θ/ with tongue tongue-tip elevation for /l/: “Instruct the client to say /θ/. Then tell the client to lower the jaw and draw the tongue tip backward until it contacts the alveolar ridge behind the upper teeth. While maintaining contact with the alveolar ridge, the client says /l/” (Secord et al, 2007, p. 90).

3. Contrast Oral Movements

To contrast is to “compare in such a way as to emphasize differences” (Jewell & Abate, 2001, p. 373). Speech-language pathologists help clients contrast jaw, lip and tongue positions in order to help them perceive the locations of articulatory contact. Techniques to contrast jaw, lip and tongue positions appeared in many of our researched texts. Examples:

Contrasting positions used to teach lip rounding for /w/: “Contrast lip spreading with lip rounding, and a large mouth opening with a small mouth opening” (Hanson, 1983, p. 206).
Contrasting tongue positions used to eliminate a frontal lisp: “A great way to wake up the tip of the tongue and to get the tip behind the teeth is to have the client say, ‘th-s-th-s-th-s-th-s’ back and forth in one continuous air stream. This practice stimulates the tip of the tongue through tactile means as it rubs forward and back against the upper central incisors” (Marshalla, 2007, p. 104).
Contrasting tongue tip and back positions used to learn /k/: “Have the client say /t/. The /t/ can be used to illustrate the build up of pressure and the quick release. Then have him attempt saying /t/ with the tongue tip behind the lower central incisors. Follow with the step of instructing the client to raise the back of the tongue up to the soft palate and attempt the /k/ production” (Secord et al, 2007, p. 31).

4. Cue Oral Movements

A cue is “a signal for action … a piece of information or circumstance that aids the memory in retrieving details not recalled spontaneously … a hint or indication about how to behave in particular circumstances” (Jewell & Abate, 2001, p. 415). Speech-language pathologists provide visual, auditory, tactile, proprioceptive and conceptual cues about oral movement and position in order to help clients learn to produce specific phonemes, and to sequence phonemes. Certain articulation programs have been based around highly stylized tactile cueing systems including: Motokinesthetics (Young and Hawk, 1953), Speech Facilitation (Vaughn & Clark, 1979) and P.R.O.M.P.T. (Chumpalik, 1984). But techniques to use some sort of cue for jaw, lip and tongue movement or position appeared, or were recommended, in almost all of our researched texts. Examples:

Visual and tactile cue for production of /st/: “The clinician may draw her finger up the child’s bare arm while saying /s/ and tap it lightly as she releases the /t/, thus calling attention to the continuancy of /s/ and the quick burst of /t/” (Hodson & Paden, 1983, p. 51).
Tactile cue for lingua-velar articulation: “Pressure applied well under the child’s chin, upward and toward the base of the tongue, will reinforce back-of-tongue … productions” (Blakely, 1983, p. 30).
Verbal and visual cues to teach fricatives: “We had Clifford stick out his tongue and blow over the top of it to produce “th” or a close approximation of it. … By providing additional cues regarding tongue, lip and teeth placement, fricative production can be shaped” (Mowrer, 1984, p. 96).
Conceptual cue (the “angry cat”) for production of /f/: “Make a loose contact between the upper front incisors and the lower lip and force the air stream between them to produce frication. Do not use voice. This is the angry cat sound. Hear the cat go ‘f-f-f-f'” (Flowers, 2003, p.39).
Hand signal cue for /m/: “Slide index finger across lips horizontally or place fingers directly over lips as in ‘blowing a kiss'” (Kaufman, 2006, p. 20).

5. Describe Oral Movements

To describe is to “give an account in words of (someone or something), including all the relevant characteristics, qualities, or events” (Jewell & Abate, 2001, p. 462). “Most patients do not improve simply by talking. They often need some instruction” (Duffy, 1995, p. 382). “Both modeling and demonstration are mostly preceded or accompanied by verbal instruction” (Hegde, 1998, p. 155). The phonetic placement approach (Van Riper, 1954) is a method of describing oral movement for phoneme production. “The phonetic placement method has probably been used as long as anyone has attempted to modify speech patterns. … [It] involves explanations and descriptions of idealized phoneme productions. The verbal explanations provided to the client include descriptions of motor gestures or movements and the appropriate points of contact (tongue, jaw, lip, velum) involved in producing the target segments” (Bernthal & Bankson, 2004, p. 301). The client “is then directed to place his articulatory mechanism in a similar position and produce a sound” (Kantner & West, 1933, p. 348). Speech-language pathologists frequently describe the movements or positions of the jaw, lips, and tongue in order to help clients achieve target phonemes and feeding skills. Descriptions of jaw, lip and tongue movements or positions appeared in almost all of our researched texts. Examples:

To describe lip position for /v/: “[The client] is told to bite his lower lip” (Scripture, 1912, p.124-125).
To describe tongue position for /t/: “Discuss how this sound is produced, including how the tongue is positioned on the alveolar ridge” (Folk, 1992, p. 6).
To describe tongue tip placement for lingua-alveolar phonemes: “See the tip of my tongue? I am going to make it real small like this. Then I am going to lift it up. See? Then the tip of my tongue is going to touch this part of my mouth. Did you see that? Can you do it?” (Hegde, 1998, p. 155).
To describe lip position for /m/: “Carefully explain the production characteristics using diagrams or illustrations if possible (e.g., pointing out to the client the lip-to-lip posturing, and pointing out that the air will escape through the nose while making the humming sound /m/)” (Secord et al, 2007, p. 74).

6. Develop Sensory Awareness and Discrimination for Oral Movements

To be aware is to have “knowledge or perception of a situation or fact” (Jewell and Abate, 2001, p. 113). To discriminate is to “recognize a distinction” and to “perceive … the difference in or between” (Jewell & Abate, 2001, p. 488). “Tongue and lip awareness activities can often be utilized with beneficial results. They are employed … to heighten the child’s awareness of tongue and lip movements” (Bauman-Waengler, 2004, p. 225). “It could be said that without sensory input there would be no movement” (Mysak, 1980, p. 194). “Evidence accumulates that somatic feedback, particularly touch-tactile and kinesthesia-proprioception, is vital to the learning and maintenance of motor speech” (Irwin, 1972, p. 20). Speech-language pathologists utilize hands, food and other objects to help a client become more aware of the different parts of his mouth and to help him learn to discriminate different sensory parameters of oral stimuli. These activities build a firm tactile foundation for learning phonemes by place and manner, and for eating. Such activities are represented broadly throughout the literature, but are especially prominent in texts with a sensorimotor and neurodevelopmental basis. Older texts often recommended these as part of their speech “warm-up” activities. Examples:

To develop general oral sensory awareness: “Learn to recognize the movement as part of some familiar biological movement such as chewing, swallowing, coughing … chew in an exaggerated fashion … practice licking the lips and cleaning the tongue and cheeks with the tongue” (Van Riper, 1954, pp. 216-218).
To develop general oral sensory awareness and discrimination: “Provide many opportunities for the child to engage in generalized mouthing activities of the hands, simple environmental objects, and toys” (Morris & Klein, 2000, P. 411)
To develop oral sensory awareness and discrimination: “Massage is completed on both the external and internal oral structures. Intraoral massage … can increase intraoral awareness and has the potential to improve the child’s responses to sensation in the oral area” (Bahr, 2001, p. 177).
To develop sensory awareness of the lips: ” ‘Bite’ the lips. First the upper and then the lower lips are ‘sucked into’ the slightly open rows of teeth … ‘Rub’ both lips together. First right and left, then forward and backward” (Bauman-Waengler, 2004, p. 225)
To develop sensory awareness and discrimination of the mouth: “Slightly dampen a non-flavored Toothette … Massage [the client’s] lips using a twisting motion. While continuing the twisting motion, work into his mouth via the buccal cavity on both sides. Progress to the surface and lateral margins of his tongue” (Rosenfeld-Johnson, 2005, p. 146).

7. Direct Oral Movements

To direct means to “aim (something) in a particular direction” (Jewell and Abate, 2001, p. 483). Speech-language pathologists direct jaw, lip and tongue movements, as well as phonation and airflow, with their own arms, hands, fingers and other instruments, and with ideas. “Gestural cues … can provide additional information for the client” (Yorkson, Beukelman, Strand and Bell, 1999, p. 554). Activities to direct oral movement or airflow were mentioned in approximately half the literature reviewed. Examples:

To direct air stream for /s/: “Have the patient practice emitting expired breath streams thru [the] small hole … of a hollow, rubber tube” (Borden & Busse, 1929, p. 184).
To direct tongue tip elevation to the alveolar ridge for production of /l/: “Place thumb and middle finger in a flattened position on upper lip points 2. Press evenly while phonating” (Vaughn & Clark, 1979, p. 200).
To direct tongue elevation for /ɚ/: “Tell the client you are going to pull on an imaginary string attached to the back of his head. As you pull the imaginary string up from the back of the client’s head, instruct the client to lift the back of a tensed tongue and say /ɚ/” (Secord et al, 2007, p. 153).

8. Dissociate Oral Movements

To dissociate means to “disconnect or separate” (Jewell & Abate, 2001, p. 494). “The ability to dissociate one movement from another and separate the movement of different parts of the body, is necessary in the developmental progression toward refinement of gross and fine motor skills” (Morris & Klein, 2000, p. 63). “Of particular importance in articulating is the ability to disassociate movements of the tongue from movements of the mandible or lips” (McDonald & Chance, 1964, p. 124). “When dissociation and grading have not developed, compensatory postures or fixing occurs … [This] inhibits mobility and thus reduces skill levels for both feeding and speech clarity” (Rosenfeld-Johnson, 2005, p. 7). Speech-language pathologists help clients dissociate between movements of the jaw, lips and tongue so that appropriate movements can be made for phoneme production and feeding skills. Techniques to dissociate jaw, lip and tongue movements appeared in many of our researched texts. Examples:

To dissociate tongue movement from jaw movement for /t/: “The insertion of the broad side of a tongue depressor between the side teeth and holding it steady while repeating t, t, t, in rapid succession will assist in securing independent action of the tongue” (Nemoy & Davis, 1937, p. 90).
To dissociate tongue tip from lip movement in production of /l/: “Retract the lips sharply, holding them back with the fingers if necessary, and ask the child to sing ‘la-la-la'” (Berry & Eisenson, 1956, p. 151).
To dissociate tongue movement from lip movement for /r/: “The lip retractor is a device designed for use by orthodontists for photographing the teeth. Placed correctly in the mouth, the lip retractor pulls the lips laterally. With the lip retractor in place, most clients will be unable to move the lips at all. This is a great way to help them focus on what their tongues should be doing” (Marshalla, 2004, p. 113).

9. Exaggerate Oral Movements

To exaggerate is to “represent (something) as being larger, greater, better, or worse than it really is” (Jewell & Abate, 2001, p. 590). Speech-language pathologists often exaggerate jaw, lip and tongue movements to make them salient for the client. Exaggeration of oral movement also is required of the client himself in order to help him understand his own oral movements, and to make his or her oral movements more precise. Recommendations to exaggerate oral movements appeared in a wide variety of texts. Examples:

To exaggerate as a general articulation method: “When the correct sound has been produced … the [client] should hold it, increasing its intensity, repeating it, whispering it, exaggerating it, and varying it in as many ways as possible without losing its identity. He should focus his attention on the ‘feel’ of the position in terms of tongue, palate, jaws, lips, and throat” (Van Riper, 1954, p. 239).
To exaggerate in order to understand incorrect movements: “Encouraging exaggeration of the undesirable movement will make it more obvious to the child” (McDonald & Chance, 1964, p. 124).
To exaggerate between oral position for /m/ and vowels in simple CV syllables: “Exaggerate the contrast between lips tightly closed and widely parted on /mah/, /maw/, and /mo/. Sustain the closed portion for a couple of seconds before opening the mouth” (Hanson, 1983, p. 201).
To exaggerate overall precision of articulation: “When a [dysarthric] patient’s articulatory movements are imprecise, he or she may be taught to exaggerate them, making them more precise” (Brookshire, 1992, p. 264-265).

10. Increase or Decrease Muscle Tone for Oral Movements

Muscular tone is “the degree of stiffness” in the musculature “to stabilize or move the skeleton” against gravity (Boehme, 1990, p. 210). “Even a relaxed muscle has a residual low-level turgor or feeling of firmness” (Rasch & Burke, 1978, p. 48) referred to as its tone. Tone can be too high (hypertonic) or too low (hypotonic): (1) Hypertonic muscles are hyper functional and in a state of excess or continual contraction. Hypertonic muscles cause body parts to move stiffly and in a jerky fashion. When severe, hypertonicity can cause body part immobility. (2) Hypotonic, or lax muscles, on the other hand, are slower and weaker in their contraction, and they tend to lack endurance for sustained contraction. Hypotonicity also can cause body part immobility when it is severe.

Speech-language pathologists use techniques to increase or decrease muscle tone in order to encourage more mature jaw, lip and tongue movement patterns for speech and feeding. “Stroking, tapping, kneading, rocking, bouncing, slapping, shaking, stretching, and compressing techniques may all be used to influence the type of muscle tone displayed by the child” (Mysak, 1980, p. 243). Oral muscles can be considered light-work muscles. “Muscles may be activated by stroking the skin area over the belly of the muscle or the area over its insertion. Brushing activates light-work muscles” (McDonald & Chance, 1964, p. 70). Older textbooks on articulation therapy that were published in the first half of the century tended to report general relaxation techniques to reduce tone, and they recommended drill-like exercises to increase tone. Newer texts that dealt with the neuromuscular and sensorimotor bases of articulation or feeding disorder described techniques to increase or decrease muscular tone using methods of physical manipulation. Examples:

To decrease muscle tone in the tongue for production of lingua phonemes: “Request the patient to protrude the tongue so that it can be grasped gently. Next, pull it forward as completely as possible … Once fully withdrawn the tongue is slowly pulled to the right corner of the mouth, held there for an out-loud count of 10 seconds, and then smoothly moved across the midline to the left corner of another count of 10 seconds to complete the trial. Although the degree of hypertonicity present will probably produce resistance to these adjustments, maintaining the lateral pulling force along the way usually proves fruitful after 10 or 15 trials with most patients” (Dworkin, 1991, p. 197).
To increase muscle tone in the tongue: “Suction tongue against ‘roof’ of mouth, as if ready to ‘pop.’ Keep whole tongue tight against top and pull chin down … Never [move the] tongue off the top. Repeat 5 times. This exercise can be difficult. If tongue falls [from] the top of the mouth, try again” (Czesak-Duffy, 1993, p. 28).
To decrease muscle tone in the facial muscles: “Use facial molding … begin with a general massage of the child’s body and face … gently mold or massage the face toward a closed mouth/closed lip position” (Morris & Klein, 2000, p. 415).

11. Increase Range of Motion for Oral Movements

Range is “the area of variation between upper and lower limits on a particular scale” (Jewell & Abate, 2001, p. 1409). Range of motion, as it relates to bodily movement, refers to the extent to which the body can flex and extend, lateralize left and right, and rotate around its axes. The full range of oral movement is explored in infancy and early childhood during feeding, mouthing and vocal play. A child and an adult can extend the jaw, lips, and tongue to their full range. But a child must learn to move his articulators inside this full range in order to achieve the refined jaw, lip, and tongue movements necessary for mature speech sound production. Moving within a full range of movement is known as grading movement. In the older articulation literature, “range” was called “flexibility of the articulators” (Berry & Eisenson, 1956, p. 139).

The process of learning the full range of oral movement during childhood can be hampered by several factors including muscle tone disturbance. In general, hypertonicity restricts range because of stiffness, while hypotonicity restricts range because of weakness. This is true of adults with motor speech disorders, too. For example, spastic dysarthria is characterized by “four major abnormalities of muscular function: spasticity, weakness, limitation of range, and slowness of movement” (Darley, Aronson & Brown, 1975, p. 131). Limited range also is seen in adult patients with low tone. “The salient feature of hypokinetic disorders is marked limitation of range of movement” (p. 177). Speech-language pathologists utilize techniques to help clients increase range of jaw, lip, and tongue movement so that appropriately graded oral movements can be achieved over time. Examples:

To increase range of jaw, lip and tongue movements for speech: “Have the patient perform lip, tongue, lower jaw … exercises calculated to give these organs increased flexibility and hence greater capacity to adjust themselves in new positions” (Borden & Busse, 1929, p. 182).
To increase range of face, lip and jaw movements in speech warm-up activities: “Imitate the faces of clowns by retracting the lips, protruding the lips, and by dropping the jaw as far down as possible while producing [vowels]” (Berry & Eisenson, 1956, p. 139).
To increase range of motion in the tongue for eating and swallowing: “The patient should be asked to open his or her mouth as wide as possible, hold it there for 1 second, and release it. Then the patient should elevate the back of the tongue as far as possible, hold it there for 1 second, and release it. This procedure should continue with the patient stretching the tongue to each side as far as possible, extending the tongue out of his or her mouth as far as possible, and pulling it back as far as possible, holding it for 1 second in each direction” (Logemann, 1983, p. 133).

12. Inhibit Oral Movements

To inhibit means to “slow down or prevent (a process, reaction, or function)” (Jewell & Abate, 2001, p. 873). “To inhibit a response means to decrease the strength of the response or to stop the response from occurring” (Bahr, 2001, p. 91). Inhibition and facilitation techniques are basic to neurodevelopmental treatment (NDT) (Langley and Thomas, 1991, p. 1). NDT is a motor therapy with many goals including: “To inhibit primitive reflexes, abnormal postures, and abnormal movement patterns or compensatory movements” (Langley & Thomas, 1991, p. 18). Speech-language pathologists inhibit unwanted oral movements so that those required for specific phonemes and feeding skills can be facilitated. Techniques are employed to prevent habitual, reflexive, tone-based, or undifferentiated movement patterns from overriding the client’s attempts at new movement. Methods to inhibit or prevent specific jaw, lip and tongue movements appeared in many of our researched texts. Examples:

To inhibit lip rounding for /l/: Place a small piece of Scotch tape. Vertically, at the corners of the mouth, with the lips slightly retracted. When the lips begin to move toward the /w/ position, the pulling of the tape signals the speaker that the unwanted movement is occurring” (Hanson, 1983, p. 214).
To inhibit tongue humping or bunching in order to encourage more tongue movement: “Treatment approaches … often include downward bouncing or patting on the tongue … The tongue can be stroked to obtain a central grooving or a lateral upward movement … Brushing the center of the tongue can facilitate flattening and a more central groove” (Morris & Klein, 2000, p. 607).
To inhibit tip elevation during production of /k/: “Using a tongue depressor, hold the tongue tip down behind the lower teeth to hinder the elevation of the tongue tip” (Secord et al, 2007, p. 30).

13. Maintain Oral Positions

To maintain is to “cause or enable (a condition or state of affairs) to continue” (Jewell & Abate, 2001, p. 1030). To maintain an oral posture is to hit and hold a posture for increasing lengths of time. Speech-language pathologists encourage clients to maintain oral positions in order to increase awareness, voluntary control, strength and skill of positions. Maintaining oral position was scattered throughout much of the researched literature. Examples:

To maintain lip-to-lip articulation for swallowing: “Once the patient is able to obtain lip closure, but has not habituated it, a graduated increase in the time required to maintain closure should be used. The patient may be asked to hold lip closure for 1 minute. This should be repeated 10 times per day” (Logemann, 1983, pp. 145-146).
To encourage lip-to-lip articulation for /p/: “Have the child pull the upper lip (using the lip muscles, not the finger) down over the upper teeth, with the mouth open, and hold for ten seconds” (Hanson, 1983, p. 201).
To maintain positions for consonants and vowels: “Another speech-motor training program is the Monitoring Articulatory Postures (MAP) … The program is in 3 phases. Phase I, Articulatory Posture Training, intends to teach the child to establish and to maintain vowel and consonant associated postures” (Jaffe, 1984, p. 178).
To maintain tongue tip elevation to the alveolar ridge: “Hold tip of tongue to the spot for at least 5 seconds, or as long as possible. Increase time to 30 seconds, continuing to press tip into the spot” (Gangale, 1993, p. 103).

14. Mark the Target of Oral Movements

To mark the target of oral movement means to indicate, through tactile means, the place where articulation should be made. Speech-language pathologists often use fingers or other tools to touch the place where articulation should occur. “Occasionally it is necessary only for the therapist to touch the articulatory organs at the point of contact” (Berry & Eisenson, 1956, p. 164). “The speech pathologist may touch the part of the child’s tongue that he wants to contact a certain place on the roof of the mouth, then touch that part of the palate or velum to demonstrate the nature of the desired articulation” (Hanson, 1983, p. 148). “Identify contacts by stroking or pressure” (Van Riper, 1954, p. 217). “Touch cues draw attention to an aspect of a sound’s production, typically the place of production” (Bleile, 2006, p. 8). “In the advanced levels of sensory assistance, the clinician concerned with speech production will find that light touching of a specific target on the palate followed by a touching of the tongue tip will help orient the tongue contact for the specific sound desired” (Nelson & Benabib, 1991, p.157). Marking a target is a form of tactile cueing. “While tactile cues outside the mouth are a part of the motokinesthetic approach, the speech-language pathologist can also give tactile stimulus inside the mouth with a tongue blade or applicator” (Bosley, 1981, p. 11). Examples:

To mark the lateral portions of the palate for production of /s/: Use “two knotted dental floss guides placed between maxillary lateral incisors and cuspids” (Vaughn & Clark, 1979, p. 183).
To mark the “spot” for tip-to-alveolar contact for correct oral rest posture: “At times we press against the spot with the end of a tongue depressor, then ask the patient to do the same. The parent watches closely, and may be asked to touch the child’s ‘spot’ with a tongue depressor” (Hanson & Barrett, 1988, p. 275).
To mark the soft palate for production of /k/: “Rub a moist cotton swab on a flavored food, such as a Lifesaver … Then touch the soft palate near the second molars with the swab and ask the client to raise the back of the tongue to the roof of the mouth to form a seal” (Secord et al, 2007, pp. 30-31).

15. Model Oral Movements

A model is “a system or thing used as an example to follow or imitate” (Jewell & Abate, 2001, p. 1096). A model is a physical representation of the desired movement or position. “The clinician uses speech production demonstrations as stimuli to induce images of desired articulatory actions, increase understanding of action sequences, and shape changes in the subject’s articulatory skills” (Fletcher, 1992, pp. 220-221) Speech-language pathologists model jaw, lip and tongue movements and positions for phoneme production and feeding skills. Live models are made with the therapist’s mouth. The hands also can be used to model movement and position. “One can often use the hands to demonstrate movements of the tongue relative to the palate. Let one hand represent the palate and the other the tongue … Then move the hand representing the tongue up or down as indicated” (Bosley, 1981, p. 13). Other three-dimensional models and pictures can be used as well. Clients are expected to imitate the required jaw, lip and tongue position from the visual information provided by the model. “We recommend that that the clinician attempt to elicit responses through imitation as an initial instructional method for production training. Usually the clinician presents several auditory models of the desired behavior (typically a sound in isolation, syllables, or words), instructs the client to watch his or her mouth and listen to the sound that is being said, and then asks the client to repeat the target behavior” (Bernthal & Bankson, 2004, p. 300). Techniques to model jaw, lip and tongue movements and positions appeared in almost all of our researched texts. Examples:

To model oral positions with apraxic patients: “Ordinarily, therapy is best conducted with the clinician and patient seated in front of a large mirror so the patient can watch both the clinician’s face as he speaks and his own face as he imitates the clinician’s model” (Darley, Aronson & Brown, 1975, p. 282).
To model lip position for /m/: “Exaggerate the degree of inter labial contact and have the child imitate you” (Hanson, 1983, p. 200).
To model tongue tip to the alveolar ridge for /t/: “Use hand gestures to demonstrate how to tap the tongue against the alveolar ridge” (Secord et al, 2007, p. 23).

16. Normalize Oral Tactile Sensitivity for Oral Movements

To normalize is to “bring or return to a normal condition or state” (Jewell & Abate, 2001, p. 1167). Tactile refers to the sensation of touch perceived through nerve endings in cutaneous tissue (skin). The lips, tongue, and palate contain very sensitive and highly discriminating cutaneous tissue. To normalize oral tactile sensitivity means to help a client accept, perceive and discriminate oral-tactile experiences in, on and around the mouth. “In order to move his speech organs correctly he must feel their movements” (Scripture, 1912, p. 122) “The various parts of the mouth need to relate to one another at a sensory level to coordinate their function” (Nelson & De Benabib, 1991, p. 137). Accurate oral movement is possible when the oral tactile system functions the way it should. Speech-language pathologists provide techniques to normalize oral-tactile sensitivity so that bi-labial, labio-dental, lingua-dental, lingua-alveolar, lingua-palatal and lingua-velar contact can be explored, utilized and habituated in phoneme production and feeding skills. Techniques to normalize oral tactile sensitivity appeared in a few early texts. Most examples were found in more recent texts that dealt with the neuromuscular and sensorimotor bases of articulation, feeding and motor speech disorders. Examples:

To normalize the hyper functional gag reflex that interferes with articulatory movement: “To lessen such sensitivity in these patients … the technique of maintained touch or pressure may be helpful” (Dworkin, 1991, p. 104).
To normalize sensitivity of the palate for lingua-alveolar, lingua-palatal and lingua-velar articulation: “We need to introduce touch to the front half of the palate, gradually moving back along the sides where the palate borders with the upper teeth. In the extremely sensitive mouth … the clinician will find it helpful to return to working on the cheeks and activating the tongue so that the individual will alter his or her own sensitivity level with spontaneous movement. We can gradually reach a tolerance for sustained touch on the forward half of the palate” (Nelson & Benabib, 1991, pp. 156-157).
To normalize oral tactile hypersensitivity for overall oral movement in speech and feeding: “If the child demonstrates atypical oral motor patterns, such as a hyper responsive gag reflex or tonic bite reaction, massage can be used to bring about an improved response” (Bahr, 2001, p. 115).

17. Practice Oral Movements

To practice is to “perform (an activity) or exercise (a skill) repeatedly or regularly in order to improve or maintain one’s proficiency” (Jewell & Abate, 2001, p. 1339). To practice is to rehearse, repeat, exercise, or drill. “The key ingredient in the typical skill-learning paradigm … is practice” (Ruscello, 1984, p. 146). Speech-language pathologists often require clients to practice specific jaw, lip or tongue movements in order to improve grading, dissociation, or direction of movement for phoneme production or feeding behavior. In a motor-skills approach, “Practice is the key variable thought necessary for mastery of any skilled motor behavior … Initially there is a sluggishness in the execution of motor skills because the learner is acquiring the movement. With practice, the motor skill is perfected and stabilized. Ultimately, the skill becomes a part of the learner’s repertoire of skilled movements and becomes automatic for the speaker” (Bernthal & Bankson, 2004, p. 295). “Corrected [oral motor] patterns are strengthened by intensive practice of carefully structured assignments” (Hanson & Barrett, 1988, p. 274). Speech-language pathologists use practice to: (1) habituate oral movements, (2) improve muscular strength and endurance for performance of an oral movement, (3) improve motor memory of a performed oral movement, (4) increase volitional control over oral movements, and (5) to make new oral movements automatic. The recommendation to practice jaw, lip and tongue movements appeared in most of our researched texts. Examples:

To practice tongue tip elevation for /l/: “Give tongue-lifting and tongue-lowering exercises, first in silence, then while blowing, then while whispering ah, then while saying ah. Gradually lift the tongue [tip] higher and higher until it finally makes contact at the right place” (Van Riper, 1954, p. 242).
To practice tongue tip elevation for lingua-alveolar phonemes: “Set the metronome to 30 [beats per minute], and instruct [the client] that the task is to raise and lower the tongue-tip alternately to the respective alveolar ridges according to the beat” (Dworkin, 1991, p. 223).
To practice lip movements: “Pucker the lips, then relax; repeat … Spread the lips, then relax; repeat … Round the lips in a wide O, relax; repeat” (Bauman-Waengler, 2004, p. 225).
For parents to practice lip movements with their children: “Blow bubbles … Blow kisses … Blow whistles or party favors … Blow on a pinwheel … Hum your favorite song together” (Dougherty, 2005, p. 89).

18. Resist Oral Movements

To resist is to “withstand the action or effect of” (Jewell & Abate, 2001, p.1449). “Resistance increases the response of muscles in voluntary action” (Mysak, 1980, p. 149). Resistance may “increase the active range of motion [and] guide voluntary motion” (Mysak, 1980, p. 149). “There is … a slight tendency for the articulators to respond … to contrary direction techniques, and these can be used to assist the client [with oral movement]” (Bosley, 1981, p. 12). “Muscles exercised repeatedly against low resistance with numerous contractions will improve endurance” (Love, 1992, p. 152). “Resistance to a movement is achieved by the therapist who applies counter pressure against the surface toward which the motion is made” (McDonald & Chance, 1964, p. 72). “Isometric exercise involves exertion against stationary resistance” (Duffy, 1995, p. 384). Speech-language pathologists resist jaw, lip and tongue movements in order to develop new movements and to facilitate improved movement of these parts. Resistance techniques were found in a wide variety of textbooks. Examples:

Use of resistance to facilitate lip protrusion: “[Have the client] retract the lips for e [i]; as the therapist holds them back, [the client should] force the lips into protrusion” (Berry & Eisenson, 1956, p. 139).
Use of resistance to increase masseter strength: “The patient is asked to bite the posterior teeth together while counting to ten and forcing the masseter muscle to activate … the forced activation of the masseter muscle strengthens it as the muscle adapts to the stress of biting action” (Garliner, 1981, p. 37).
Use of resistance to facilitate lateral tongue elevation for /s/: “If the elevation is difficult, have him work on lifting the sides of the tongue against resistance. This resistance can be supplied by a pair of swab sticks pushing downward on the sides of the tongue” (Hanson, 1983, p, 228).
Use of resistance to improve lip function using a quarter-sized button: “Loop the string through two buttonholes and tie a knot at the end. After instructing the patient to close the teeth, position the button against the teeth behind the midline of the lips … In a tug-of-war fashion, pull on the string with moderate force as the patient is required to resist this effort to dislodge the button by vigorously contracting the circumoral musculature” (Dworkin, 1991, p. 213).
Use of resistance to strengthen tongue-tip extension: “Stick out the tongue as far as possible, keeping it hard and straight. … place horizontal length of [tooth] brush against tip. Push against tongue, keeping the tongue hard and unmoving” (Czesak-Duffy, 1993, p. 46).

19. Speed Up or Slow Down Oral Movements

Speed refers to the “rapidity of movement or action” (Jewell & Abate, 2001, p. 1639). “The fundamental speed of speech movement is the most rapid of any movement in the body” (Nelson & De Benabib, 1991, p. 135). Many clients “do not move with the speed and precision demanded by good speech … When poor muscle co-ordination is an important factor in producing the articulatory errors, we devote part of our therapy to improving the speed and precision of the articulatory musculature” (Van Riper, 1954, p. 216). Speed of oral movement is addressed in therapy with clients who lose precision of movement as they approach the normal articulatory rate involved in connected speech. Examples:

To increase speed of oral movement: “Chew in an exaggerated fashion … Do this to a simple rhythm tapped out by the teacher, very slowly at first, then increasing speed” (Van Riper, 1954, p. 217).
Adjusting speed of oral movement in the treatment of apraxia: “Slowing the rate gives the individual more time to process sensory information … The speaker has more time to ‘feel’ the movement … Varying the rate can be an effective tool during repetitive practice of targeted utterances. This will facilitate habituation of articulatory movement” (Yorkson, Beukelman, Strand & Bell, 1999, p. 552).
To improve rate and rhythm of chewing: “Increase the timing and coordination of the chewing pattern … Encourage rhythmic activities during chewing … Many children will stomp their feet spontaneously or kick rhythmically as they are chewing” (Morris & Klein, 2000, p. 481).

20. Stabilize Oral Movements

To stabilize is “to make or become stable” (Jewell & Abate, 2001, p. 1656) or “not likely to change” (p. 1656). Stability is a fundamental concept in motor therapy. “We must have a stable base from which to develop movement and functional skills. Without that stability, our function or mobility is less controlled [and may be] impossible” (Morris & Klein, 2000, p. 62). There is an inter play of stability and mobility in all movement. Stability does not mean rigid or fixed, however. Stability is relative and dynamic: one part of the body holds relatively still so that another part can move with greater accurately. The body stabilizes proximally while moving distally. “Generally, the central or proximal parts of the body are the first to develop stability or become controlled. From a controlled, proximal base of stability, the infant can have the possibility of greater mobility and more refined distal control” (Morris & Klein, 2000, p. 62). “Postural control of a part of the body always precedes movement control of that part” (Mysak, 1980, p. 105).

Speech-language pathologists utilize techniques to stabilize the jaw for improved lip and tongue mobility. “The ability to stabilize the jaw creates the needed prerequisite for the development of skilled and refined tongue and lip movements” (Morris & Klein, 2000, p. 63). Techniques to stabilize the cheeks and face are used to improve lip mobility. Techniques to stabilize the back lateral margins of the tongue are used in order to facilitate improved mobility of other parts of the tongue. And techniques to stabilize the hip and should girdle, and the head and neck, also are incorporated in order to facilitate improved jaw mobility. “The emergence of stability and mobility functions is an essential part of speech skill development” (Fletcher, 1992, p. 13). Techniques to facilitate oral stability are found in a variety of texts. Examples:

To stabilize the jaw for improved tongue mobility for production of lingua phonemes: “Using a bite block to stabilize the mandible and reduce mandibular support during speech may help to increase independent lingual movement and result in improved oral articulation for speech … [The] bite block is placed between the first molars on one or both sides … With the block in place and following a period in which the child adjusts to the presence of the block, a series of speech sounds and sound sequences are presented for imitation by the child” (Crary, 1993, p. 224).
To stabilize the lips and facial muscles with low muscle tone: “Play patty-cake, peek-a-boo, and other children’s games that incorporate patting, tapping, stroking, and other types of tactile and proprioceptive stimulation of the cheeks and lips. Tapping can be done directly around the temporomandibular joint to provide better jaw stability for lip and cheek mobility” (Morris & Klein, 2000, p. 445).
To stabilize the back of the tongue for eliminating a frontal lisp: “We can help our clients keep the tongue inside the mouth by developing [the tongue’s] back lateral stability” (Marshalla, 2007, p. 115). Techniques include: “draw a picture,” “stroke the zones,” “smile,” “bite gently on the zones,” “establish the butterfly position,” “hold the butterfly position,” and “spread the back of the tongue” (p. 115-116).

21. Stimulate Reflexive Oral Movements

A reflexive action is “a response of some peripheral organ to stimulation of the sensory branch of a reflex arc, the action occurring immediately, without the aid of the will or without even entering consciousness” (Osol, 1973, p. 669). “Voluntary neuromuscular response may be facilitated through the use of reflex excitation … The procedure involves the simultaneous stimulation of the reflex and the voluntary motion in the same muscle group” (Mysak, 1980, p. 150). “Muscles may be activated by stroking the skin area over the belly of the muscle or the area over its insertion” (McDonald & Chance, 1964, p. 70). Speech-language pathologists use reflex stimulation to facilitate jaw, lip and tongue movement for phoneme production and feeding skill development. Techniques to stimulate reflexive oral movement appeared only in textbooks with a sensory and motor focus. Examples:

To stimulate tongue cupping: “The purpose of this exercise is to stimulate the involuntary reflex, similar to the grasp reflex, that depresses the middle portion of the tongue in response to a stimulus. … Tap the middle of the tongue with a tongue depressor … Continue tapping long enough to demonstrate the proper procedure, then have the patient do so. This is to be continued during each of the three practices each day for one minute” (Hanson & Barrett, 1988, pp. 278-279).
To stimulate elevation of the tongue’s lateral margins: “Touching or stroking a baby’s tongue elicits a spoon-shaped lingual configuration, characterized by an upraised ridge around its outer border … a similar posture could be elicited in adulthood by repeatedly touching, lightly stroking, or directing a stream of air across the tongue” (Fletcher, 1992, pp. 10-11).
To stimulate elevation of the back of the tongue for lingua-velar phonemes: “Back elevation can be facilitated by stimulating the Tongue Retraction Response (TRR). … Stroke down the middle of the tongue to about half way toward the back … The whole tongue humps up and back into a ball shape which completely fills the posterior oral cavity and occludes the airway” (Marshalla, 1992, p. 98).

22. Vivify Gross Oral Movements

To vivify is to “enlighten or animate” (Jewell & Abate, 2001, p. 1889). Some clients do not recognize the possibilities of their own oral movements. “Many individuals have difficulty in realizing how great a repertoire of tongue movements they possess … Too many articulation cases have only one or two stereotyped tongue movements in their speech repertoire … They need to learn how adaptable the tongue really is” (Van Riper, 1954, p. 238-239). “The chief enemies of clear articulation are a tight jaw, lazy tongue, and immobile lips … A large part of [this] re-education is kinesthetic: the child becomes aware, often for the first time, of what it feels like to open his mouth … to use his lips vigorously … and to perform certain important movements with his tongue” (Anderson, 1953, p.158). Speech-language pathologists use hands, fingers and other objects to vivify jaw, lip and tongue movement for feeding and speech. Stetson said, “Be alert to … chance success with the movement; nail it for the patient right then and there” (Hartson, 1988, p. 5). Techniques to vivify oral movement were found in a wide variety of textbooks. Examples:

To vivify general oral movement: “If these [phonetic placement] devices and instruments have any real value, it seems to be that of vivifying the movements of the tongue, and of providing a large number of varying tongue positions, from which the correct one may finally emerge” (Van Riper, 1954, p. 238).
To facilitate gross movement of the tongue: “Chew gum, rolling it to the side, ‘plaster’ it against the palate, slowly move the gum back over the palate, etc. Attempt to feel the tongue position with each movement” (Berry & Eisenson, 1956, p. 139).
To vivify gross oral movement for speech rehabilitation: “In instances of severe involvement … movement may be so limited that differentiation of the various vowels and consonants is next to impossible. One can try in such a case to help the patient concentrate his energy first on activities preliminary to speech production … The intent is to help the patient regain some concept of where his articulators are and where he must put them” (Darley, Aronson & Brown, 1975, p. 273-274).

SUMMARY

Eighty-four textbooks on articulation, phonology, motor speech, feeding, dysphagia, orofacial myology, and oral motor, as well as introduction to speech-language-hearing sciences and one parent guidebook, published from 1912 through 2007, were reviewed for their oral (jaw, lip, tongue) motor (sensory, movement, and positioning) techniques. It was discovered that these methods have had a prominent role in the speech-language-hearing profession, and that professionals of the highest rank have written about and advocated these methods. These methods were identified by at least 42 functional phrases throughout this century, from “tongue gymnastics”, in 1912, through “methods and techniques that can be used when the client cannot produce a target sound at all”, in 2007. These classic publications did not use, nor do they appear related to, the term “non-speech oral motor exercises”. The writers of oral (jaw, lip, and tongue) motor (sensory, movement, and positioning) techniques have relied upon a deep understanding of the way phonemes are produced. The term “exercise” meaning “activity” was used to refer to at least 22 “fundamental methods” of oral motor facilitation when these methods were viewed from a sensory and motor perspective. Although identical methods course through each of the treatment areas studied, there have been only two attempts to take a broad overview of this material. This article has proposed a framework to organize these methods based upon basic parameters of sensory and movement skill. This literature review revealed a cornucopia of techniques that satisfy the need for trial-and-error internal clinical evidence. Suggestions for future controlled studies to provide external evidence were made.

REFERENCES

Anderson, V. A. (1953) Improving the child’s speech. New York: Oxford University Press.
Arvedson, J. C., & Brodsky, L. (Eds.) (1993) Pediatric swallowing and feeding: Assessment and management. San Diego: Singular.
Asher, I. E. (1984) Management of neurologic disorders: The first feeding session. In Dysphagia: Diagnosis and management. Groher, M. E. (Ed.) (Pp. 133-155) Boston: Butterworths.
Bahr, D. (2008, January 16) A topical bibliography on oral motor assessment and treatment. Oral Motor Institute, 2 (1).
Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston: Allyn and Bacon.
Banotai, A. (2007, September 3) Reviewing the evidence: Gregory Lof’s critical take on oral-motor therapy. Advance for speech-language pathologists and audiologists, 17 (36).
Bauman-Waengler, J. (2004, 2000). Articulatory and phonological impairments: A clinical focus. Boston: Pearson.
Bernthal, J. E. & Bankson, N. W. (2004, 1981). Articulation and phonological disorders. Boston: Pearson.
Berry, M. F., & Eisenson, J. (1956) Speech disorders: Principles and practices of therapy. New York: Appleton-Century-Crofts.
Blache, S. E. (1982) Minimal word-pairs and distinctive features. In Phonological intervention: Concepts and procedures. Crary, M. (Ed.) San Diego: College-Hill. Pp. 61-96.
Blakely, R. W. (1983) Treatment of developmental apraxia of speech. In Current trends of communication disorders: Dysarthria and apraxia. Perkins, W. H. (Ed.) (Pp. 25-34) New York: Thieme.
Bleile, K . M. (2006) The late eight. San Diego: Plural.
Boehme, R. (1990) “Integration of neuro-developmental treatment and myofascial release in adult orthopedics.” In J. F. Barnes (Ed.), Myofascial release: The search for excellence: A comprehensive evaluatory and treatment approach (pp. 209-217). Peoli, PA: John F. Barnes.
Borden, G. (1984) Consideration of motor sensory targets and a problem in perception. In Treating articulation disorders: For clinicians by clinicians. Winitz, H. (Ed.) (Pp. 51-66) Baltimore: University Park Press.
Borden, R. C., & Busse, A. C. (1929). Speech Correction. New York: F. S. Crofts & Co.
Bosley, E. C. (1981) Techniques for articulatory disorders. Springfield: Charles C. Thomas.
Brookshire, R. H. (1992). An introduction to neurogenic communication disorders, 4th edition. St. Louis: Mosby.
Campbell, S. K. (1978) Oral sensorimotor physiology. In Oral-motor function and dysfunction in children, Wilson, J. M. (Ed.). Conference proceedings, May 25-28, 1977. Chapel Hill: University of North Carolina.
Chumpalik (Hayden), D. (1984). The PROMPT system of therapy. Seminars in speech and language, 5, pp. 139-156.
Crary, M. A. (1993). Developmental motor speech disorders. San Diego: Singular Publishing Group.
Creaghead, N. A., Newman, P. W., & Secord, W. A. (1989) Assessment and remediation of articultory and phonological disorders, 2nd edition. Columbus: Merrill.
Czesak-Duffy, B. A. (1993). Triathlon Articulation Training. Kearney, NJ: Creative Communication Concepts.
Darley, F. L., & Aronson, A. E., & Brown, J. R. (1975) Motor speech disorders. Philadelphia: W. B. Saunders.
Dollaghan, C. A. (2007) The handbook for evidence-based practice in communication disorders. Baltimore: Paul H. Brooks.
Dougherty, D. P. (2005) Teach me how to say it right. Oakland: New Harbinger.
Dworkin, J. P. (1991). Motor speech disorders: A treatment guide. St. Louis: Mosby.
Duffy, J. R. (1995) Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis: Mosby.
Elbert, M., & Gierut, J. A. (1986) Handbook of clinical phonology: Approaches to assessment and treatment. San Diego: College-Hill.
Fletcher, S. G. (1992). Articulation: A physiological approach. San Diego: Singular.
Flowers, A. M. (2003). The big book of sounds, 5th edition. Austin: Pro-Ed.
Folk, M. J. (1992). Straight speech. Vero Beach, FL: Speech Bin.
Gangale, D. C. (1993). The source for oral-facial exercises. East Moline, IL: LinguiSystems.
Garliner, D. (1981) Myofunctional therapy. Coral Gables: Institute for Myofunctional Therapy.
Groher, M. E. (1984) Dysphagia: Diagnosis and management. Boston: Butterworths.
Hanson, M. L. (1983) Articulation. Philadelphia: W. B. Saunders.
Hanson, M. L., & Barrett, R. H. (1988) Fundamentals of orofacial myology. Springfield: Charles C. Thomas.
Hardy, J. C. (1983) Cerebral palsy. Remediation of communication disorders series. Martin, F. N. (Ed.) Englewood Cliffs: Prentice-Hall.
Hartson, L. D. (1988). Stetson: A biographical sketch. In R. H. Stetson’s Motor Phonetics. Kelso, J. A. S., & Munhall, K. G. (Eds.) (Pp. 1-8) Boston: College-Hill.
Hawk, S. S., and Young, E. H. (1955). Moto-kinesthetic speech training. Stanford: Stanford University Press.
Hegde, M. N. (1998) Treatment procedures in communicative disorders. Austin: Pro-Ed.
Hodge, M., Salonka, R., & Kollias, S. (2005). Use of Nonspeech oral-motor exercises in children’s speech therapy. San Diego, CA: Poster session presented at the American Speech-Language-Hearing Association Convention, November 18.
Hodson, B. W., & Paden, E. P. (1983, 1991). Targeting intelligible speech: A phonological approach to remediation. San Diego: College Hill.
Irwin, J. V. (1972) Disorders of articulation Indianapolis: Bobbs-Merrill.
Jaffe, M. B. (1984). “Neurological impairment of speech production: Assessment and treatment (1984). In Speech disorders in children: Recent advances. Costello, J. M. (Ed.). (Pp. 157-186) San Diego: College-Hill.
Jewell, E. J., and Abate, F. (2001). The new Oxford American dictionary. New York: Oxford University Press.
Kantner, C. E., & West, R. (1933) Phonetics: An introduction to the principles of phonetic science from the point of view of English speech. New York: Harper & Brothers.
Kaufman, N. (2006) The Kaufman speech praxis workout book: Treatment materials and a home program for childhood apraxia of speech. Gaylord, MI: Northern Rehabilitation Services.
Kent, R. (2008) Personal correspondence. March 8.
Kent, R. (1980) Articulatory and acoustic perspectives on speech development. In The communication game: Perspective on the development of speech, language and non-verbal communication skills. Reilly, A. P. (Ed.) Pediatric Round Table: 4. (Pp. 38-42) Johnson & Johnson. United States.
Langley, M. B., & Thomas, C. (1991) Introduction to the neurodevelopmental approach. In Neurodevelopmental strategies for managing communication disorders in children with severe motor dysfunction. Langley, M. B., & Lombardino, L. J. (Eds.) (Pp. 1-28) Austin: Pro-Ed.
Lof, G. L., & Watson, M. (2004, November). Speech-language pathologist’s use of nonspeech oral-motor drills: National survey results. Philadelphia, PA: Poster presented at annual meeting of the American Speech-Language-Hearing Association.
Lof, G. L., & Watson, M. (2008). A nationwide survey of non-speech oral motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing Services in the Schools (in press).
Logemann, J. A. (1983) Evaluation and treatment of swallowing disorders. San Diego: College-Hill.
Love, R. J. (1992) Childhood motor speech disability. New York: Merrill.
Lowe, R. J. (1994) Phonology: Assessment and intervention applications in speech pathology. Baltimore: Williams & Wilkins.
Marshalla, P. J. (2007). Frontal lisp, lateral lisp: Articulation and oral-motor procedures for diagnosis and treatment. Mill Creek, WA: Marshalla Speech and Language.
Marshalla, P. J. (2004). Successful R therapy: Take your oral-motor and articulation therapy to new heights. Mill Creek, WA: Marshalla Speech and Language.
Marshalla, P. J. (1992). Oral motor techniques in articulation and phonological therapy. Seattle: Innovative Concepts.
McDonald, E. T., & Chance, B. (1964) Cerebral palsy. Englewood Cliffs: Prentice-Hall.
Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development, 2nd addition. Austin: Pro-Ed.
Mowrer, D. (1984) Correcting multiple misarticulations. In Treating articulation disorders: For clinicians by clinicians. Winitz, H. (Ed.) Baltimore: University Park Press. (Pp. 91-103).
Mysak, E. D. (1980). Neurospeech therapy for the cerebral palsied: A neuroevolutional approach, 3rd edition. New York: Teachers College Press.
Nelson, C. A., & De Benabib, R. M. (1991). Sensory preparation of the oral-motor area. In Neurodevelopmental strategies for managing communication disorders in children with severe motor dysfunction. Langley, M. B., & Lombardino, L. J. (Eds.) (Pp. 131-158) Austin: Pro-Ed.
Nemoy, E. M., & Davis, S. F. (1954, 1937). The correction of defective consonant sounds. Magnolia, MA: Expression.
Newman, P. W., & Creaghead, N. A., & Second, W. (1985) Assessment and remediation of articulatory and phonological disorders. Columbus: Charles E. Merrill.
Osol, A. (1973). Blakiston’s pocket medical dictionary, 3rd edition. New York: McGraw-Hill.
Rasch, P. J., & Burke, R. K. (1978). Kinesiology and applied anatomy: The science of human movement. Philadelphia: Lea & Febiger.
Rosenfeld-Johnson, S. (2001) Oral-motor exercises for speech clarity. Tucson: Talk Tools.
Rosenfeld-Johnson, S. (2005) Assessment and treatment of the jaw. Tucson: Talk Tools.
Ruscello, D. M. (1984) “Motor learning as a model for articulation instruction.” In Speech disorders in children: Recent advances. J. Costello (Ed.) (Pp. 129-156) San Diego: College-Hill.
Scripture, E. W. (1912). Stuttering and lisping. New York: MacMillan.
Secord, W. A., & Boyce, S. E., & Donohue, J. S., & Fox, R. A., & Shine, R. E. (2007). Eliciting sounds: Techniques and strategies for clinicians, 2nd edition. Clifton Park: Thomson Delmar Learning.
Stinchfield, S. M., & Young, E. H. (1938). Children with delayed or defective speech: Motor-kinesthetic factors in their training. Stanford: Stanford University Press.
Travis, L. E. (1931) Speech pathology: A dynamic neurological treatment of normal speech and speech deviations. New York: Appleton-Century.
Tuchmn, D. N., & Walter, R. S. (1994) Disorders of feeding and swallowing in infants and children. San Diego: Singular.
Van Riper, C. (1954, 1947, 1939). Speech correction: Principles and methods. New York: Prentice-Hall.
Van Hattum, R. J. (1980) Communication disorders: An introduction. New York: McMillan.
Vaughn, G. R., & Clark, R. M. (1979). Speech facilitation: Extraoral and intraoral stimulation technique for improvement of articulation skills. Springfield: Charles C. Thomas.
Weiss, C. E., & Lillywhite, H. S., & Gordon, M. E. (1980) Clinical management of articulation disorders. St. Louis: C. V. Mosby Co.
West, R., & Kennedy, L., & Carr, A., & Backus, O. (1947). The rehabilitation of speech. New York: Harper & Brothers.
Winitz, H. (1975) From syllable to conversation. Baltimore: University Park Press.
Wilson, J. M. (Ed.) (1978) Oral-motor function and dysfunction in children. Conference proceedings, May 25-28, 1977. Chapel Hill: University of North Carolina.
Yorkson, K. M., & Beukelman, D. R., & Strand, E. A., & Bell, K. R. (1999). Management of motor speech disorders in children and adults. Austin: Pro-Ed.
Young, E. H., & Hawk, S. S. (1955) Motokinesthetic speech training. Stanford: Stanford University Press.

APPENDIX A

Publications reviewed for the study by treatment area.

ARTICULATION

Anderson, V. A. (1953) Improving the child’s speech. New York: Oxford University Press.
Berry, M. F., & Eisenson, J. (1956) Speech disorders: Principles and practices of therapy. New York: Appleton-Century-Crofts.
Bleile, K . M. (2006) The late eight. San Diego: Plural.
Borden, R. C., & Busse, A. C. (1929). Speech Correction. New York: F. S. Crofts & Co.
Bosley, E. C. (1981) Techniques for articulatory disorders. Springfield: Charles C. Thomas.
Carrell, J. A. (1968) Disorders of articulation. Englewood Cliffs: Prentice-Hall.
Costello, J. M. (Ed.) (1984). Speech disorders in children: Recent advances. San Diego: College-Hill.
Czesak-Duffy, B. A. (1993). Triathlon Articulation Training. Kearney, NJ: Creative Communication Concepts.
Daniloff, R. G. (Ed.) (1984) Articulation assessment and treatment issues. San Diego: College Hill.
Diedrich, W. M., & Bangert, J. (1980) Articulation Learning. Houston: College-Hill.
Fletcher, S. G. (1992). Articulation: A physiological approach. San Diego: Singular.
Flowers, A. M. (2003). The big book of sounds, 5th edition. Austin: Pro-Ed.
Folk, M. J. (1992). Straight speech. Vero Beach, FL: Speech Bin.
Hanson, M. L. (1983) Articulation. Philadelphia: W. B. Saunders.
Hawk, S. S., and Young, E. H. (1955). Moto-kinesthetic speech training. Stanford: Stanford University Press.
Irwin, J. V. (1972) Disorders of articulation. Indianapolis: Bobbs-Merrill.
Kantner, C. E., & West, R. (1933) Phonetics: An introduction to the principles of phonetic science from the point of view of English speech. New York: Harper & Brothers.
Marshalla, P. J. (2007). Frontal lisp, lateral lisp: Articulation and oral-motor procedures for diagnosis and treatment. Mill Creek, WA: Marshalla Speech and Language.
Marshalla, P. J. (2004). Successful R therapy: Take your oral-motor and articulation therapy to new heights. Mill Creek, WA: Marshalla Speech and Language.
McDonald, E. T. (1964) Articulation Testing and treatment: A sensory-motor approach. Pittsburgh: Stanwix House.
Nemoy, E. M., & Davis, S. F. (1954, 1937). The correction of defective consonant sounds. Magnolia, MA: Expression.
Newman, P. W., & Creaghead, N. A., & Second, W. (1985) Assessment and remediation of articulatory and phonological disorders. Columbus: Charles E. Merrill.
Scripture, E. W. (1912). Stuttering and lisping. New York: MacMillan.
Secord, W. A., & Boyce, S. E., & Donohue, J. S., & Fox, R. A., & Shine, R. E. (2007). Eliciting sounds: Techniques and strategies for clinicians, 2nd edition. Clifton Park: Thomson Delmar Learning.
Sommers, R. K. (Ed.) (1983) Articulation disorders. Remediation of communicaion disorders series. Martin, F. N. (Series Editor). Englewood Cliffs: Prentice-Hall.
Stinchfield, S. M., & Young, E. H. (1938). Children with delayed or defective speech: Motor-kinesthetic factors in their training. Stanford: Stanford University Press.
Travis, L. E. (1931) Speech pathology: A dynamic neurological treatment of normal speech and speech deviations. New York: Appleton-Century.
Van Riper, C. (1954, 1947, 1939). Speech correction: Principles and methods. New York: Prentice-Hall.
Vaughn, G. R., & Clark, R. M. (1979). Speech facilitation: Extraoral and intraoral stimulation technique for improvement of articulation skills. Springfield: Charles C. Thomas.
Weiss, C. E., & Lillywhite, H. S., & Gordon, M. E. (1980) Clinical management of articulation disorders. St. Louis: C. V. Mosby Co.
West, R., & Kennedy, L., & Carr, A., & Backus, O. (1947). The rehabilitation of speech. New York: Harper & Brothers.
Weston, A. J., & Leonard, L. B. (1976) Articulation disorders: Methods of evaluation and treatment. Lincoln: Cliffs Notes.
Winitz, H. (Ed.) (1984) Treating articulation disorders: For clinicians by clinicians. Baltimore: University Park Press.
Winitz, H. (1975) From syllable to conversation. Baltimore: University Park Press.
Young, E. H., & Hawk, S. S. (1955) Motokinesthetic speech training. Stanford: Stanford University Press.

PHONOLOGY

Bernthal, J. E., & Bankson, N. W. (1994) Child phonology: Characteristics, assessment, and intervention with special populations. Current therapy of communication disorders series. Perkins, W. H. (Series Ed.) New York: Thieme.
Blodgett, E. G., & Miller, V. P. (1990) Easy does it for phonology: A complete program to remediate phonological disorders in young children. East Moline: LinguiSystems.
Crary, M. (1982) Phonological intervention: Concepts and procedures. San Diego: College-Hill.
Edwards, M. L., & Shriberg, L. D. (1983) Phonology: Applications in communicative disorders. San Diego: College-Hill.
Elbert, M., & Gierut, J. A. (1986) Handbook of clinical phonology: Approaches to assessment and treatment. San Diego: College-Hill.
Hodson, B. W., & Paden, E. P. (1983, 1991). Targeting intelligible speech: A phonological approach to remediation. San Diego: College Hill.
Ingram, D. (1976) Phonological disability in children. New York: Elsevier.
Lowe, R. J. (1994) Phonology: Assessment and intervention applications in speech pathology. Baltimore: Williams & Wilkins.

COMBINED ARTICULATION and PHONOLOGY

Bauman-Waengler, J. (2004, 2000). Articulatory and phonological impairments: A clinical focus. Boston: Pearson.
Bernthal, J. E. & Bankson, N. W. (2004, 1981). Articulation and phonological disorders. Boston: Pearson.
Creaghead, N. A., Newman, P. W., & Secord, W. A. (1989) Assessment and remediation of articultory and phonological disorders, 2nd edition. Columbus: Merrill.
Newman, P. W., & Creaghead, N. A., & Second, W. (1985) Assessment and remediation of articulatory and phonological disorders. Columbus: Charles E. Merrill.
Pena-Brooks, A., & Hedge, M. N. (2000) Assessment and treatment of articulation and phonological disorders in children. Austin: Pro-Ed.

MOTOR SPEECH (including cerebral palsy)

Brookshire, R. H. (1992). An introduction to neurogenic communication disorders, 4th edition. St. Louis: Mosby.
Crary, M. A. (1993). Developmental motor speech disorders. San Diego: Singular Publishing Group.
Darley, F. L., & Aronson, A. E., & Brown, J. R. (1975) Motor speech disorders. Philadelphia: W. B. Saunders.
Dworkin, J. P. (1991). Motor speech disorders: A treatment guide. St. Louis: Mosby.
Duffy, J. R. (1995) Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis: Mosby.
Hardy, J. C. (1983) Cerebral palsy. Remediation of communication disorders series. Martin, F. N. (Ed.) Englewood Cliffs: Prentice-Hall.
Kaufman, N. (2006) The Kaufman speech praxis workout book: Treatment materials and a home program for childhood apraxia of speech. Gaylord, MI: Northern Rehabilitation Services.
Kelso, J. A. S., & Munhall, K. G. (Eds.) (1988). R. H. Stetson’s Motor Phonetics: A retrospective edition. Boston: College-Hill.
Langley, M. B., & Lombardino, L. J. (Eds.) (1991) Neurodevelopmental strategies for managing communication disorders in children with severe motor dysfunction. Austin: Pro-Ed.
Love, R. J. (1992) Childhood motor speech disability. New York: Merrill.
McDonald, E. T., & Chance, B. (1964) Cerebral palsy. Englewood Cliffs: Prentice-Hall.
McNeil, M. R., & Rosenbeck, J. C., & Aronson, A. E. (Eds.) (1984) The dysarthrias: Physiology, acoustics, perception, management. San Diego: College-Hill.
Mysak, E. D. (1980). Neurospeech therapy for the cerebral palsied: A neuroevolutional approach, 3rd edition. New York: Teachers College Press.
Perkins, W. H. (Ed.) (1983) Dysarthria and apraxia. Current trends of communication disorders. New York: Thieme.
Rosenbek, J. C., & McNeil, M. R., & Aronson, A. E. (1984) Apraxia of speech: Physiology, Acoustics, Linguistics, Management. San Diego: College-Hill.
Vogel, D., & Cannito, M. P. (Eds.) (1991) Treating disordered speech motor control: For clinicians by clinicians. Austin: Pro-Ed.
Yorkson, K. M., & Beukelman, D. R., & Strand, E. A., & Bell, K. R. (1999). Management of motor speech disorders in children and adults. Austin: Pro-Ed.

FEEDING and DYSPHAGIA (adult and pediatric)

Arvedson, J. C., & Brodsky, L. (Eds.) (1993) Pediatric swallowing and feeding: Assessment and management. San Diego: Singular.
Groher, M. E. (1984) Dysphagia: Diagnosis and management. Boston: Butterworths.
Langley, J. (1988) Working with swallowing disorders. Bicester, Oxon: Winslow Press.
Logemann, J. A. (1983) Evaluation and treatment of swallowing disorders. San Diego: College-Hill.
Morris, S. E., & Klein, M. D. (2000, 1987). Pre-feeding skills: A comprehensive resource for mealtime development, 2nd addition. Austin: Pro-Ed.
Morris, S. E. (1982) The normal acquisition of oral feeding skills: Implications for assessment and treatment. Conference proceedings. Boston, MA June 20-23, 1981. Central Islip: Therapeutic Media.
Tuchmn, D. N., & Walter, R. S. (1994) Disorders of feeding and swallowing in infants and children. San Diego: Singular.

OROFACIAL MYOLOGY

Garliner, D. (1981) Myofunctional therapy. Coral Gables: Institute for Myofunctional Therapy.
Hanson, M. L., & Barrett, R. H. (1988) Fundamentals of orofacial myology. Springfield: Charles C. Thomas.

ORAL MOTOR

Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston: Allyn and Bacon.
Gangale, D. C. (1993). The source for oral-facial exercises. East Moline, IL: LinguiSystems.
Marshalla, P. J. (1992). Oral motor techniques in articulation and phonological therapy. Seattle: Innovative Concepts.
Rosenfeld-Johnson, S. (2001) Oral-motor exercises for speech clarity. Tucson: Talk Tools.
Rosenfeld-Johnson, S. (2005) Assessment and treatment of the jaw. Tucson: Talk Tools.
Wilson, J. M. (Ed.) (1978) Oral-motor function and dysfunction in children. Conference proceedings, May 25-28, 1977. Chapel Hill: University of North Carolina.

INTRODUCTORY (OR BROAD-BASED) SPEECH-LANGUAGE

Hegde, M. N. (1998) Treatment procedures in communicative disorders. Austin: Pro-Ed.
Travis, L. E. (1971) (Ed.) Handbook of speech pathology and audiology. Englewood Cliffs: Prentice-Hall.
Van Hattum, R. J. (1980) Communication disorders: An introduction. New York: McMillan.

GUIDE BOOKS FOR PARENTS

Dougherty, D. P. (2005) Teach me how to say it right. Oakland: New Harbinger.

APPENDIX B

Authors from our study who served as president of the American Speech-Language-Hearing Association (Source: American Speech-Language-Hearing Association Action Center):

Authors and Term(s)

• Robert W. West 1925-28
• Lee E. Travis 1935-36
• Sara Stinchfield-Hawk 1939-40
• Jon Eisenson 1958
• Rolland J. Van Hattum 1977
• Jerilyn A. Logemann 1994, 2000
• John E. Bernthal 2001
• Nancy A. Creaghead 2002

Please cite this article as:

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

THE ORAL MOTOR DEBATE – PART I

Oral Motor Institute
Volume 3, Monograph No. 1, 1 September 2011

THE ORAL MOTOR DEBATE – PART I

UNDERSTANDING THE PROBLEM

By Diane Bahr, MS, CCC-SLP, CIMI

Key Words: oral motor treatment, nonspeech oral exercise, controversy, evidence-based practice

ABSTRACT

Purpose

To study the origin of the “oral motor treatment” controversy beginning with general, negative statements heard by speech-language pathologists (SLPs) across the United States of America (USA), the reported sources of these statements, and the resulting problems in the field of speech-language pathology (SLP). The goal of Part I is to understand the origin of the debate, so effective resolutions can be explored in Parts II and III of this article series (Bahr, in press; Bahr & Banford, in press).

Method

Five-hundred SLPs from across the USA were surveyed to determine what they had heard regarding the “oral motor treatment” debate and from whom. In addition, 353 SLPs from across the USA including Puerto Rico were surveyed to help determine potential resolutions for the controversy. Participants received instructions on how to complete the surveys, but no information (about the subject) was provided, in order to avoid as much bias as possible.2

Results

Between 32 and 74 percent of the 500 SLPs responding to the “Survey on Oral Motor Treatment” reported hearing general, negative statements regarding “oral motor treatment” from a variety of typically reliable sources. These generalizations seemed to result from lack of uniform definition and terminology usage in the SLP field. SLPs also expressed 173 written concerns and questions via the “Survey for Future Research,” a follow-up to the “Survey on Oral Motor Treatment.”

Conclusions

Lack of uniform definition and terminology usage appeared to contribute to significant misunderstanding, confusion, disharmony, and concern throughout the SLP field. Therefore, the topic of oral sensory-motor assessment and treatment requires a thorough discussion, so appropriate resolutions can be determined and reflected in research projects, training programs, and treatment practices.

INTRODUCTION

During the last decade, the “oral motor treatment” controversy3 has specifically surrounded the use of nonspeech oral exercise/activities (i.e., only one aspect of oral sensory-motor4 treatment) in the facilitation of pediatric speech sound production. However, use of the encompassing term “oral motor treatment” to refer to nonspeech oral exercise/activities seemed to confound academics5, clinicians, speech-language pathology (SLP) students, and consumers of SLP services. In The ASHA6 Leader, Clark (2005, p. 8) spoke of the confusion and frustration resulting from “the inconsistent messages circulating throughout the profession regarding the use of oral motor treatments.” These inconsistent messages, along with imprecise terminology usage and discreet population identification, likely resulted in the following three (commonly heard) general, negative7 statements:

Oral motor treatment does not work.
There is no research on oral motor treatment.
ASHA does not support oral motor treatment.

Part I of this clinical series explores:

The prevalence and sources of these general statements according to surveyed speech-language pathologists (SLPs) in the United States of America (USA);
the accuracy of these negative statements;
an apparent relationship between these statements and lack of uniform definition/terminology usage and discreet population identification; as well as
ongoing concerns expressed by SLPs regarding the controversy

The data was collected for this clinical article series via two surveys (Appendix A and Appendix B). The purpose of Part I is to understand the origin of the “oral motor treatment” controversy prior to discussing possible resolutions in Parts II and III of this series. Part II (Bahr, in press) will cover SLP definitions and treatment practices. Part III (Bahr & Banford, in press) will discuss SLP research and training ideas/needs.

METHOD

Two surveys (developed by D. Bahr) were initiated by members of the Oral Motor Institute (OMI) to determine the origin, evolution, and possible resolution of the “oral motor treatment” controversy. The OMI is an all-volunteer group with more than 1100 members8 dedicated to studying the “oral sensory and motor components of articulation, motor speech, and feeding development, disorders, assessment, and treatment.”9

Survey participants were volunteer, consenting adults (SLPs) from all parts of the USA and Puerto Rico; therefore, no human subject review was required. SLPs (who completed the surveys) seemed to have some interest in the topic, as they attended workshops and participated in websites on the subject. Random groups of SLPs treating children with feeding, oral phase swallowing, and motor speech disorders may have revealed somewhat different results. However, the trends found in these surveys seemed accurate based on the literature discussed in Parts I, II, and III of this article series (Bahr, in press; Bahr & Banford, in press). Additionally, most individuals willing to take the time to complete surveys are likely to have an interest in the survey topic (which may influence the results of most surveys). The surveys are found in Appendices A and B.

“Survey on Oral Motor Treatment” (Appendix A)

Between February and September of 2008, five-hundred SLPs (across the USA) completed a simple one-page survey entitled “Survey on Oral Motor Treatment” to determine their perceptions, definitions, and practices relative to “oral motor treatment.” Questions on the survey were factual choices and not based on survey-takers’ viewpoints. Participants were asked to circle all responses that applied. The first two survey questions from the “Survey on Oral Motor Treatment” (Appendix A) are the focus of Part I of this series.

Regarding the survey process, SLPs completed the “Survey on Oral Motor Treatment” prior to the start of continuing education training programs,11 so that information presented in trainings would not impact respondent answers.12 No instructional time was taken from the continuing education programs for this process. The survey was also distributed to SLPs via the OMI and Marshalla Speech & Language websites.13

D. Starkey (an engineer who routinely used Microsoft Excel in research) helped D. Bahr develop the Excel database for the “Survey on Oral Motor Treatment.” The data was entered and the results were compiled by J. Bahr (a former business teacher who had taught Excel). The data and the compilation of results were double checked by D. Bahr (SLP). The results from the “Survey on Oral Motor Treatment” were initially presented at the November, 2008 ASHA Convention by Bahr (2008b).14

Group demographics for the “Survey on Oral Motor Treatment” are listed in Table 1. The 500 survey participants had a wide distribution of professional experience. The majority of SLPs completing the survey had more than five years of experience (i.e., 65%). Thirty-four percent had less than five years of experience, and 19 percent had greater than 20 years of experience. The majority of the participants lived in the northeastern and southern regions of the USA. Forty-one percent of the participants lived in the Northeast, 31 percent lived in the South, 10 percent lived in the Midwest, and 17 percent lived in the West. The regions were based on the United States Census Regions and Divisions map (2010).

“Survey for Future Research” (Appendix B)

Between November of 2008 and November of 2009, another simple one-page survey entitled “Survey for Future Research” (Appendix B) was completed by 353 SLPs across the USA including Puerto Rico. It was a “follow-up” survey to the previous “Survey on Oral Motor Treatment,” completing a two-year evaluation of the “oral motor treatment” debate by the OMI. The “Survey for Future Research” explored ideas to resolve the controversy (e.g., the development of academic-clinician research teams15 discussed in Part III of this article series; Bahr & Banford, in press). Data from the “Survey for Future Research” was compiled by R. J. Banford using Microsoft Excel.16

Regarding the survey process, 37 participants completed the “Survey for Future Research” following Bahr’s 2008(b) poster presentation at the ASHA Convention in Chicago, IL, and 316 participants responded to a survey request on the OMI and Marshalla Speech and Language websites. It is likely the “Survey for Future Research” and the “Survey on Oral Motor Treatment” had some of the same respondents, since the “Survey for Future Research” was a “follow-up” to the “Survey on Oral Motor Treatment” and both were distributed (at least partially) via the OMI and Marshalla Speech and Language websites.

Respondents (to the “Survey for Future Research”) were asked to circle any or all of the first 6 questions that were important to them regarding the resolution of the “oral motor treatment” controversy. Question 7 required written responses (i.e., “What other related questions do you have?”). Some of the 173 written responses are found in Part I as examples of the confusion, concern, frustration, and apparent disharmony in the SLP field surrounding the “oral motor treatment” controversy. Other questions from this survey will be discussed in Parts II and III of the article series (Bahr, in press; Bahr & Banford, in press).

Group demographics for the “Survey for Future Research” are listed in Table 2. Twenty-six percent of the participants lived in the Northeast, 18 percent lived in the South, 31 percent lived in the Midwest, 24 percent lived in the West, and one percent lived in Puerto Rico. Regions were based on the United States Census Regions and Divisions map (2010).

RESULTS AND DISCUSSION

General, Negative Statements Reported by SLPs

Between 32 and 74 percent of the 500 SLPs surveyed across the USA via the “Survey on Oral Motor Treatment” reported hearing the following general, negative statements:

“Oral motor treatment does not work.”
“There is no research on oral motor treatment.”
“ASHA does not support oral motor treatment.”

These statements seemed to reflect beliefs regarding the science surrounding oral sensory-motor treatment. The percentages of surveyed SLPs who heard these general, negative statements along with their reported sources are found in Table 3.

Seventy-four percent of SLPs (completing the survey) reported hearing the general, negative statement “Oral motor treatment does not work.” Fifty-six percent said they heard the statement “There is no research on oral motor treatment.” Approximately one-third of SLPs reported hearing “ASHA does not support oral motor treatment.”

SLPs most frequently reported hearing these generalizations from colleagues (55%) and professors/instructors (42%). However, SLPs also said they heard them from newsletters/magazines (35%) and peer-reviewed journal articles (25%). All of these sources are typically considered reliable in the SLP field.

The Accuracy of These General, Negative Statements

According to Webster’s New Collegiate Dictionary (1980, p. 473), “to form generalizations” means “to make vague or indefinite statements.” Generalizations usually contain a partial truth but may not be completely accurate. Their meaning is often defined by the person making the generalization; however, the person hearing the generalization may have a different interpretation. In the “oral motor treatment” controversy, the three generalizations reportedly heard by SLPs seemed misleading and raised significant professional questions regarding the actual practices in question.

Regarding the first generalization, what does the statement “Oral motor treatment does not work.” mean? That answer would depend on the individual speech-language pathologist’s definition of this treatment area as no standard definition appears to exist (examined in Part II; Bahr, in press). If the SLP includes all areas of oral sensory-motor function17 in the definition, this general statement does not appear logical or accurate because the following would be true:

Feeding and oral phase swallowing treatments do not work.
Motor speech treatment does not work.
Orofacial myofunctional treatment does not work.

Regarding the second generalization, is it accurate that there is “no research on oral motor treatment?” In 2008(a), Bahr compiled a partial bibliography of journal literature on oral sensory-motor topics for the OMI study group. She found 157 articles on feeding and oral phase swallowing, 113 articles on motor speech, 49 articles on oral sensory awareness/discrimination/facilitation, 42 articles on oral activities/exercises, and 11 articles on orofacial myofunctional therapy with additional articles available from the International Journal of OROFACIAL MYOLOGY (IJOM). It appeared that a significant body of peer-reviewed journal literature existed on feeding, oral phase swallowing, motor speech, and related oral sensory-motor topics.19

Bahr (2008a) also completed a brief review of the PubMed database in November of 2007. This review revealed almost 5000 journal articles with some form of the term “oral motor” (i.e., oral motor, oral-motor, oromotor, and oro-motor). Many oral sensory-motor articles had been published since the 1950s in fields such as medicine, dentistry, psychology, nutrition, occupational therapy, as well as speech-language pathology. Therefore, the general statement, “There is no research on oral motor treatment.” did not appear to be accurate.20

Regarding the third general statement, “ASHA does not support oral motor treatment,” no official statement on or definition of “oral motor treatment” was found on the ASHA website.21 However, ASHA has position statements and technical reports on various aspects of oral sensory-motor treatment that include orofacial myofunctional disorders, swallowing and feeding disorders, as well as childhood apraxia of speech (1991, 1993, 2001, 2002, 2007a, 2007b).

Recently, ASHA’s National Center for Evidence-Based Practice in Communication Disorders (N-CEP) completed 7 evidence-based systematic reviews (EBSRs) on oral sensory-motor topics. The apparent topic of the “oral motor treatment” controversy was evaluated in ASHA’s N-CEP “Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech” by McCauley, Strand, Lof, Schooling, and Frymark in 2009. The authors reported “insufficient evidence to support or refute the use of oral motor exercises to produce effects on speech…in the research literature” (p. 343).

ASHA’s EBSRs (facilitated by the N-CEP) indicated ASHA’s apparent interest in oral sensory-motor treatment. These EBSRs also revealed the crucial need for well-designed, oral sensory-motor treatment research with “well-described participant groups” (McCauley, et al., 2009, p. 343). Part III of this article series (Bahr & Banford, in press) will discuss ASHA’s EBSRs relative to SLP oral sensory-motor research and training needs/ideas.

Emergence of General, Negative Statements and Related Concerns

The previously discussed general, negative statements seemed to emerge from a generic use of the term “oral motor treatment,” where it was equated with “nonspeech oral exercise/activities.” Presentation and article titles in Table 4 provide concrete examples. Each title contains some generic form of the term “oral motor treatment” (i.e., oral motor therapy, oral motor training, or oral motor techniques). However, the authors and presenters seemed to be specifically discussing “nonspeech oral exercise/activities” (only one aspect of oral sensory-motor treatment).

Additionally, most of the articles and presentations listed in Table 4 referred to typically-developing children with phonological or articulation disorders, not children with feeding, motor speech, or other oral function disorders (e.g., children with Down syndrome, cerebral palsy, etc.). This distinction was not apparent in many of the article and presentation titles found in Table 4. Therefore, population ambiguity seemed to add to SLPs’ confusion and misunderstanding regarding the topic of the debate.

The Publication Manual of the American Psychological Association (APA, 2010, p. 23) states that a title “should be a concise statement of the main topic” and “fully explanatory when standing alone.” The titles in Table 4 do not appear to fulfill this requirement, which may help explain some of the apparent confusion regarding the term “oral motor treatment.” Application of APA principles may have assisted with topic clarity in these titles.

The articles and presentations in Table 4 were sorted into three categories for further analysis (i.e. theoretical opposition, research initiation, and understanding the problem). Consideration was given to the type of presentation/article, population identification, and whether listed titles were peer-reviewed and/or research journal articles. Peer-review and research have been central in the discussion of evidence-based practice (EBP) and the “oral motor treatment” controversy.

Several of the authors and presenters (listed in Table 4) were theoretically opposed to what they called “oral motor treatment/therapy” (e.g., Bowen, Lass, Pannbacker, and Ruscello). However, these individuals seemed to be discussing the indiscriminate use of nonspeech oral exercises and activities (e.g., “tongue wagging” and “cheek puffing”)22 in the treatment of children with mostly articulation and phonological disorders. Banotai (2007) also used the generic term “oral motor therapy” to describe G. Lof’s opposition to the use of nonspeech oral exercises. Those adamantly and vocally opposed to what they referred to as “oral motor treatment/therapy” may have inadvertently contributed to the prevalence of general negative statements surrounding oral sensory-motor treatment and the idea that clinicians and academics were on opposite sides of the controversy (See Part II; Bahr, in press).

Others (listed in Table 4) initiated research on the topic of concern. Polmanteer and Fields, (2002) studied six groups of preschool and kindergarten children exhibiting difficulties with phoneme production. Insalaco, Mann-Kahris, Bush, and Steger (2004) used an ABAB case-study design to assess traditional articulation treatment with and without oral exercise for an 8-year-old boy. Pruett-Hayes (2005) studied six 4-year-olds with functional articulation errors. Flaherty and Bloom (2007) studied 50 treatment sessions looking for a relationship between oral exercises used and treatment rationale. Forrest and Iuzzini (2008) used an alternating design to compare traditional speech production treatment to the use of nonspeech oral exercise in nine children. The populations under discussion were identified in 4 out of 5 of these article or presentation titles. While most of the studies were limited in scope and sample size, they demonstrated a step toward resolving the “oral motor treatment” controversy via necessary empirical research (discussed in Part III of this article series; Bahr & Banford, in press).

Ideas to promote understanding of the “oral motor treatment” controversy were found in two of the clinical articles listed in Table 4. Clark (2005, p. 8) spoke of the confusion and frustration experienced by clinicians resulting from “the inconsistent messages circulating throughout the profession regarding the use of oral motor treatments.” She suggested “a thorough understanding of the nature of neuromuscular impairments as well as the treatments” addressing these impairments for sound clinical decision-making. Williams, Stephens, and Connery (2006, p. 89) addressed definition and terminology problems. They stated, “Oral motor therapy is not discretely defined – it is an umbrella term, used to cover a whole variety of different approaches and techniques.” The Clark (2005) and Williams, et al. (2006) articles seemed to use the term “oral motor treatments/therapy” to refer to nonspeech oral exercise/activities in response to others’ generic use of the term. For example, the article by Williams, et al. (2006) was a direct response to the article written by Bowen in 2005 entitled, “What is the Evidence for Oral Motor Therapy?

The articles by Bowen (2005), Clark (2005), and Williams, et al. (2006) were clinical and theoretical23 in nature. They were not peer-reviewed. The Forrest and Iuzzini (2008) article is the only peer-reviewed, research article listed in Table 4. The topics of peer-review and research are discussed further in Parts II and III of this article series (Bahr, in press; Bahr & Banford, in press).

All of the titles listed in Table 4 reflected some generic use of the term “oral motor treatment,” where it was equated with “nonspeech oral exercise/activities.” Uniform definition and terminology usage could have assisted with clarity and avoided some of the confusion, misunderstanding, concern, and apparent disharmony within the SLP field surrounding oral sensory-motor treatment.

Ongoing Questions and Concerns Expressed by SLPs Surrounding the Controversy

The “Survey for Future Research” (Appendix B) explored ongoing SLP questions and concerns, as well as potential resolutions regarding the “oral motor treatment” controversy. While most of the items from the “Survey for Future Research” will be discussed in Parts II and III of this article series (Bahr, in press; Bahr & Banford, in press), SLP responses to Question 7 (i.e., What other related questions do you have?) illustrated many of the ideas presented in Part I.

Question 7 generated 173 written responses. Out of these 173 questions and comments, 20 concerned the controversy itself, 13 concerned other disciplines’ involvement, and 11 concerned definition and terminology usage. A sampling of responses is listed below in the words24 of the SLPs surveyed, supporting the need for a thorough discussion of the “oral motor treatment” controversy:

“From where in the profession did the initial disconnect in oral motor treatment begin?”
“Are individuals that have opposing views regarding oral motor therapy actually discussing the same issues?”
“Appropriate populations need to be clarified.”
“It seems as though the academics (college profs.) look down on oral motor theory/treatment but those in the field can see its benefits. Can’t we come to an agreement about its efficacy?”
“I teach a class at the graduate level that focuses on pediatric dysarthria and childhood apraxia of speech. I spoke about this topic…at a focus group…and am very concerned about the negativity that surrounds anything to do with oral motor.”
“Could subjective experiences surrounding the oral motor conflict (e.g., apparent professional bullying/elitism, apparent personal vendetta/gain) reflect deeper concerns within the profession?”
“There are so many different opinions on oral motor and its place in treatment, it would be nice to all be ‘on the same page’ about this issue.”
“My bottom line is how I can best facilitate improvement in my students’ swallowing, eating, and speaking skills…. I am very motivated to help my infants and toddlers and their caregivers but lack adequate training/experience/confidence in facilitating rapid change. The controversy only adds to my frustration in adequately assisting my clients.”
“Do SLPs realize that we are losing this aspect of speech pathology?…”
“Why are occupational therapists so active in oral motor work while SLPs continue to argue about it?”
“Is anyone concerned that if SLPs are not doing oral motor therapy, other therapists (occupational therapists, physical therapists) are going to start doing it?”
“….This debate, I believe, is reflective of the lack of collaboration between treatment and research.”
“Can ASHA present a position statement on the use of oral motor therapy and its use with various populations?…”
“When the ASHA committee states that there is no research to support the use of oromotor therapy, what are they referring to?”
“How do you define ‘nonspeech oral motor’?”
“How can we get those who insist on defining oral motor as NSOME [nonspeech oral motor exercises] to participate in useful dialogue?”
“How does one define successful oral motor therapy in terms of types of movement?…”
“I think it is important that the terminology we use be cohesive with reimbursable conditions so our patients can maximize the use of their insurance plans….”
“Why is there a conflict?”
“Why is there such anger?”

CONCLUSIONS AND CLINICAL IMPLICATIONS

There appears to be a relationship between the generic use of the term “oral motor treatment” (as exemplified by article and presentation titles in Table 4) and general, negative statements reportedly heard by SLPs across the USA (Table 3). These generalizations do not appear accurate and may misinform SLPs, SLP students, and consumers of SLP services regarding the science surrounding oral sensory-motor treatment. Contrary to the statements:

There are effective oral sensory-motor treatments (e.g., evidence-based feeding and motor speech treatments)
There is a significant body of research and journal literature on oral sensory-motor topics.
ASHA appears to support research that would provide the evidence on the efficacy of oral sensory-motor treatment.

SLPs continue to express confusion, misunderstanding, frustration, disharmony,26 and concern regarding this topic. However, there is currently no official or standard definition of the term “oral sensory-motor treatment” by ASHA. Without clear definition, clinicians and academics debating the merits or limitations of “oral sensory-motor treatment” may continue to find they are not referring to the same treatment practices. For example, the general statement, “oral motor treatment does not work” could be interpreted by some (who may not know the specifics of the controversy) as “feeding and motor speech treatments do not work.” The lack of uniform definition and terminology usage may confound the speech-language pathologist’s selection of appropriate and effective assessment and treatment approaches, ultimately impacting patient or client treatment outcomes and welfare.

Clark (2005, p. 8) suggested that “sound clinical decision-making” requires a thorough understanding of the problem. Sound clinical decision-making is crucial for EBP. Part I of this clinical article series discussed the apparent origin of the “oral motor treatment” controversy. The evolution of the debate and ideas for resolution will be covered Parts II and III of this series (Bahr, in press; Bahr & Banford, in press). Some of the questions explored in Parts II and III will be:

How do SLPs define oral sensory-motor treatment?
What types of oral sensory-motor techniques do SLPs use?
How much time do SLPs spend on these techniques in treatment?
Is there an appropriate place and use of nonspeech and/or nonfeeding oral sensory-motor treatments with appropriate populations?
How can the evidence-base for and required research on oral sensory-motor treatment be attained?
Is there a way to coordinate treatment and training materials as well as undergraduate, graduate, and continuing education programs on this topic?

RELATED INFORMATION

Acknowledgements

To all who participated in the surveys, data compilation, and feedback for this article series including the volunteer SLP, masked peer-reviewers who were independent of the OMI.

Declarations of Interest

The author, Diane Bahr, is the co-owner of Ages and Stages, LLC (a continuing education company and private practice) and volunteer co-chair of the OMI study group. She is also the author of Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development (Sensory World, 2010) and Oral Motor Assessment and Treatment: Ages and Stages (Allyn & Bacon, 2001).

Financial Support

No financial support was provided to those participating in the surveys, data compilation, or article review. The author volunteered her time to write the article. Rhonda J. Banford, MAT, CCC-SLP and Maigen Bundy, M. Cl. Sc., Reg. CASLPO voluntarily provided feedback and editing independent of the OMI. Members of the OMI board and others voluntarily reviewed this article and facilitated the masked peer-review process (independent of the OMI). The OMI website is donated by Marshalla Speech and Language.

Author Information

Diane Bahr, MS, CCC-SLP is a certified speech-language pathologist in private practice. She has also taught university and/or continuing education courses on the topics of neurology, childhood language and reading disorders, adult disorders, and augmentative communication as well as feeding, motor speech, and mouth function. Email questions and comments regarding this article series to dibahr@cox.net.

REFERENCES

Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010, November). Evidence-Based systematic review: The effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of Speech-Language Pathology, 19, 321-340.
American Psychological Association (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: American Psychological Association.
American Speech-Language-Hearing Association (1991). The role of the speech-language pathologist in management of oral myofunctional disorders, ASHA, 33 (Suppl. 5), 7.
American Speech-Language-Hearing Association (1993). Orofacial myofunctional disorders: Knowledge and skills, ASHA, 35 (Suppl. 10), 21-23.
American Speech-Language-Hearing Association (2001). Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders [Technical Report]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association (2002). Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders [Position Statement]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association (2007a). Childhood Apraxia of Speech [Technical Report]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association (2007b). Childhood Apraxia of Speech [Position Statement]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association (2010). Code of Ethics [Ethics]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association, National Center for Evidence-Based Practice in Communication Disorders (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Journal of Rehabilitation Research & Development, 46(2), 175-222.
Bahr, D. (2008a). A topical bibliography on oral motor assessment and treatment. Oral Motor Institute, 2(1). Retrieved from www.oralmotorinstitute.org/mons/v2n1_bahr.html.
Bahr, D. (2008b, November). The oral motor debate: Where do we go from here? Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL (Full handout available from http://convention.asha.org/handouts/1420_2054 Bahr_Diane_124883_Nov03_2008_Time_103047AM.doc).
Bahr, D. (in press). Part II – The oral motor debate: Exploring terminology and practice patterns. Oral Motor Institute. Monograph will be available from www.oralmotorinstitute.org.
Bahr, D., & Banford, R. J. (in press). Part III – The oral motor debate: Exploring research and training needs/ideas. Oral Motor Institute. Monograph will be available from www.oralmotorinstitute.org.
Banotai, A. (2007, September). Reviewing the evidence: Gregory Lof’s critical take on oral-motor therapy. Advance for Speech-Language Pathologists & Audiologists, 7-9.
Bowen, C. (2005). What is the evidence for oral motor therapy? Acquiring Knowledge in Speech, Language, and Hearing, 7, 144-147.
Clark, H. (2005, June 14). Clinical decision making and oral motor treatments. The ASHA Leader, 8-9, 34-35.
Flaherty, K., & Bloom, R. (2007, November). Current practices & oral motor treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Boston, MA.
Forrest, K., & Iuzzini, J. (2008, November). A comparison of oral motor and production training for children with speech sound disorders. Seminars in Speech and Language, 29, 304-311.
Insalaco, D., Mann-Kahris, S., Bush, C., & Steger, M. (2004, November). Equivocal results of oral motor treatment on a child’s articulation. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Philadelphia, PA.
Lass, N., Pannbacker, M., Carroll, A., & Fox, J. (2006, November). Speech-language pathologists’ use of oral motor treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Miami, FL.
Lof, G. L., & Watson, M. (2008, July). A nationwide survey of nonspeech oral motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing Services in Schools, 39, 392-407.
McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009, November). Evidence-based systematic review: Effects of nonspeech oral motor exercises on speech. American Journal of Speech-Language Pathology, 18, 343-360.
Pannbacker, M., & Lass, N. (2002, November). The use of oral motor therapy in speech-language pathology. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Atlanta, GA.
Pannbacker, M., & Lass, N. (2003, November). Effectiveness of oral motor treatment in Slp. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL.
Pannbacker, M., & Lass, N. (2004, November). Ethical issues in oral motor treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Philadelphia, PA.
Polmanteer, K., & Fields, D. (2002, November). Effectiveness of oral motor techniques in articulation and phonology treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Atlanta, GA.
Pruett-Hayes, S. (2005, November). Comparison of two treatments: Oral motor and traditional articulation treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, San Diego, CA.
Ruscello, D. M. (2005, November). Oral motor treatment: Current state of the art. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, San Diego, CA.
Scott, K. S., Bahr, D., Reardon-Reeves, N. (2009, November). Creating effective and efficient research teams. Session presented at the annual meeting of the American Speech-Language-Hearing Association, New Orleans, LA (Full handout available from www.asha.org/Events/convention/handouts/2009/1926_Scaler_Scott_Kathleen.htm.).
United States Census Information. (accessed May 1, 2010). United States Regions and Divisions map. Retrieved from www.eia.doe.gov/emeu/reps/maps/us_census.html.
Williams, P., Stephens, H., & Connery, V. (2006). What’s the evidence for oral motor therapy? A response to Bowen 2005. Acquiring Knowledge in Speech, Language, and Hearing, 8, 89-90.
Woolf, H. B. (Ed.). (1980). Webster’s New Collegiate Dictionary. Springfield, MA: G. & C. Merriam Company.

APPENDIX A

Survey on Oral Motor Treatment27State of Residence:________
Diane Bahr, MS, CCC-SLPToday’s Date:____________

Circle all responses that apply to you.

Have you heard:

Oral motor treatment does not work?
There is no research on oral motor treatment?
ASHA does not support oral motor treatment?

Where did you hear the above comment(s)?

Colleagues
Professors/Instructors
Newsletters/Magazines
Peer Reviewed Journal Articles

How long have you practiced speech-language pathology?

Undergraduate or Graduate Student
1-2 years
2-5 years
5-10 years
10-15 years
15-20 years
20+ years

How do you define oral motor treatment?

oral awareness/discrimination
oral activities/exercises
feeding/oral phase swallowing
myofunctional
motor speech

If you use oral motor techniques, what type do you use?

oral awareness/discrimination
oral activities/exercises
feeding/oral phase swallowing
myofunctional
motor speech

Circle approximate number of minutes per session you spend on each aspect of oral motor treatment:

oral awareness/discrimination (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)
oral activities/exercises (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)
feeding/oral phase swallowing (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)
myofunctional (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)
motor speech (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)

APPENDIX B

Survey for Future Research:State of Residence:________

Diane Bahr, MS, CCC-SLPToday’s Date:____________

Many specific questions regarding oral motor treatment became apparent from studying the likely root of the oral motor controversy, the “Survey on Oral Motor Treatment,” and the review of oral motor journal literature.

Circle questions important to you. Write other questions you have.

Would a clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myofunctional treatment, oral awareness/discrimination, and oral activities/exercises) help researchers and clinicians use the terminology more accurately?
How can SLPs become more cohesive as a profession? Could group-design research projects combining the efforts of researchers (often doctoral level SLPs) with SLPs who carry active caseloads (often master’s level SLPs) be developed?
What is being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function? Are students still being taught how to adequately conduct, interpret, and use the results of an oral examination?
How can continuing education better meet the needs of working therapists? Is there a way to better coordinate undergraduate, graduate, and continuing education on the topic of oral motor assessment and treatment as well as other topics?
Is there a professional interest in an updated text on oral motor assessment and treatment? Should researchers and practicing clinicians collaborate on this?
Is there an appropriate place and use of nonspeech and/or nonfeeding oral treatments with appropriate populations? What is this place and use?
What other related questions do you have?

ENDNOTES

1 Ages and Stages, LLC; Las Vegas, NV

2 Survey details are provided in the “Method” section of the article.

3 A controversy is “a discussion marked especially by the expression of opposing views” (Webster’s New Collegiate Dictionary, 1980, p. 245). This definition appears to best describe the oral motor debate.

4 The term “oral sensory-motor” seemed to best describe the functions and techniques under discussion in the debate. Adequate, organized sensory processing is required for adequate, organized motor function.

5 Academics are “member[s] of an institute of learning” (Webster’s New Collegiate Dictionary, 1980, p. 6).

6 The American Speech-Language-Hearing Association

7 Negative is defined as “expressing negation” using words such as “no” or “not” (Webster’s New Collegiate Dictionary, 1980, p. 762). It is a descriptive term.

8 S. Marshalla, personal communication, February 24, 2011.

9 Retrieved October 30, 2010 from www.oralmotorinstitute.org/index.html

10 Experimental human subject research requires a review from an independent review board (IRB). This survey did not require human subject review as survey participants were adults who choose to complete the survey with knowledge of its use. ASHA and other organizations use similar survey procedures without human subject review.

11 Participants completed surveys at workshops given by TalkTools Therapies and Ages and Stages, LLC before instruction time began. Participants were instructed in the completion of the survey but were given no other information, in order to avoid as much bias as possible.

12 While oral exercise was one topic of the trainings, feeding and motor speech were the foci.

13 www.oralmotorinstitute.org and www.pammarshalla.com

14 This database is extensive, lending itself to further queries/articles beyond the scope of the current article series.

15 Scaler Scott, Bahr, and Reardon-Reeves presented on the topic of academic-clinician research teams at the 2009 ASHA Convention in New Orleans, LA.

16 Rhonda J. Banford, MAT, CCC-SLP compiled the data from the “Survey for Future Research.” She used Microsoft Excel for the demographics and Questions 1 through 6. She used her SLP background to categorize the written responses to Question 7.

17 The various aspects of “oral sensory-motor” function may include feeding, oral phase swallowing, orofacial myology, motor speech, oral awareness/discrimination, and oral activities/exercises.

18 “Orofacial myology is a specialized professional discipline that evaluates and treats a variety of oral and facial (orofacial) muscle (myo-) postural and functional disorders and habit patterns that may disrupt normal dental development and also create cosmetic problems” (retrieved April 21, 2011from www.iaom.com/category/page/about/what-orofacial-myology).

19 Bahr (2008a) did not assess the quality of available peer-reviewed journal literature on oral sensory-motor topics; however, ASHA’s National Center for Evidence-Based Practice (N-CEP) has completed 7 evidence-based systematic reviews (EBSRs) on the topic.

20 Oral sensory-motor research will be discussed in Part III of this article series (Bahr & Banford, in press).

21 ASHA Website (www.asha.org) reviewed on November 28, 2010

22 Terms used by Lof and Watson (2008, p. 393) and others.

23 Clinical, theoretical articles usually contain ideas and hypotheses based on literature review and author opinion.

24 Information that could lead to identification of survey participants was omitted.

25 ASHA’s Code of Ethics (2010, p. 4) states, “Individuals’ statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations.”

26 ASHA’s Code of Ethics (2010, p. 4) states, “Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious interprofessional and intraprofessional relationships, and accept the professions’ self-imposed standards.”

27 It is recommended that future surveys use discrete time frames without overlapping years or minutes (e.g., 1-2 minutes, 3-5 minutes, 6-10 minutes, etc.).

Please cite this article as:

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

THE ORAL MOTOR DEBATE – PART II

Oral Motor Institute

Volume 3, Monograph No. 2, 17 November 2011

THE ORAL MOTOR DEBATE – PART II

EXPLORING TERMINOLOGY AND PRACTICE PATTERNS

By Diane Bahr1, MS, CCC-SLP, CIMI

Keywords: oral motor treatment, nonspeech oral exercise, controversy, evidence-based practice

ABSTRACT

Purpose

Part II of this article series explores the evolution of the “oral motor treatment” debate. It discusses speech-language pathologists’ (SLPs’) definitions and practice patterns and suggests some potential resolutions for the controversy.

Method

Five-hundred SLPs from across the United States of America (USA) were surveyed to determine their definitions and oral sensory-motor treatment practices. In addition, 353 SLPs from across the USA, including Puerto Rico, were surveyed regarding potential resolutions for the controversy. A review of pertinent journal literature provided background regarding the continued evolution of the “oral motor treatment” debate.

Results

SLPs included 5 treatment areas in their oral sensory-motor definitions and practices (i.e., feeding/oral phase swallowing, orofacial myology2, motor speech, oral awareness/discrimination, and oral activities/exercises). The “follow-up” survey (regarding controversy resolutions) revealed that 92 percent of the 353 surveyed SLPs thought clear definitions of oral sensory-motor function and the many aspects of oral sensory-motor treatment were important for the field.

Conclusions

While the “oral motor treatment” controversy has evolved, population ambiguity, terminology problems, and professional disharmony have persisted. Standard terms (with clear definitions) may assist SLPs in discussing the many aspects of oral sensory-motor treatment and in effectively resolving these problems. It is recommended that academics3 and clinicians work together on oral sensory-motor research, assessment and treatment development, and training.

INTRODUCTION

Part II of this article series explores the continued evolution of the “oral motor treatment” controversy and several questions:

How do speech-language pathologists (SLPs) define oral sensory-motor treatment?
What types of oral sensory-motor techniques do SLPs use?
How much time do SLPs spend on these techniques in treatment?
Is there an appropriate place for and use of nonspeech and/or nonfeeding oral sensory-motor treatments with appropriate populations?
How can the “oral motor treatment” controversy be resolved?

METHOD

SLPs’ definitions, practice patterns, and resolutions (relative to the “oral motor treatment” debate) were explored via two surveys initiated by the Oral Motor Institute (OMI)4. Five-hundred SLPs (across the United States of America/USA) completed the simple one-page survey entitled “Survey on Oral Motor Treatment” (Appendix A) between February and September of 2008. This survey explored SLPs’ perceptions, definitions, and practices on the topic of “oral motor treatment.” Three-hundred, fifty-three SLPs (across the USA, including Puerto Rico) completed the “follow-up,” one-page survey entitled “Survey for Future Research” (Appendix B) between November of 2008 and November of 20095. This survey explored the importance of suggested resolutions for the “oral motor treatment” controversy. The administration procedures and demographics for both surveys were reported in Part I (Bahr, 2011).

Five clinical, theoretical articles (Powell a & b, Ruscello, Lof & Watson, Lass & Pannbacker, 2008) provided the background for Part II. These articles were pertinent to the continued evolution of the “oral motor treatment” debate.

BACKGROUND INFORMATION: CONTINUED EVOLUTION OF THE “ORAL MOTOR TREATMENT” CONTROVERSY

The “oral motor treatment” controversy continued to evolve in 2008, when a group of academics (i.e., Powell a & b, Ruscello, Lof & Watson, and Lass & Pannbacker) presented their concerns in Language, Speech, and Hearing Services in Schools (LSHSS) via a “Clinical Forum.” LSHSS is an American Speech-Language-Hearing Association (ASHA) journal, and SLPs were the intended audience for this series.

The “Clinical Forum” articles combined literature review and theory with opinion. They were not research articles. These articles appeared to alleviate some of the confusion and misunderstanding regarding topics and populations under discussion in the “oral motor treatment” controversy. However, the “Clinical Forum” authors also expressed their ongoing concerns regarding oral sensory-motor clinical practices. Academics and clinicians seemed to be on opposite sides of the debate, and professional disharmony appeared to persist.

Treatments and Populations Discussed by the “Clinical Forum” Authors

The stated concern by the “Clinical Forum” authors was the use of “nonspeech oral motor treatments” (NSOMTs) and “nonspeech oral motor exercises” (NSOMEs) to facilitate speech production in children exhibiting “developmental speech sound disorders.” NSOMT and NSOME were discrete terms, no longer equated with the general term “oral motor treatment.” This may have alleviated some of the apparent confusion and misunderstanding among SLPs regarding the precise practices in question (discussed in Part I; Bahr, 2011).

Lof and Watson (2008, p. 394) defined NSOME as “any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities.” They stated that “most NSOMEs are decontextualized, and they dis-integrate the highly integrated task of speaking” (p. 395). Lass and Pannbacker (2008, p. 408) defined NSOMTs as “nonspeech movements of the speech mechanism such as exercise, blowing, icing, swallowing, and other nonspeech activities.” Based on these definitions, NSOMEs and NSOMTs did not appear to encompass oral sensory-motor activities used by SLPs to attain actual speech and voice production, such as:

using a kazoo to attain adequate respiration, voicing, and prosody;
placing a tongue depressor on the inner lip borders to help a child actually produce the “m” sound; or
using bite blocks to establish appropriate jaw heights while attaining front vowel sounds.

The terms NSOME and NSOMT were more descriptive than the general term “oral motor treatment” (previously used to describe the topic of the debate). However, these terms would likely benefit from further refinement. The term “nonspeech oral motor exercise” (NSOME) could be reduced to “nonspeech oral exercise,” since exercise is a motor activity6. The term “nonspeech oral motor treatment” (NSOMT) could be expanded to “nonspeech oral sensory-motor treatment,” since both sensory and motor treatment techniques were under discussion (Lass & Pannbacker, 2008).

The “Clinical Forum” authors identified children with “developmental speech sound disorders” as the population(s) of concern. Ruscello (2008, p. 380) defined “developmental speech sound disorders” as “a collective term that refers to clinical differences in the development of a child’s sound system.” Ruscello continued this definition by saying, “a child may exhibit sensory motor-based phonetic errors, linguistic errors, or a combination of these two types of errors.”

The term “speech sound disorder” appeared to be a general term used to describe mostly articulation and phonological disorders in typically developing children (Kamhi, 2005, p. 215). Bernthal, Bankson, and Flipsen (2009) seemed to confirm this idea in the title of their updated textbook Articulation and Phonological Disorders: Speech Sound Disorders in Children (6th ed.).

Both Ruscello (2008) and Powell (2008a, 2008b) mentioned the work of Shriberg and his colleagues, who developed the Speech Disorders Classification System (SDCS). The SDCS provides SLPs with a flow chart of defined pediatric speech disorders, based on a large epidemiological study (Shriberg, 1993, 1994; Shriberg, Austin, Lewis, McSweeny, & Wilson, 1997). However, the term “developmental speech sound disorders” (used by the “Clinical Forum” authors) did not appear to be an original subtype of the SDCS.

In addition, Ruscello (2008) made an important distinction between treatment of “developmental speech sound disorders” and treatment of childhood dysarthria. He stated (p. 386), “It should be noted that childhood speech disorders caused by neuromuscular deficits…need to be treated accordingly” and “the reader must be mindful of the fact that the client has a motor speech disorder, not a developmental speech sound disorder.” Childhood Apraxia of Speech (CAS)7 is also considered a motor speech disorder. Motor speech disorders did not appear to be the topic of discussion in the “Clinical Forum” articles.

Most of the “Clinical Forum” authors spoke of children with phonological disorders as the population of concern. Lof and Watson (2008, p. 397) added two other populations they described as language-based disorders (i.e., hearing impairment and late talking)8. However, Lass and Pannbacker (2008) spoke more generally about individuals with speech and swallowing disorders as populations of concern. Therefore, some population ambiguity seemed to persist.

Concerns about SLPs’ Clinical Practices

Powell (2008a, p. 374) began the “Clinical Forum” Prologue by citing Lof and Watson (2008). He summarized concerns regarding SLPs’ clinical practices with the following general statement: “Party horns…blow ticklers… bubbles… straws…. Items such as these are being used by speech-language pathologists (SLPs) across America to treat a wide range of communication disorders.” While Powell and others likely used general statements to “make a point,” the “Clinical Forum” authors seemed specifically concerned about SLPs using indiscriminate oral activities and exercises with the expectation of improving speech production in children (exhibiting mostly language-based speech disorders).

In addition, Lof and Watson (2008) seemed to question SLPs’ clinical decision-making and use of available science in practice. Here are three examples from Lof’s and Watson’s article:

“SLPs should not choose to use NSOMEs based simply on perceived therapeutic changes in the absence of any real data” (p. 395).
“Although opinions and a practitioner’s own clinical experience can be useful, they can also be biased” (p. 393, citing Lass & Pannbacker, 2008 and Kamhi, 2004).
Bernstein-Ratner (2005) speculated “that many practitioners do not read professional journals, nor do they typically incorporate new evidence into their existing belief systems”9 (p. 397).

A number of experienced master clinicians10 (e.g., D. Bahr, C. Boshart, D. Beckman, P. Marshalla, S. Rosenfeld-Johnson, P. Taylor, and others) were named in support of indiscriminate nonspeech activities by the “Clinical Forum” authors. Yet, most of the SLPs (in question) treated children with motor speech disorders (i.e., dysarthria and CAS). While children with motor speech disorders did not appear to be a topic of the “Clinical Forum” series, both Ruscello (2008, p. 386) and Powell (2008b, p. 423) identified children with dysarthria as one group likely to benefit from motor-based treatment. Additionally, most of the SLPs (in question) used a variety of specific tactile-proprioceptive techniques (including PROMPT11 and Moto-kinesthetics12) to attain actual speech production (Bahr, 2001; Bahr & Rosenfeld-Johnson, 2010). Based on Lof’s and Watson’s definition (2008, p. 394), activities that attain actual speech production are not NSOMEs.

Academics vs. Clinicians

The impression that academics and clinicians were on opposite sides of the debate seemed apparent throughout the “oral motor treatment” controversy. The academics (who wrote the “Clinical Forum” series) questioned clinical practices they perceived as widely used (Powell, 2008a, p. 374) and ineffective from a theoretical perspective. They cited other academics in support of their concerns. This may have added to the perception that academics and clinicians were on opposite sides of the controversy. Since ASHA’s membership and readership were mostly clinical service providers13, the Clinical Forum” article series may have inadvertently contributed to the apparent disharmony in the field.

Throughout the “Clinical Forum” series14, experienced master clinicians (e.g., D. Bahr, C. Boshart, D. Beckman, P. Marshalla, S. Rosenfeld-Johnson, P. Taylor, and others) were generally characterized as proponents of NSOME and NSOMT, while academics (e.g., H. Clark, M. Crary, R. Kent, M. Hodge, C. Moore, E. Strand, and others) were generally portrayed as opponents. As an example, Bahr’s textbook Oral Motor Assessment and Treatment: Ages and Stages (2001)15 was often cited as support for NSOMT and NSOME, while Clark’s tutorial (2003) on “neuromuscular treatments for speech and swallowing” was frequently cited as opposition16. Both publications were informational, peer-reviewed, and published by respected entities. Neither publication was research17 or opinion. However, Clark’s tutorial was characterized as a “seminal work” by Ruscello (2008, p. 384), while Bahr’s textbook was listed as “Level IV (opinion) evidence” by Lass and Pannbacker (2008, p. 416). Lof and Watson (2008, p. 393) listed Bahr’s textbook among self-published works; however, it was published by a respected speech-language pathology (SLP) publisher18.

Despite the perception that they were on opposite sides of the controversy, academics and clinicians named in the “Clinical Forum” articles seemed to have similar end goals (i.e., effective feeding, swallowing, and/or motor speech treatment). Their areas of expertise appeared more similar than different. See Table 1. Based on their expertise, these SLPs could likely combine their talents and efforts for the development and implementation of:

crucial research projects,
assessment and treatment procedures, and
training activities.

Clinical Opinion vs. Research

The “Clinical Forum” series combined literature review and theory with clinical opinion. While systematic in nature, no specific research processes (e.g., meta-analyses, randomized controlled studies, etc.) were reported. The articles most closely resembled Lass’s and Pannbacker’s (2008, p. 410) description of Level IV evidence (i.e., “Weak: Opinion of authorities, based on clinical experience”).

Most of the “Clinical Forum” authors were openly opposed to what had previously been referred to as “oral motor treatment,” now clarified as NSOME and NSOMT. The opinions found within the “Clinical Forum” series were likely filtered by the belief systems and biases of the authors. As examples, Lass and Pannbacker (2008, p. 418) said, “Unfortunately, despite a lack of supportive evidence, a number of SLPs have ‘jumped on the oral motor bandwagon’….” (when citing Peterson-Falzone, Trost-Cardamone, Karnell, and Hardin-Jones, 2006). Lass and Pannbacker stated (p. 417), “The quality of information from experts varies considerably from high quality and credible to low quality (i.e., biased and even deceptive and misleading).” They also stated, “The ethics of clinical practice requires a complex balancing of commitment to EBP [evidence-based practice] and the rights of clients/family to be accurately informed and protected from risks, harm, and exploitation” (p. 417). Words such as “bandwagon, deceptive, misleading, harm, and exploitation” seem pejorative and accusatory in nature21.

Table 2 provides a visual summary of the “Clinical Forum” series. The topics of peer review and research are central in the discussion of EBP and have been in the forefront of the controversy on “oral motor treatment.” All of the “Clinical Forum” articles were peer reviewed. However, none of the articles were research articles.

RESULTS AND DISCUSSION

Need for Standard Definitions and Terminology Usage

Part I of this article series (i.e., “The Oral Motor Debate: Understanding the Problem;” Bahr, 2011) documented the confusion, misunderstanding, and concern surrounding terminology usage and population identification in the “oral motor treatment” controversy. The “Clinical Forum” articles in LSHSS (July, 2008) revealed that the controversy had evolved, yet some population ambiguity and terminology problems continued.

The “Survey for Future Research” (Appendix B) explored the importance of standard terminology development and usage as a resolution in the “oral motor treatment” controversy. Ninety-two percent22 of 353 surveyed SLPs reflected their desire for clear definitions of terms by circling “Question 1” on this survey. It read, “Would a clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myofunctional treatment, oral awareness/discrimination, and oral activities/exercises) help researchers and clinicians use the terminology more accurately?”

Additional written comments and questions submitted by SLPs (completing the “Survey for Future Research”) confirmed the need for standard definitions and terminology usage to accurately identify topics and populations under discussion in the debate. Here are 5 examples:

“How does one define successful oral motor therapy in terms of types of movement?…”
“How can we get those who insist on defining oral motor [treatment] as NSOME to participate in a useful dialog?”
We need to “define different types of oral motor treatment for different types of populations/problems.”
“Appropriate populations need to be clarified.”
“…. Perhaps using more medically or neurologically based terminology will lend credibility to disorders ….”

The first step in standardizing terminology is definition. Since ASHA is the official SLP organization in the USA, the ASHA website was reviewed for a formal definition of “oral motor treatment.”23 None was found; however, ASHA (1991, 1993) had published guidelines for orofacial myology. The historical use of the term “oral motor” and recent attempts to define “oral motor treatment” were then reviewed.

Historically, the term “oral motor” appeared in 1980s journal literature as a general term, describing various aspects of mouth function. In 1987, Alexander presented information on both feeding and motor speech in an article entitled “Oral-Motor Treatment for Infants and Young Children with Cerebral Palsy.” Morris (1989) wrote an article entitled “Development of Oral-Motor Skills in the Neurologically Impaired Child Receiving Non-Oral Feedings.” In 1990, ASHA created a training module entitled “Issues in Oral Motor, Feeding, Swallowing, and Respiratory-Phonatory Assessment and Intervention (A Building Blocks Module).” As of November 2007, nearly 5000 journal articles contained some form of the term “oral motor” in the Pub Med database (Bahr, 2008a). The term appeared to be defined by authors’ use.

Recently, some SLPs have attempted to define oral sensory-motor function and treatment:

Bahr (2008b) suggested:
- Oral motor function is fine motor function of the oral mechanism (i.e., jaw, tongue, lips, and cheeks) for the purposes of eating, drinking, speaking, and other mouth activities.
- Oral motor treatment addresses sensory processing as well as dissociation, grading, direction, timing, and coordination of mouth movement for eating, drinking, speaking, and other mouth activities. The speech-language pathologist focuses treatment on eating, drinking, and speaking.
P. Flipsen (personal communication, February 17, 2011) suggested:
- ORAL-MOTOR ACTIVITY – any therapy activity involving the use of the oral musculature (e.g., lips, teeth[24], mandible, cheeks, velum) that DOES NOT INCLUDE the production of speech sounds at the same time. The goal of such activities is to improve the function of such musculature by way of improving such things as strength, flexibility, coordination, balance, tone and/or range of motion. Such activities might include (but not necessarily be limited to) use of horns, straws, chewing appliances, repetitive bubble blowing, repetitive lip rounding or retraction, and repetitive raising and lowering of the tongue or mandible.
- SPEECH-MOTOR ACTIVITY – any therapy activity involving the use of the oral musculature (e.g., lips, teeth, mandible, cheeks, velum) that INCLUDES the production of speech sounds at the same time. The goal of such activities is to practice real speech while providing supplemental and/or augmented input. Such activities might include (but not necessarily be limited to) traditional articulation therapy activities such as sound shaping, use of successive approximations, the moto-kinesthetic approach, use of touch cues and metaphors, and/or verbal descriptions of phonetic placement provided to the client to assist them in producing the actions and/or postures required to produce speech sounds. This would include the PROMPT[25] approach and any other similar approach, so long as real speech (i.e., at least a complete phoneme) was being produced during the activity.
Hammer (2007; personal communication, March, 7, 2011) defined “oral motor” as “having to do with movements and placements of the oral structures such as the tongue, lips, palate, and jaw.” He also said, “oral motor strategies” were “speech therapy… techniques which draw the child’s attention and effort to the oral musculature/articulators while simultaneously engaging the child in speech production practice.”
Marshalla (2004, p. 10) stated, “oral-motor therapy … can be defined as the process of facilitating improved oral (jaw, lip, tongue) movements.”
S. Rosenfeld-Johnson (personal communication, December 3, 2010) said:

Oral motor therapy is used for children and adults who cannot learn to imitate speech sounds based upon “look at me, listen to me and say what I say.” These clients are not able to imitate speech sounds through auditory and/or visual stimuli. However, when a tactile cue (tongue depressor between the lips for bilabials or a Bite Block holding the jaw in the desired location for an open mouth vowel product – “ah”) is added to the auditory and visual cues the client can produce the sound. Oral-motor therapy techniques add the tactile component to an already established program which is addressing speech clarity.
Strand (2010) stated:

When considering “oromotor” skill, one needs to differentiate between two main types of motor processing:
1. The execution problems that result from weakness, decreased range of motion, decreased speed or impaired coordination in movement of the oral articulators. This is usually caused by some impairment in the central or peripheral nervous system.
2. Problem with the ability to plan movement (praxis). This is usually caused by some determined (acquired) or undetermined (developmental) problem in [the] cortex.

These attempts at definition by individual SLPs may be a step toward standard terminology development and use. Perhaps some combination of these definitions could cover the many aspects of oral sensory-motor treatment in which SLPs engage. Standard and official terminology (established by ASHA and used by academics, students, and practicing clinicians) would help SLPs know they are speaking about the same topics and information when using terms. Without standard definitions, problems with terminology usage are likely to continue.

SLPs’ “Oral Motor Treatment” Definitions and Practice Patterns

SLPs’ definitions and practice patterns were studied and compared using two questions from “The Survey on Oral Motor Treatment” (Appendix A). Five-hundred SLPs were asked, “How do you define oral motor treatment?” and “If you use oral motor treatment techniques, what type do you use?” SLPs were given the following five choices and asked to circle all areas that applied for both questions:

feeding/oral phase swallowing
myofunctional
motor speech
oral awareness/discrimination
oral activities/exercises

Similar response distributions were found in SLPs’ definitions and practice patterns. Seventy-two percent included feeding/oral phase swallowing treatment in their definitions, and 62 percent said they used these techniques in practice. Fifty-three percent included orofacial myofunctional treatment in their definitions, and 40 percent said they used this in practice. Sixty-seven percent of surveyed SLPs included motor speech treatment in their definitions, and the same percentage said they used this type of treatment in practice.

A large percentage of SLPs identified oral awareness/discrimination and oral activities/exercises as aspects of their definitions and treatment practices. Eighty-five percent of the respondents included oral awareness/discrimination in their definitions, and 90 percent said they used these techniques in practice. Ninety-five percent included oral activities/exercises in their definitions, and 94 percent said they used these techniques in practice. These percentages are interestingly similar to ASHA’s (2006) percentages of SLP clinical service providers (i.e., 81%) and SLPs with master’s degrees (i.e., 93%) and may reflect what clinicians typically do in treatment. SLPs are trained to develop and use activities/exercises26 involving oral awareness/discrimination to facilitate and attain the functional processes of eating, drinking, and speaking (e.g., foods in cheesecloth or a safe-feeder placed on the back molars to teach chewing).

The results of the “Survey on Oral Motor Treatment” revealed that the majority of the respondents included all 5 areas surveyed (i.e., feeding/oral phase swallowing, orofacial myofunctional, motor speech, oral awareness/discrimination, and oral activities/exercises) in their definitions and treatment practices. These percentages were compared with ASHA demographics at the time of the survey (ASHA, 2007b). It seemed that surveyed SLPs treated more feeding/swallowing and orofacial myofunctional cases than SLPs within the general ASHA membership. For example, only 30 percent of ASHA’s membership reportedly treated swallowing, while 62 percent of the surveyed SLPs said they treated feeding/oral phase swallowing. Only 11 percent of ASHA’s membership reportedly treated orofacial myofunctional disorders compared to 40 percent of those surveyed. As stated in Part I (Bahr, 2011), SLPs completing the survey were likely to have an interest in the topic. They were also likely to be knowledgeable about the topic. Figure 1 summarizes SLPs’ definitions and practices as well as ASHA (2007b) demographics.

The “Survey on Oral Motor Treatment” (Appendix A) explored the time SLPs reported spending on feeding/oral phase swallowing, orofacial myofunctional, and motor speech27 treatment (i.e., the functional aspects of oral sensory-motor treatment). A similar distribution of treatment time was noted in all three treatment areas. The largest percentage of SLPs spent 5 to 10 minutes in the treatment of feeding/oral phase swallowing, orofacial myofunctional, and motor speech disorders. The distribution was generally a Bell curve, where most SLPs spent between 2 and 20 minutes in these types of treatment.

The time SLPs reportedly spent in the areas of feeding/oral phase swallowing and motor speech treatment seemed relatively low considering the typical complexity of these cases. This finding may be related to SLPs’ overriding responsibilities to address numerous treatment areas within their scope of practice, as well as SLPs’ training and comfort with these cases. It may also be related to the limited time SLPs have to treat clients because of increasing caseloads, decreased funding, and practice parameters in certain settings (e.g., educational vs. medical). Figure 2 provides a visual summary of time SLPs reportedly spent in feeding/oral phase swallowing, orofacial myofunctional, and motor speech treatment28.

SLPs’ Practices: Oral Awareness/Discrimination and Oral Activities/Exercises

The treatment areas of oral awareness/discrimination and oral activities/exercises have frequently been equated with NSOME and NSOMT during the “oral motor treatment” controversy. However, many of these activities do not fit the definition of NSOME provided by Lof and Watson, (2008, pp. 394 & 395). They are not “decontextualized” or disintegrated from function. In fact, many are used to attain the functional processes of eating, drinking, and speaking. For example, the placement of a sweet taste on the alveolar ridge behind the top front teeth can encourage tongue tip elevation as the clinician simultaneously facilitates the “t,” “d,” or “n” sounds via PROMPT29 (Hayden, 2004, 2006), Moto-kinesthetics (Young & Hawk, 1955), or another appropriate method.

The “Survey on Oral Motor Treatment” (Appendix A) explored the time SLPs reportedly spent on oral awareness/discrimination and oral activities/exercises during treatment. The survey revealed that most SLPs spent between 2 and 10 minutes on these areas. A significant decrease was noted beyond the 10 minute range for both areas. See Figure 3.

Since awareness/discrimination and activities/exercises are used in most areas of SLP treatment, surveyed SLPs could have been reporting on speech, nonspeech, feeding and/or nonfeeding activities. For example, repetitive speech sound practice is technically an oral sensory-motor activity/exercise. SLPs’ definitions (regarding the surveyed processes) likely varied based on clinical experience and training, since standard definitions seemed unavailable and terminology usage appeared inconsistent. The term “exercise” (the apparent topic of the debate) means “something performed or practiced in order to develop, improve, or display a specific power or skill” (Webster’s New Collegiate Dictionary, 1980, p. 397).

What about Nonspeech/Nonfeeding Oral Sensory-Motor Activities?

“Question 6” from the “Survey for Future Research” (Appendix B) asked the 353 surveyed SLPs about the importance of the following questions:

“Is there an appropriate place [for] and use of nonspeech and/or nonfeeding oral treatments with appropriate populations?”
“What is this place and use?”

Seventy-nine percent of the surveyed SLPs indicated these questions were important to them.

SLPs submitted 173 additional written comments and questions in response to the “Survey on Future Research.” Here is one participant’s comment about nonspeech/nonfeeding oral sensory-motor activities that seemed to summarize the thoughts and feelings of many SLPs on the topic:

…. I might very well use whistles and horns with a child, just to get their interest in general in the oral cavity, and I do not want that misconstrued as expecting a specific oral motor movement.

While this ‘controversy’ has been enlightening, I shall continue to use what I have found successful in the past with varying my approaches because of the uniqueness of the patient be that in their motivation, personality, or communication/dysphagia challenges….

Lof and Watson (2008, p. 396) explored the relationship between speech and nonspeech activities in their survey. They found that 93 percent30 of their respondents reported using combined approaches. Therefore, in the majority of cases, NSOMEs were likely combined with speech treatment and not used in lieu of speech treatment. They also reported that SLPs used NSOMEs primarily with children who exhibited motor speech disorders (i.e., those most likely to benefit from this type of treatment and who did not seem the original target of the debate). The rank order was “(1) dysarthria, (2) CAS [childhood apraxia of speech], (3) structural anomalies (e.g., cleft palate), and (4) Down syndrome” (p. 397). According to Lof and Watson (2008), fewer SLPs reportedly used NSOMEs with children who exhibited language-based speech disorders (the apparent population of concern in the “oral motor treatment” controversy).

In addition, Lof and Watson (2008, p. 396) reported the “10 most frequent benefits” of NSOME (according to their survey respondents) in rank order: “(1) tongue elevation, (2) awareness of the articulators, (3) tongue strength, (4) lip strength, (5) lateral tongue movement, (6) jaw stabilization, (7) lip and tongue protrusion, (8) drooling control, (9) velopharyngeal competence, and (10) sucking ability.” It is worth noting that lateral tongue movement, drooling control, and sucking ability are not speech processes (the apparent focus of Lof’s and Watson’s survey). However, this listing may actually reflect the systematic task analyses used by SLPs in treatment. For example, effective oral phase swallowing and/or speech production would not be possible without adequate tongue elevation. Therefore, facilitation and attainment of tongue elevation may be a successive approximation for a targeted process.

The discussion surrounding nonspeech treatment has also led to other questions for future consideration and research (Bahr, 2008b)31:

Could carefully and appropriately chosen nonspeech and nonfeeding activities be used as one-minute oral sensory-motor activities to keep the oral mechanism engaged while providing a break from the intensity of feeding and motor speech work in appropriate populations? Could this be a better choice than unrelated game activities for motivation (e.g., Candy Land)?
Aren’t activities like chewing, sipping, and blowing also organizing from a sensory processing perspective and engaging from a motor perspective? Haven’t blowing and chewing activities been standard and accepted methodology in voice rehabilitation?
Are oral sensory-motor treatments used only to improve muscle tone and increase overall strength (areas frequently mentioned in the “oral motor treatment” controversy)? Why is there so much discussion about increasing strength when graded strength is used for the tactile-kinesthetic acts of eating, drinking, and speaking? What about dissociation, grading, and direction of movement? Aren’t these just as important as adequate muscle tone and strength?
Regarding oral massage and facilitation, can a motor speech therapist (using a hands-on method such as PROMPT – Prompts for Restructuring Oral Muscular Phonetic Targets, Hayden, 2004, 2006) or a feeding therapist “talk” a child out of tactile defensiveness, a hyperresponsive gag, or a tonic bite?

CONCLUSIONS AND CLINICAL IMPLICATIONS

Part II (of this article series) explored the evolution of the “oral motor treatment” controversy, SLPs’ definitions and practice patterns relative to oral sensory-motor treatment, and ideas to help the field move past the debate and better serve consumers of SLP services. Here are a few conclusions from Part II:

Regarding the evolution of the controversy:
- The “Clinical Forum” authors (i.e., Powell a & b, Ruscello, Lof & Watson, Lass & Pannbacker, 2008) placed their concerns into writing and began to clarify treatment areas and populations under discussion in the controversy32. This seemed to be a positive change from the general, negative statements of concern and significant population ambiguity discussed in Part I (Bahr, 2011).
- While some terminology and population ambiguity persisted, the “Clinical Forum” authors seemed primarily concerned about the indiscriminate use of oral activities and exercises replacing speech treatment. Examples of indiscriminate oral activities and exercises included “tongue wagging” and “cheek puffing” (Lof & Watson, 2008, p. 393). Populations of concern included children with phonological disorders, children with hearing impairment, and those who were late talking (Lof & Watson, 2008, p. 397).
- While academics and clinicians were often portrayed on opposite sides of the “oral motor treatment” controversy, they could likely combine their talents and efforts to develop and implement crucial research projects, effective assessment and treatment procedures, and appropriate training activities (topics of Part III; Bahr & Banford, in press).
Regarding treatment population(s):
- SLPs use oral sensory-motor treatments with discrete populations (e.g., children with feeding, orofacial myofunctional, and motor speech disorders).
- SLPs are less likely to use oral sensory-motor treatments with children exhibiting language-based speech disorders (Lof & Watson, 2008, p. 396).
- Use of the “Speech Disorders Classification System” (SDCS) may assist academics and clinicians with specific (pediatric speech) population identification.
Regarding terminology and clinical practices:
- SLPs want clear definitions and standard terms (established by ASHA and used by academics, students, and practicing clinicians), so they are speaking about the same topics and information when discussing oral sensory-motor assessment and treatments.
- SLPs include 5 areas of treatment in their oral sensory-motor definitions and practices:
  - Feeding/Oral phase swallowing
  - Orofacial myology
  - Motor speech
  - Oral awareness/discrimination
  - Oral activities/exercises
  Therefore the term, “oral sensory-motor treatment” is likely the best overall term to describe the topic.
- Oral awareness/discrimination and oral activities/exercises do not equal NSOMT33 or NSOME34. The terms NSOME and NSOMT only describe the nonspeech aspects of oral awareness/discrimination treatment and oral activities/exercises.
- SLPs facilitate/attain awareness and discrimination via activities and exercises involving the functional processes of eating, drinking, and speaking when possible. When the actual functional processes cannot be used, approximations toward these processes may be selected.
A new way of looking at oral sensory-motor treatment (beyond NSOMT and NSOME) may promote collegial discussion among academics and clinicians:
- To help resolve the “oral motor treatment” controversy,
- To help the SLP field progress toward crucial research, assessment and treatment procedures, training, and EBP (topic of Part III; Bahr & Banford, in press), and
- Most importantly to help SLPs effectively serve clients, patients, and other consumers of SLP services.

Figure 4 represents one new way of thinking about oral sensory-motor treatment based on SLPs’ survey feedback. It is a paradigm/decision tree (similar to the SDCS in concept) progressing from left to right. Here are some key points:

Oral sensory-motor treatment seems most appropriate for children with oral sensory-motor problems (i.e., children with feeding/oral phase swallowing, orofacial myofunctional35, and motor speech disorders). These three areas are placed toward the left side of the diagram in Figure 4.
Ideal treatment involves actual functional processes (i.e., working on feeding to improve feeding or working on speech to improve speech).
When this proves impossible or exceptionally difficult, SLPs may use nonfeeding or nonspeech activities to attain the grading, dissociation, and direction of movement as successive approximations toward the functional task. These areas are in gray because they would not be the speech-language pathologist’s first choice.
Oral awareness/discrimination tasks and oral activities/exercises are what SLPs do in oral sensory-motor treatment whether these are feeding, nonfeeding, speech, or nonspeech tasks. The term “exercise” means “something performed or practiced in order to develop, improve, or display a specific power or skill” (Webster’s New Collegiate Dictionary, 1980, p. 397). Most SLP treatment involves some form of awareness/discrimination and activities/exercises.

RELATED INFORMATION

Acknowledgements

Many SLPs participated in the surveys, data compilation, and feedback for this article. The masked peer-reviewers donated their time independent of the OMI.

Declarations of Interest

Diane Bahr, is the co-owner of a continuing education company Ages and Stages, LLC and the volunteer co-chair of the OMI study group. She authored Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development (Sensory World, 2010) and Oral Motor Assessment and Treatment: Ages and Stages (Allyn & Bacon, 2001).

Financial Support

No financial support was given to SLPs or others participating in the surveys, data compilation, article review, or writing of this article. Rhonda J. Banford, MAT, CCC-SLP and Maigen Bundy, M. Cl. Sc., Reg. CASLPO voluntarily provided feedback and edited the article, independent of the OMI. Marshalla Speech and Language pays for the OMI website, which is free of advertisements and endorsements.

Author Information

Diane Bahr, MS, CCC-SLP is a certified speech-language pathologist in private practice who also teaches continuing education courses on feeding, motor speech, and mouth function. She has practiced speech-language pathology since 1980 and has taught courses on neurology, augmentative communication, child language, and adult disorders in addition to feeding and motor speech disorders at the university level. Please send comments and questions regarding this article series to dibahr@cox.net.

REFERENCES

Alexander, R. (1987). Oral-motor treatment for infants and young children with cerebral palsy. Seminars in Speech and Language, 8(1). 87-100.
American Psychological Association (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: American Psychological Association.
American Speech-Language-Hearing Association. (1990). Issues in oral motor, feeding, swallowing, and respiratory-phonatory assessment and intervention. [A Building Blocks Module].
American Speech-Language-Hearing Association (1991). The role of the speech-language pathologist in management of oral myofunctional disorders, ASHA, 33 (Suppl. 5), 7.
American Speech-Language-Hearing Association (1993). Orofacial myofunctional disorders: Knowledge and skills, ASHA, 35 (Suppl. 10), 21-23.
American Speech-Language-Hearing Association (Year-end 2006). Annual Counts of the ASHA Membership and Affiliation. [ASHA’s Surveys and Information Team].
American Speech-Language-Hearing Association (2007a). Childhood Apraxia of Speech [Technical Report]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association (2007b). Childhood Apraxia of Speech [Position Statement]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association (2010). Code of Ethics [Ethics]. Available from www.asha.org/policy.
Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages, Boston, MA: Allyn & Bacon.
Bahr, D. (2008a). A topical bibliography on oral motor assessment and treatment. Oral Motor Institute, 2(1). Retrieved from www.oralmotorinstitute.org/mons/v2n1_bahr.html.
Bahr, D. (2008b, November). The oral motor debate: Where do we go from here? Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL (Full handout available from http://convention.asha.org/handouts/1420_2054 Bahr_Diane_124883_Nov03_2008_Time_103047AM.doc).
Bahr, D. (2011). Part I – The oral motor debate: Understanding the problem. Oral Motor Institute, 3(1). Monograph available from www.oralmotorinstitute.org.
Bahr, D., & Banford, R. J. (in press). Part III – The oral motor debate: Exploring research and training needs/ideas. Oral Motor Institute. Monograph will be available from www.oralmotorinstitute.org.
Bahr, D., & Rosenfeld-Johnson, S. (2010, February). Treatment of children with speech oral placement disorders (OPDs): A paradigm emerges. Communication Disorders Quarterly, 31, 131-138.
Beckman, D., Neal, C., Phirsichbaum, J., Stratton, L., Taylor, V., & Ratusnik, D. (2004). Range of movement and strength in oral motor therapy: A retrospective study. Florida Journal of Communication Disorders, 21, 7-14.
Bernstein-Ratner, N. (2005). Evidence-based practice in stuttering: Some questions to consider. Journal of Fluency Disorders, 30, 163-168.
Bernthal, J., Bankson, N., & Flipsen, P. (2009). Articulation and phonological disorders: Speech sound disorders in children (6th ed.). Boston: Pearson.
Caruso, A. J., & Strand, E. A. (1999). Clinical management of motor speech disorders in children. New York: Thieme Medical Publishers.
Clark, H. M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12, 400-415.
Hayden, D. A. (2004). PROMPT: A tactually grounded treatment approach to speech production disorders. In I. Stockman (Ed.), Movement and action in learning and development: Clinical implications for pervasive developmental disorders (pp. 255-297). San Diego: Elsevier-Academic Press.
Hayden, D. A. (2006). The PROMPT model: Use and application for children with mixed phonological-motor impairment. Advances in Speech-Language Pathology, 8(3), 265-281.
Hammer, D. (2007). Childhood apraxia of speech: New perspectives on assessment and treatment. Workshop presented in Las Vegas, NV: The Childhood Apraxia of Speech Association.
Kamhi, A. (2004). A meme’s eye view of speech-language pathology. Language, Speech, and Hearing Services in Schools, 35, 105-111.
Kamhi, A. G. (2005). Summary, reflections, and future directions. In A. G. Kamhi and K. E. Pollock (Eds.). Phonological disorders in children: Clinical decision making in assessment and intervention. Baltimore: Paul H. Brooks Publishing Company, 211-228.
Koenig, M., & Gunter, C. (2005). Fads in speech-language pathology. In J. Jacobson, R. Foxx, & J. Mulich (Eds.), Controversial therapies for developmental disabilities: Fad, fashion, and science in professional practice (pp. 215-236). Mahwah, NJ: Erlbaum.
Lass, N. J., & Pannbacker, M. (2008, July). The application of evidence-based practice to nonspeech oral motor treatments. Language, Speech, and Hearing Services in Schools, 39, 408-421.
Lof, G. L., & Watson, M. (2008, July). A nationwide survey of nonspeech oral motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing Services in Schools, 39, 392-407.
Marshalla, P. (2004). Oral-Motor techniques in articulation & phonological therapy. Mill Creek, WA: Marshalla Speech and Language.
Morris, S. E. (1989). Development of oral-motor skills in the neurologically impaired child receiving non-oral feedings. Dysphagia, 3(3). 135-154.
Peterson-Falzone, S. J., Trost-Cardamone, J., Karnell, M. P., & Hardin-Jones, M. A. (2006). The clinician’s guide to treating cleft palate speech. St. Louis, MO: Mosby.
Powell, T. W. (2008a, July). The use of nonspeech oral motor treatments for developmental speech sound production disorders: Interventions and interactions. Language, Speech, and Hearing Services in Schools, 39, 374-379.
Powell, T. W. (2008b, July). An integrated evaluation of nonspeech oral motor treatments. Language, Speech, and Hearing Services in Schools, 39, 422-427.
Ruscello, D. M. (2008, July). Nonspeech oral motor treatment issues related to children with developmental speech sound disorders. Language, Speech, and Hearing Services in Schools, 39, 381-391.
Shriberg, L. D. (1993). Four new speech and prosody-voice measures for genetics research and other studies in developmental phonological disorders. Journal of Speech and Hearing Research, 36, 105-140.
Shriberg, L. D. (1994). Five subtypes of developmental phonological disorders. Clinics in Communication Disorders, 4(1), 38-53.
Shriberg, L. D., Austin, D., Lewis, B., McSweeny, J. L., & Wilson, D. L. (1997). The speech disorders classification system (SDCS): Extensions and lifespan reference data. Journal of Speech, Language, and Hearing Research, 40, 723-740.
Strand, E. A. (2010). Differential diagnosis and treatment of childhood apraxia of speech. Workshop presented in Las Vegas, NV: The Childhood Apraxia of Speech Association.
Woolf, H. B. (Ed.). (1980). Webster’s New Collegiate Dictionary. Springfield, MA: G. & C. Merriam Company.
Young, E. H., & Hawk, S. S. (1955). Moto-kinesthetic speech training. Stanford, CA: Stanford University Press.

APPENDIX A

Survey on Oral Motor Treatment[27]State of Residence:________
Diane Bahr, MS, CCC-SLPToday’s Date:____________

Circle all responses that apply to you.

Have you heard:

Oral motor treatment does not work?
There is no research on oral motor treatment?
ASHA does not support oral motor treatment?

Where did you hear the above comment(s)?

Colleagues
Professors/Instructors
Newsletters/Magazines
Peer Reviewed Journal Articles

How long have you practiced speech-language pathology?

Undergraduate or Graduate Student
1-2 years
2-5 years
5-10 years
10-15 years
15-20 years
20+ years

How do you define oral motor treatment?

oral awareness/discrimination
oral activities/exercises
feeding/oral phase swallowing
myofunctional
motor speech

If you use oral motor techniques, what type do you use?

oral awareness/discrimination
oral activities/exercises
feeding/oral phase swallowing
myofunctional
motor speech

Circle approximate number of minutes per session you spend on each aspect of oral motor treatment:

oral awareness/discrimination (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)
oral activities/exercises (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)
feeding/oral phase swallowing (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)
myofunctional (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)
motor speech (1-2, 2-5, 5-10, 10-15, 15-20, 20+ minutes)

APPENDIX B

Survey for Future Research:State of Residence:________

Diane Bahr, MS, CCC-SLPToday’s Date:____________

Circle questions important to you. Write other questions you have.

Would a clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myofunctional treatment, oral awareness/discrimination, and oral activities/exercises) help researchers and clinicians use the terminology more accurately?
How can SLPs become more cohesive as a profession? Could group-design research projects combining the efforts of researchers (often doctoral level SLPs) with SLPs who carry active caseloads (often master’s level SLPs) be developed?
What is being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function? Are students still being taught how to adequately conduct, interpret, and use the results of an oral examination?
How can continuing education better meet the needs of working therapists? Is there a way to better coordinate undergraduate, graduate, and continuing education on the topic of oral motor assessment and treatment as well as other topics?
Is there a professional interest in an updated text on oral motor assessment and treatment? Should researchers and practicing clinicians collaborate on this?
Is there an appropriate place and use of nonspeech and/or nonfeeding oral treatments with appropriate populations? What is this place and use?
What other related questions do you have?

ENDNOTES

1 Ages and Stages, LLC; Las Vegas, NV

2 “Orofacial myology is a specialized professional discipline that evaluates and treats a variety of oral and facial (orofacial) muscle (myo-) postural and functional disorders and habit patterns that may disrupt normal dental development and also create cosmetic problems” (retrieved from www.iaom.com, April 21, 2011).

3 Academics are “member[s] of an institute of learning” (Webster’s New Collegiate Dictionary, 1980, p. 6).

4 The 1100+ member (S. Marshalla, personal communication, February 24, 2011) Oral Motor Institute (OMI) studies the “oral sensory and motor components of articulation, motor speech, and feeding development, disorders, assessment, and treatment (Retrieved October 30, 2010 from www.oralmotorinstitute.org/index/html). It is an all-volunteer group.

5 Rhonda J. Banford, MAT, CCC-SLP volunteered countless hours to compile the data from the “Survey for Future Research” and to provide editorial feedback for this article series.

6 The Publication Manual of the American Psychological Association (APA, 2010, p. 67) discourages the use of redundant terminology in professional writing.

7 For a complete discussion of CAS, see the ASHA Technical Report (2007a) on “Childhood Apraxia of Speech.”

8 SLPs use oral sensory-motor techniques such as Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT; Hayden, 2004, 2006) and Moto-kinesthetic Speech Training (Young & Hawk, 1955) to facilitate speech movements in children who are hearing impaired and/or late talking.

9 Ideas for putting available science into practice will be discussed in detail in Part III of this article series (Bahr & Banford, in press).

10 Refer to Language, Speech, and Hearing Services in Schools (LSHSS), July 2008, Vol. 39, pp. 287-427 to find specific citations and references.

11 Prompts for Restructuring Oral Muscular Phonetic Targets (Hayden, 2004, 2006)

12 Moto-kinesthetic Speech Training (Young & Hawk, 1955)

13 According to American Speech-Language-Hearing Association statistics (ASHA, 2006), approximately 5 percent of ASHA’s membership had doctorates, approximately 4 percent worked in college or university settings, and approximately 1 percent considered themselves researchers, while approximately 93 percent of ASHA’s membership had master’s degrees and approximately 81 percent were clinical service providers.

14 Refer to Language, Speech, and Hearing Services in Schools (LSHSS), July 2008, Vol. 39, pp. 287-427 to find specific citations and references.

15 The textbook Oral Motor Assessment and Treatment: Ages and Stages (Bahr, 2001) covered a full range of oral sensory-motor assessment and treatment topics including anatomy, physiology, neurology, feeding, and motor speech. It reported on assessment and treatment practices in use at the time it was written.

16 Tutorials often review the current state of the science and discuss practice implications. Textbooks often look at SLP practices in light of the current state of the science.

17 “Empirical studies are reports of original research (American Psychological Association, 2010, p. 10).

18 ASHA’s Code of Ethics (2010, p. 4) states, “Individuals’ statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations.”

19 The “Areas of Expertise” were mostly based on information published by these individuals.

20 Debra Beckman’s work (personal communication, March 21, 2011) focuses on hands-on assessment and treatment of oral muscle function (Beckman, D., Neal, C., Phirsichbaum, J., Stratton, L., Taylor, V., & Ratusnik, D., 2004).

21 ASHA’s Code of Ethics (2010, p. 4) states, “Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious interprofessional and intraprofessional relationships, and accept the professions’ self-imposed standards.”

22 This percentage is interestingly similar to ASHA’s (2006) percentage of SLPs with master’s degrees (i.e., 93%), many of whom were likely to be practicing clinicians.

23 ASHA Website accessed November 28, 2010

24 This requires clarification, since teeth are not muscles.

25 Prompts for Restructuring Oral Muscular Phonetic Targets (Hayden, 2004, 2006)

26 Most definitions of “exercise” described “something performed or practiced in order to develop, improve, or display a specific power or skill” (Webster’s New Collegiate Dictionary, 1980, p. 397). Only one definition involved “physical fitness.”

27 No definition was provided for the term “motor speech;” however, childhood dysarthria and CAS are typically defined as motor speech disorders (Caruso & Strand, 1999).

28 The length of treatment sessions and the percentage of time spent in feeding, orofacial myofunctional, and motor speech treatment would be useful in future study of this topic.

29 Prompts for Restructuring Oral Muscular Phonetic Targets

30 This percentage is interestingly similar to ASHA’s (2006) percentage of SLPs with master’s degrees (i.e., 93%), many of whom were likely to be practicing clinicians.

31 Presented by Bahr at the 2008 ASHA Convention in Chicago, IL

32 The term “controversial” was found in the “Clinical Forum” articles (e.g., Powell, 2008a, p. 374; Lass & Pannbacker, 2008, p. 408), so it seemed these authors agreed there was a controversy.

33 NSOMTs are described as “nonspeech movements of the speech mechanism such as exercise, blowing, icing, swallowing, and other nonspeech activities” (Lass & Pannbacker, 2008, p. 408).

34 NSOMEs include “any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities” (Lof & Watson, 2008, p. 394).

35 The bidirectional arrows in Figure 4 indicate that orofacial myofunctional treatment is a bridge connecting the areas of feeding/oral phase swallowing and motor speech treatment. Orofacial myology encompasses many aspects of mouth function. ASHA (1991, 1993) published official guidelines for orofacial myofunctional treatment.

Please cite this article as:

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

THE ORAL MOTOR DEBATE – PART III

Oral Motor Institute

Volume 4, Monograph No. 1, 20 January 2012

THE ORAL MOTOR DEBATE – PART III

EXPLORING RESEARCH AND TRAINING NEEDS/IDEAS

By Diane Bahr1, MS, CCC-SLP, CIMI
and Rhonda J. Banford2, MAT, CCC-SLP

Key Words: oral motor treatment, nonspeech oral exercise, controversy, evidence-based practice

ABSTRACT

Purpose

Part III of this article series explores the continued evolution of the “oral motor treatment” debate. It discusses speech-language pathology (SLP) research needs, evidence-based assessment and treatment development, and training ideas that may help resolve the nearly decade-long controversy.

Method

Pertinent literature between 2008 and 2010 was reviewed on the topic. Three-hundred fifty-three speech-language pathologists (SLPs) from across the United States of America, including Puerto Rico, were surveyed regarding potential resolutions for the controversy.

Results

Between 60 and 78 percent of surveyed SLPs indicated a desire for coordinated research (i.e., academics3 and clinicians working together) and training (i.e., coursework offered from undergraduate through continuing education) on the various aspects of oral sensory-motor assessment and treatment (e.g., feeding, motor speech, orofacial myology, etc.).

Conclusions

SLPs want the “oral motor treatment” controversy resolved. While the debate focused on a narrow4 aspect of SLP practice, it revealed research, assessment, treatment, and training ideas that apply across SLP practice areas. Application of these ideas could greatly benefit SLPs and SLP consumers.

INTRODUCTION

Part III explores the continued evolution of the “oral motor treatment” controversy between 2008 and 2010. A review of relevant literature provides the background, and the following questions are considered:

What continues to concern clinicians and academics regarding the “oral motor treatment” controversy?
How can the evidence-base for, and required research on, oral sensory-motor assessment and treatment be attained?
Is there a way to coordinate assessment, treatment, and training materials as well as undergraduate, graduate, and continuing education programs on this topic?
How can academics and clinicians work together to accomplish all three aspects of evidence-based practice (EBP)?

METHOD

Three-hundred fifty-three SLPs (speech-language pathologists) from across the United States of America (USA), including Puerto Rico, completed the “Survey for Future Research” (Appendix C; Bahr, 2008b). The survey had been initiated by the Oral Motor Institute (OMI)5 study group to explore resolutions for the “oral motor treatment” controversy. Demographics and specific administration procedures for this survey were reported in Part I (Bahr, 2011a). Some resolutions for the controversy were discussed in Part II (Bahr, 2011b). The discussion of “best current evidence,” evidence-based systematic reviews (EBSRs), and opinion vs. research provides the background for the data and ideas presented in Part III.

BACKGROUND INFORMATION

Despite much recent discussion surrounding “best current evidence,” the American Speech-Language-Hearing Association (ASHA) has not adopted a standard scale for rating “levels of evidence.”6 However, ASHA’s National Center for Evidence-Based Practice (N-CEP) has developed and implemented a 17-step EBSR process to help SLPs find the “best current evidence.” In 2009, one EBSR was completed on the use of nonspeech oral exercises in speech treatment (the apparent topic of the “oral motor treatment” debate). By comparison, 14 theoretical opinion articles were published on the topic in 2008. While theoretical articles are informative, empirical research is needed to prove or disprove the effectiveness of clinical practices.

“Best Current Evidence” (One Aspect of Evidence-Based Practice)

Evidence-based practice (EBP) is important in the SLP field. ASHA’s “Introduction to Evidence-Based Practice” (n.d.-b, p. 1) states, “the goal of EBP is the integration of: (a) clinical expertise, (b) best current evidence, and (c) client values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve.” ASHA’s 2011 president Dr. Paul R. Rao (June 2011) said, “EBP is not about identifying the one best approach – it is about deciding which among the many acceptable options is likely to work best for a particular individual.”

During the nearly decade-long “oral motor treatment” controversy, clinicians and academics appeared to assign differing levels of importance to the three aspects of EBP. Clinicians seemed most concerned about their “clinical expertise” being valued when serving “the interests, values, needs, and choices” of their clients and patients. Academics (speaking and writing about the controversy) appeared most concerned about the availability of the “best current evidence.”

“Best current evidence” is usually discussed relative to a rating scale. However, no single scale for rating levels of evidence exists. In fact, Lohr reported that over 100 such scales were in existence in 2004. This has made it difficult for SLPs to effectively evaluate and discuss available empirical research and other forms of evidence.

Two examples of potential rating scales (for use by SLPs) were provided by Robey (ASHA Leader article, 2004) and ASHA (Technical Report, 2004). Robey (2004, p. 3) developed a chart entitled “Example Levels of Evidence” based on information from the Agency for Healthcare Research and Quality (2002 a & b). ASHA’s Research and Scientific Affairs Committee (2004, p. 2) produced an example entitled “Levels of Evidence for Studies of Treatment Efficacy” based on information from the Scottish Intercollegiate Guideline Network (2002).

Empirical research is crucial for the generation of “best current evidence.” The Publication Manual of the American Psychological Association (2010, p. 10) defines “empirical studies” as “reports of original research” that “test hypotheses by presenting novel analyses of data not considered addressed in previous reports.” All of Robey’s “Example Levels of Evidence” (2004) involved empirical research. However, ASHA’s chart/example (2004) differed significantly from Robey’s with regard to “Level 4/IV” evidence. Robey’s “Level 4” suggested “observational studies without controls” (i.e., empirical research that tests a working hypothesis via observation). ASHA’s “Level IV” suggested “expert committee report, consensus conference, [and] clinical experience of respected authorities.” Table 1 compares ASHA’s and Robey’s charts/examples.

ASHA’s suggestion for Level IV assigned value to clinical review and expertise. Yet, the title of ASHA’s chart/example contained the term “studies” (implying empirical research). This discrepancy may have caused some confusion among SLPs, since many seem to equate the terms “evidence” and “studies” with empirical research alone. This did not appear to be ASHA’s intent, judging by the contents of their chart/example.

Reportedly, ASHA has not adopted an official scale reflecting levels of evidence.7 Yet, Lass and Pannbacker (2008, p. 410) reported that the scale “adapted from the Scottish Intercollegiate Guideline Network (2002)” was “employed by ASHA.” Apparent information conflicts such as these make it difficult for academics and clinicians to decide what constitutes evidence and what does not. An official scale, adopted by ASHA and named to reflect the content, would help resolve this problem.

Evidence-Based Systematic Reviews (EBSRs)

In 2005, ASHA’s N-CEP surveyed ASHA members via the “Knowledge-Attitudes-Practices Survey” to determine what SLPs needed to effectively progress toward EBP. The N-CEP found the following:

Survey respondents remarked that they had little or no time to search and analyze the peer-reviewed literature. Further, the majority of clinicians reported that the evidence for effective clinical practice was nonexistent, conflicting, or irrelevant and ultimately identified a number of clinical areas in need of further examination (Frymark, Schooling, Mullen, Wheeler-Hegland, Ashford, McCabe, Musson, & Hammond, 2009, p. 175).

EBSRs seemed to be one answer to these problems as they are compilations and discussions of best-available empirical evidence pertaining to clinical questions. They are meant to help practicing SLPs evaluate data in a streamlined fashion, so that the most effective methods may be chosen and incorporated into clinical practice. Justice and Fey (2004) recommended EBSRs of published research as a first step in helping SLPs find the “best current evidence.”

EBSRs are qualitatively different from typical reviews of the literature found in most journal articles. They are a 17-step process (Mullen, 2006) involving the “critical appraisal of study quality,” “identification of study by phase/stage of clinical research,” and “synthesis of the body of evidence by quality and stage of research” (Frymark, et al., 2009, p. 177). However, the “level of evidence” under which EBSRs fall (See Table 1) is a question for ASHA’s N-CEP.

In 2009 and 2010, ASHA’s N-CEP completed seven EBSRs on nonspeech and behavioral/nonfeeding/nonswallowing oral sensory-motor treatments. With so much discussion surrounding the topic of oral exercise, these EBSRs (summarized in Appendix A) seemed to be a logical “starting point” for ASHA’s N-CEP. However, six of these EBSRs addressed feeding and swallowing, while only one addressed the use of nonspeech oral exercise in speech treatment (the apparent topic of the “oral motor treatment” controversy). The single EBSR on nonspeech oral exercise revealed “insufficient evidence to support or refute the use of OMEs [oral motor exercises] to produce effects on speech…in the research literature” (McCauley, Strand, Lof, Schooling, & Frymark; November 2009, p. 343), confirming SLPs’ observations that empirical research frequently identified areas for further study rather than “evidence for effective clinical practice” (Frymark, et al., 2009, p. 175).

While the EBSRs on oral sensory-motor treatment were a good “starting point” for ASHA’s N-CEP, EBSRs, meta-analyses, and empirical studies of the many forms of pediatric speech treatment are greatly needed. According to the United States Department of Labor, approximately 48 percent of SLPs worked in educational settings in 2010. ASHA’s 2010 Schools Survey – SLP Caseload Characteristics Report revealed that 91.6 percent of school-based SLPs treated articulation/phonological disorders and 58.8 percent addressed childhood apraxia of speech (CAS), while only 9.4 percent treated feeding and swallowing disorders. ASHA’s 2009 “Health Care Survey” revealed that SLPs in healthcare spent a greater portion of their time (i.e., 24 percent) treating articulation and phonological disorders than pediatric feeding and swallowing (i.e., 16 percent). In light of the large percentages of SLPs treating pediatric speech disorders, it is essential the empirical research be conducted on specific speech treatments (e.g., “bottom-up,” “hierarchical,” “auditory-visual,” “tactile-proprioceptive,” etc.) and populations (e.g., CAS, childhood dysarthria, articulation disorders, phonological disorders, etc.).

Opinion vs. Empirical Research

In contrast to the single EBSR on the use of oral exercise in speech treatment (McCauley, et al., 2009), most other recent articles on this topic have been theoretical in nature (expressing the ideas and opinions of the authors). These articles stressed the importance of empirical research, yet many of the authors had not done empirical studies on the topic. Therefore, no new empirical data was provided for SLPs’ clinical decision-making.

In 2008, a total of 14 theoretical articles were published on the topic of nonspeech oral sensory-motor treatment. The five-article “Clinical Forum” series (found in LSHSS)9 was discussed in Part II (Bahr, 2011b). Another nine theoretical articles appeared in Seminars in Speech and Language (Volume 29, Number 4). A tenth article in this series was a research article (Forrest & Iuzzini, 2008). The nine theoretical articles in Seminars in Speech and Language (Volume 29, Number 4) added to the SLP knowledge base because authors from different areas of the field discussed a variety of treatment populations relative to the topic (summarized in Appendix B). Despite the usefulness of theoretical journal articles, empirical research is greatly needed.

Most of the theoretical articles on the topic of nonspeech oral sensory-motor treatment were informational. However, three authors (Lass & Pannbacker, 2008; Kamhi, 2008) expressed strong opinions regarding nonspeech oral sensory-motor treatments and the SLPs perceived as promoting them. For example, Kamhi (2008, p. 337) stated:

As I found more and more reasons to explain the use of NSOMEs [nonspeech oral motor exercises], I began to think that the more interesting question was to determine why a clinician is not using NSOMEs. The small percentage of clinicians (< 15%) who do not use NSOMEs [10] must strongly believe that these activities have absolutely no value for speech sound production. Someone needs to sample these clinicians to find out how they have been able to resist the allure of NSOMEs. The next step would be to recruit these “NSOME-resisters” to spearhead a practitioner-directed attack against the use of NSOMEs to treat children with speech sound disorders. I hope that the guest editor of this issue [Gregory L. Lof, PhD] will continue to lead us in the ongoing battle to reduce the widespread and indiscriminate use of NSOMEs.

According to Kamhi (2008), G. Lof appeared to be waging a war. Similar yearly ASHA convention presentations and handouts by Lof and others (e.g., Lof & Watson, 2005; Lof, 2006, 2007, 2008a, & 2009) may have perpetuated this idea. Pannbacker and Lass (who were also openly opposed to the use of nonspeech activities and exercises) presented frequently at ASHA conventions (Pannbacker & Lass, 2002, 2003, & 2004; Lass, Pannbacker, Carroll, & Fox, 2006). Rather than a debate (where both sides were equally represented), there seemed to be a campaign against those who used the term “oral motor treatment” to describe their work.

As examples, Lass and Pannbacker (2008, p. 415) and Kamhi (2008, p. 336) expressed a number of written claims, concerns, and opinions regarding SLPs they appeared to perceive as promoting the indiscriminate use of nonspeech oral sensory-motor treatment. They included the Oral Motor Institute (OMI) study group in their claims. Table 2 compares some of these claims, concerns, and opinions relative to information found contrary to them.

Kamhi (2008) and Lass and Pannbacker (2008) made strong statements and claims regarding the OMI study group, continuing education, and SLPs they perceived as supporting nonspeech oral sensory-motor treatment. However, independent study groups like the OMI are usually considered an asset in a field of study. They tend to bring fresh perspectives and “clinical expertise” (an aspect of EBP) to the topics under discussion. It would be difficult to find a study group, a professional journal group, or an organization (e.g., ASHA) in which the members do not have some vested interest. Such interests are disclosed as part of advertising and publication.

Two statements from ASHA’s Code of Ethics (2010) have been points of interest throughout the three-part “Oral Motor Debate” series. The claims, concerns, and opinions listed in Table 2 (Kamhi, 2008; Lass & Pannbacker, 2008) should be considered in light of these statements.

ASHA’s Code of Ethics (2010, p. 4) states, “Individuals’ statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations.” The concerns expressed by Kamhi (2008) and Lass and Pannbacker (2008) regarding continuing education and the OMI seemed mostly unfounded and inaccurate (See Table 2). However, they may help explain some of the concerns expressed by SLPs in Part I of this article series (Bahr, 2011a) and the perception that academics and clinicians were on opposite sides of the controversy (discussed in Part II; Bahr, 2011b).

Additionally, ASHA’s Code of Ethics (2010b, p. 4) states, “Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious interprofessional and intraprofessional relationships, and accept the professions’ self-imposed standards.” The use of words such as “attack” and “battle” in professional journal literature (Kamhi, 2008, p. 337) does not promote this goal. The SLP profession would be better served by cooperative and collaborative professional efforts that focus on improving SLP research, training, assessment, and treatment.

In a 2008(b) ASHA convention poster session, Bahr asked some questions in response to the concerns and claims expressed by Kamhi, Lass, Pannbacker, and others:

“Are continuing education courses really promoting nonspeech treatments in place of speech treatment …?”
“Do SLPs trained, certified, and licensed according to ASHA standards really provide therapy consisting largely or exclusively of nonspeech or nonfeeding work with the expectation of improvement in speech or feeding?”
“Would a properly trained SLP [speech-language pathologist] do oral awareness/discrimination and oral activities/exercises with children who do not need them …? If so, are these therapists properly trained?”

Three questions were then queried in the simple one-page “Survey for Future Research” (Appendix C) developed by Bahr (2008b):

“What is being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function? Are students still being taught how to adequately conduct, interpret, and use the results of an oral examination?”
“How can continuing education better meet the needs of working therapists? Is there a way to better coordinate undergraduate, graduate, and continuing education on the topic of oral motor assessment and treatment as well as other topics?”
“Is there a professional interest in an updated text on oral motor assessment and treatment? Should researchers and practicing clinicians collaborate on this?”

These and other questions from “Survey for Future Research” (Appendix C; Bahr 2008b) targeted ideas for the resolution of the “oral motor treatment” debate. The results and discussion of this survey follow.

RESULTS AND DISCUSSION

“Survey for Future Research” Summary of Results

Three-hundred fifty-three SLPs from across the USA, including Puerto Rico, completed the “Survey for Future Research” (Appendix C; Bahr 2008b). This survey explored resolutions for the “oral motor treatment” controversy by asking respondents to identify questions they would like addressed on the topic. The questions seemed pertinent to the surveyed SLPs, as 60 percent or more responded to each question. Those completing the survey appeared to have an interest in the topic, as they either attended an ASHA convention presentation or participated in a website on the topic. Refer to Part I (Bahr, 2011a) for demographics and specific administration procedures for this survey. Table 3 summarizes the results of the “Survey for Future Research.”

Questions 1 and 6 from the “Survey for Future Research” were discussed in Part II (Bahr, 2011b). Regarding “Question 1,” 92 percent of the respondents were interested in a “clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myology, oral awareness/discrimination, and oral activities/exercises)” to “help researchers and clinicians use this terminology more accurately.” Regarding “Question 6,” 79 percent of the surveyed SLPs were concerned about the appropriate place for and “use of nonspeech and/or nonfeeding oral sensory-motor treatments with appropriate populations.”

“Question 7” yielded 173 written comments and questions covered in the next section. Questions 2 through 5 queried oral sensory-motor research and training needs/ideas discussed in subsequent sections of this article.

Question 7: Written Comments and Questions

One-hundred seventy-three additional written comments or questions were submitted in response to “Question 7” of the “Survey for Future Research” (found in Appendix C). It asked, “What other related questions do you have?” SLPs seemed to have much to ask or say on the subject of oral sensory-motor treatment.

The largest percentage of questions and comments (i.e., 23 percent) involved evidence and research. Respondents were clear in their desire for more quality research to obtain definitive answers. More than one respondent pointed out the need for researchers and academics to work with clinicians to find answers. Respondents also wanted SLPs with clinical experience to work with researchers on developing evidence-based assessments to determine treatment effectiveness. Some SLPs expressed concerns regarding the current state of SLP research.

They suggested that:

researchers and academics were too far-removed from the types of problems clinicians face,
academics and researchers were not researching clinically necessary and appropriate topics and populations, and
treatments and techniques (with “larger” evidence bases) may reflect past or present topics of interest within the academic community instead of current consumer needs.

Education and training questions/comments comprised the next largest area of concern (i.e., 14 percent). Surveyed SLPs expressed that graduate school should adequately prepare students for the types of clients and patients they will treat once they are working. A number of respondents seemed concerned that they did not receive training on specific oral sensory-motor topics such as swallowing and feeding in their university programs; yet, ASHA and employers expected them to perform these types of treatment. Several respondents questioned the wisdom of expecting SLPs to address such critical needs as swallowing without specialty certification. Many surveyed SLPs expressed the desire for a variety of good-quality workshops to address oral sensory-motor function, feeding, and swallowing assessment/treatment, since they had not learned about these areas at their universities.

Thirteen percent of respondent comments and questions involved the impact of oral sensory-motor issues on speech and communication. Surveyed SLPs had many questions about treating clients and patients who exhibited significant speech concerns such as childhood apraxia of speech (CAS), childhood dysarthria, and other speech disorders beyond articulation and phonological concerns. Treatment for CAS appeared to be a particular area of concern for many clinicians. The PROMPT17 method (one reported treatment for CAS) generated a lot of confusion. Respondents wondered whether to consider PROMPT an oral sensory-motor treatment or not. They also wondered whether PROMPT was supported by empirical research.

Respondents commented on earlier developing skills that preceded speech development, including feeding and non-speech activities such as mouthing objects and other forms of mouth play. In light of the many developmental approaches to therapy, surveyed SLPs wondered why opponents of oral sensory-motor treatment did not value working on such earlier-developing skills. Some respondents expressed concerns that researchers and academics might be “missing the mark” by not addressing the underpinnings of speech problems.

Twelve percent of respondents’ questions and concerns revolved around the oral sensory-motor treatment controversy and disagreement itself. Although one respondent questioned the need for agreement on the topic, the majority expressed discomfort regarding the conflict among members in the field. Some respondents expressed distress over the perception that others, within the field, seemed to be dictating therapy practices by asking SLPs to stop using techniques they found clinically successful. Most respondents expressed a desire for consensus that clinicians could use any method that they find works, without fear of censure by peers. While a couple of respondents indicated their disapproval of oral motor practitioners, more of the surveyed SLPs seemed annoyed with what they described as arrogance and a lack of open-mindedness in their peers. A number of comments indicated that SLPs would like ASHA to thoroughly research the topic and issue an official stand.

Eight percent of respondents had other treatment questions/comments, and another eight percent were concerned about the involvement of other disciplines. There were a number of questions aimed at the meaning of the term “evidence-based.” Some respondents interpreted it to mean solely founded in statistical evidence, while others found importance in anecdotal evidence. One respondent asked if anecdotal evidence in the “real world ever trumps the results of studies contrived in the laboratory.”

Misunderstanding appeared to abound within the questions and comments gathered from SLPs. Case in point, one participant said that she thought universities did not teach students to conduct, interpret, and use the results of an oral mechanism examination [a long-accepted and basic aspect of speech and swallowing assessment] because “it is not evidence-based.”

Survey respondents also expressed interest in evidence and research by adjunct disciplines such as occupational therapy, physical therapy, orofacial myology, neurology, sports medicine, etc. A few respondents seemed concerned that other disciplines were “taking on” traditional SLP treatment roles while SLPs were arguing over “oral motor treatment.”

Six percent of respondents’ comments and questions involved definition and terminology. Surveyed SLPs requested a variety of information. Some asked for precise definitions18 of treatments to dispel confusion over therapy practices. A number indicated the importance of clarifying the types of oral sensory-motor treatment appropriate for particular populations and problems. Respondents seemed concerned that misunderstandings within the field may be the result of researchers, academics, and clinicians who are not discussing like practices nor precisely specifying the populations under discussion. Some respondents indicated a desire for more information on the definition and etiology of motor disturbances, while one respondent expressed a concern about how to measure successful oral sensory-motor treatment outcomes.

Another area of concern for respondents was the potential for “vested interest” in those SLPs who promote forms of oral sensory-motor treatment and sell products or services related to their practices. Survey takers expressed a desire for evidence from those without anything monetary to gain. This could be accomplished if researchers and the developers of products and services worked together.

The number of written questions and comments in response to the “Survey for Future Research” (Appendix C) indicated that the topic of oral sensory-motor assessment and treatment is important to clinicians. SLPs are still looking for answers, despite hearing generalities that “oral motor treatment” does not work. This fact, in itself, highlights the importance of the subject and the need for more than basic speech therapy techniques to address the complex cases SLPs treat in schools, hospitals, and clinics. Clearly, there is also a need for objective data to support or refute specific oral sensory-motor practices used in speech and feeding treatment. The data from “Question 7” can be found in Table 4.

Question 2: Attaining the Empirical Evidence-Base

“Question 2” from the “Survey for Future Research” (Appendix C) asked SLPs about the importance of clinicians and researchers working together on research projects. It read, “How can SLPs become more cohesive as a profession? Could group-design research projects combining the efforts of researchers (often doctoral level SLPs) with SLPs who carry active caseloads (often master’s level SLPs) be developed?”

Sixty percent of surveyed SLPs circled “Question 2” as important, and an additional 40 written questions and comments were submitted on the topic (See Tables 3 and 4). The lower response percentage for this question compared to other survey questions may reflect SLPs’ lack of confidence in clinicians and academics working together to resolve the problem (the essence of “Question 2”). However, the large number of questions and comments (almost double compared to other areas) revealed the importance of solving it.

The topics of empirical research and peer-reviewed journal literature were frequently discussed throughout the “oral motor treatment” controversy. Paucity of empirical research is not specific to oral sensory-motor treatment, despite the number of theoretical articles calling for research on the topic (See previous section “Opinion vs. Empirical Research”). Justice, Nye, Schwarz, McGinty, and Rivera (2008) reported limited group-design treatment research across SLP treatment areas when they reviewed the three major ASHA journals (i.e., AJSLP19, LSHSS, and JSLHR20) between 1997 and 2006. Paucity of peer-reviewed journal literature is also not specific to oral sensory-motor treatment. In a survey of 117 AJSLP articles between 2004 and 2007, Bahr (2008a) found limited peer-reviewed journal literature on most speech-related topics (i.e., motor speech, phonology, fluency, and voice). At the time, the majority of AJSLP articles focused on language and communication. The SLP field is in great need of treatment-oriented, empirical evidence and peer-reviewed journal literature across treatment areas.

In response to concerns within the SLP community regarding the generation of empirical research, Scaler Scott, Bahr, and Reardon-Reeves presented a collaborative research model at the 2009 ASHA Convention. The model supported ASHA’s “Strategic Pathway to Excellence” (ASHA, n.d.-a) by suggesting the active participation of ASHA members (clinicians and researchers) in the generation of empirical research and the use of this evidence in clinical decision-making. Scaler Scott, Bahr, and Reardon-Reeves outlined a systematic plan to unite researchers (who comprise approximately 1 percent of ASHA’s membership) and clinicians (who comprise approximately 81 percent of ASHA’s membership) on crucial research projects (statistics from ASHA, Year-End 2006). Roadblocks that could preclude the success of this plan were also evaluated and discussed.

Figure 1 summarizes the research model suggested by Scaler Scott, Bahr, and Reardon-Reeves (2009). The first step in this model is to systematically match strengths, background, training, interests, and goals of academics and clinicians to create a research dyad. The clinician researcher provides the clinical caseload, teaches the academic researcher about the techniques/clinical procedures being studied, assesses and treats clients/patients, and takes data. The academic researcher mentors the clinician researcher as they set up the project, analyze the data, and write the resulting paper together.21 The academic researcher trains the clinician researcher to follow research protocol and assist with reliability checks. Proactive partnership, training, and coordination assist the dyad in working though individual and institutional roadblocks (e.g., knowledge gap, project time, funding, etc.). With a plan in place, crucial assessment/treatment research and improved relationships between academics and clinicians could result. Since clinicians tend to treat caseloads of individuals with similar problems, group-design research would be more likely to occur with this model, resolving the paucity of group-design research discussed by Justice, et al. (2008). Such research would provide empirical evidence for SLP clinical decision-making while meeting the needs of current clinical populations.

Justice and Fey discussed the progression from empirical research to clinical practice (2004, pp. 7-8):

First comes the scaling up of research, or endorsing researchers’ conduct and publication of research that targets real clinical problems and, ultimately, is implemented in non-laboratory, clinical settings. Second comes the scaling up of practices, or removing barriers that affect the translation of research findings to clinical practices…. EBP requires a synergy between the research community, which is charged with accumulating evidence, and the clinical community, which is charged with examining the preponderance of evidence, to make decisions about the best ways to evaluate and treat children…. Systemic changes are needed first at the organizational level, encompassing the discipline and its professional associations, and secondly, at the individual level.”

Empirical research in the SLP field is usually based on clinical problems. Such research has the potential to validate or invalidate clinical procedures which ultimately impact client and patient outcomes/welfare. EBSRs (such as those summarized in Appendix A) may be a “first step” in resolving the apparent “disconnect” between empirical research and practice. A collaborative research model may be the next step, and a revised training model may help SLPs put empirical research into practice.

Questions 3, 4, and 5: Training Needs/Ideas

Three questions from the “Survey for Future Research” targeted SLP training needs/ideas relative the resolution of the “oral motor treatment” controversy (Bahr, 2008b; Appendix C). The response percentages were similar for all three questions. In response to “Question 3,” 78 percent of surveyed SLPs said they were interested in knowing what was “being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function” and whether students were being taught to “conduct, interpret, and use” results from oral mechanism exams. In response to “Question 4,” 75 percent of surveyed SLPs seemed concerned about ways continuing education could “better meet the needs” of working SLPs and whether there was a way to “coordinate undergraduate, graduate, and continuing education training.” In response to “Question 5,” 77 percent of surveyed SLPs indicated an interest in an updated textbook22 on oral sensory-motor assessment and treatment using a researcher-clinician collaborative model.

The survey results revealed that SLPs were concerned about SLP training in the areas of feeding, motor speech, and mouth function. Additional written questions and comments (See previous “Question 7” summary) indicated that SLPs were concerned about their ability to meet current consumer23 needs with their present training. Therefore, a different training model may better meet the needs of SLPs and SLP consumers as well as the standards of EBP. Two questions would be important for this process:

What model could accomplish the coordination of training levels and programs from undergraduate through continuing education?
What curriculum content flow could adequately train SLPs in the various aspects of oral sensory-motor treatment (e.g., feeding, swallowing, motor speech, and orofacial myology)?

Figure 2 is a conceptual model for evidence-based training that could be applied across the SLP field. In this model, “clinical expertise, best current evidence, and patient/client values” are inherent in all training levels (undergraduate training through continuing education). Textbooks, tutorials, assessment materials, and treatment materials (used as part of the training process) also reflect these three aspects of EBP. The arrows pointing from the tutorials, textbooks, and materials toward the various levels of SLP instruction demonstrate this concept. A training model, such as this, could help resolve many of the problems encountered in the “oral motor treatment” controversy (e.g., development of evidence-based assessment and treatment materials, updated SLP training on current treatments and populations, etc.).

Currently, the SLP field seems to be at least partially meeting the requirements of this evidence-based training model. Textbooks and tutorials are developed from relevant literature review and the clinical expertise of the author(s).24 Assessment materials are based on developmental and other norms, as well as client/patient behavioral observations. Treatment materials usually contain suggested activities that SLPs have found successful and motivational in treatment. They are not prescriptive in nature, and clinicians use their expertise to choose appropriate treatment materials for clients and patients based on assessment results. Yet, the paucity of empirical research has significantly limited the availability of “best current evidence” for these processes. In fact, few recent assessment and treatment materials seem to reflect all three aspects of EBP including the supportive empirical research.25

With regard to SLP training, undergraduate and graduate programs adhere to ASHA’s standards and requirements. ASHA provides limited curriculum guidelines26 and significant academic freedom. University training programs often vary relative to available faculty. The clinical or research interests and expertise of faculty may determine specific courses taught, how they are taught, and some clinical aspects of training programs (e.g., types of clients drawn to graduate clinics or placements for student clinicians). Therefore, students may not receive instruction or “hands-on” experience with the variety of clients/patients/consumers treated in clinics, schools, and hospital settings. This may ultimately limit their ability to make appropriate clinical decisions in the work environment.

Currently, continuing education (CE) is mostly consumer-driven. It is based on SLPs’, clients’, and patients’ needs and usually focuses on clinical decision-making. SLPs frequently take courses that apply to their current clients/patients and available jobs within the field. CE courses often attempt to provide training that SLPs did not receive at the university level. ASHA and its Special Interest Groups (SIGs) provide CE opportunities. ASHA also has many affiliated CE Providers who agree to detailed standards for course development and administration. Both academics and experienced master clinicians teach CE courses.

The coordination of university training programs and CE could systematize SLP training. Such coordination would require that instructors have at least 5 to 10 years of clinical experience in the subjects they teach and an understanding of current empirical research. Students would then learn from experienced clinicians who could guide them to the “best current evidence” and teach them about the assessment and treatment of current clinical populations (e.g., children with autism, Down syndrome, CAS, dysarthria, orofacial myofunctional disorders, etc.).

Standardization of core curriculum at the graduate and undergraduate levels would allow CE to focus on advanced level, specialized training. A survey of what is currently taught in undergraduate, graduate, and continuing education programs would likely be the first step in studying the overall training process. A network of academics and clinicians who teach on similar topics could then be established, and “collective knowledge” could be used “to advance the goals” of the field (Rao, March 2011, p. 23).27 Team teaching (i.e., academics and master clinicians teaching together) could be effective at all training levels.

SLPs want and need specific and appropriate training to assess and treat clients with oral sensory-motor disorders that impact the functional processes of eating, drinking, and speaking. The idea of incorporating oral-sensory motor training into university programs is not new. Pierce and Taylor (2001) surveyed 128 SLPs, and 97 percent of their respondents “believed that more coursework on oral myofunctional disorders [was] needed in [university] training programs” (p. 27). They suggested that “speech pathologists, orofacial myologists, ASHA, IAOM [International Association of Orofacial Myology], colleges, and universities work together to improve undergraduate and graduate training programs so that practicing clinicians are adequately trained to provide assessment and treatment of orofacial myofunctional disorders” (p. 30).

In some South American countries, dentists and SLPs train together in university courses.28 SLPs, dentists, orthodontists, and others also train together in continuing education programs offered by the IAOM throughout the world. Interdisciplinary training with dentists and orthodontists likely provides SLPs with a better understanding of orofacial development, overall oral sensory-motor function, and the ways orofacial myofunctional phenomena can affect speech development and production. ASHA also has three SIGs that address the various aspects of oral sensory-motor function (i.e., SIG 2: Neurophysiology and Neurogenic Speech and Language Disorders; SIG 5: Speech Science and Orofacial Disorders; and SIG 13: Swallowing and Swallowing Disorders).

Table 5 represents one potential curriculum content flow from undergraduate training through CE for the topic of oral sensory-motor assessment and treatment. In this model, functional anatomy and physiology courses, taught at the undergraduate level, would be directly applicable to assessment and treatment. A course on typical sensory-motor development would provide information on detailed whole-body movement development (beginning at birth) that leads to task-specific processes (e.g., speech acquisition). A survey course on feeding, swallowing, orofacial myofunctional, and motor speech assessment/treatment in pediatric/adult populations would familiarize students with these areas prior to, or in conjunction with, observations of these techniques (in schools, clinics, and hospitals). Another survey course on research and scientific thinking would help students develop the habit of accessing and evaluating professional literature to assist in clinical problem solving. SLPAs (speech-language pathology assistants), who are usually trained at an undergraduate (associate or bachelor) level and work under the guidance of certified SLPs, would benefit from a similar foundation.29

In the “Table 5” model, two courses would be offered on oral sensory-motor assessment and treatment at the graduate level.30 There could be separate pediatric and adult courses on feeding, swallowing, orofacial myofunctional, and motor speech assessment and treatment. As another option, one course could be offered on the assessment and treatment of pediatric and adult feeding, swallowing, and orofacial myofunctional disorders, while a second course was offered on the assessment and treatment of pediatric and adult motor speech disorders.

With a relatively standard curriculum in place at the undergraduate and graduate levels of SLP training, CE courses could provide specialized and updated training in the areas of feeding, swallowing, motor speech, and orofacial myology. Such courses could provide a forum for SLPs to share their expertise, collate their knowledge, establish mentoring networks, and team with members of other disciplines, as appropriate.

CLINICAL IMPLICATIONS

Speech is a complex sensory-motor act. Yet, throughout the controversy, there was limited discussion of the sensory-motor processes and physical support systems involved in speech production. This was likely related to the fact that the debate initially focused on children with articulation and phonological disorders (who reportedly did not have oral sensory-motor problems). Children with motor speech disorders have now been added to the discussion. Specific information on muscle function, motor programming, and the systems supporting oral function is needed for sound clinical decision-making in the assessment and treatment of these pediatric populations (i.e., children with dysarthria and/or CAS).

Muscle Function, Motor Programming, and Systems that Support Oral Function

Two “building blocks” of movement (i.e., muscle tone and strength) were discussed by those expressing concerns about the use of NSOMTs and NSOMEs in speech treatment. Children with dysarthria have problems with strength and muscle tone; however, they were not the target population in the controversy. Strength is directly related to muscle tone. Weakness can result if muscle tone is too high or too low (Hillis & Bahr, 2001; Duffy, 1995). While muscle tone and strength are two crucial aspects of muscle function, movement is an extremely complex process based on equally complex sensory processing.

Figure 3 is a very simplified, conceptual model of the complex interrelatedness among the many sensory-motor components impacting the treatment of oral movement disorders. Three types of oral sensory-motor treatment (i.e., feeding/oral phase swallowing, orofacial myofunctional,32 and motor speech treatment) are listed toward the left side of Figure 3. Bidirectional arrows indicate a relationship among these treatment areas, as orofacial myofunctional treatment may involve oral phase swallowing and/or motor speech treatment.

Moving toward the right side of Figure 3, ideas are found regarding the potential relationships between muscle tone/function and motor plans/gestures.33 Adequate muscle tone (and the resulting muscle function) along with task-specific motor plans/gestures support the grading, dissociation, and direction of movement used in the task-specific processes of eating, drinking, and speaking. If muscle tone is too high or too low, the body is not ready for precise, differentiated movement. The development of unique and precise motor plans/gestures is based upon this “preparedness for movement.”34 The apparent relationship between muscle function and motor programming may help explain why children with muscle function problems also tend to have motor programming problems (e.g., children with Down syndrome, children with cerebral palsy, etc.).

Listed on the right side of Figure 3 are some of the components thought to be directly related to muscle tone/function and motor programming. Proprioception (defined as “the inner awareness in the muscles and the joints”) is a likely component of both processes. Eating, drinking, and speaking involve significant tactile-proprioceptive sensory processing (in addition to other sensory processing) and task-specific timing and coordination.

An understanding of the systems in the body that support oral sensory-motor function is also needed to effectively assess and treat children with oral movement disorders. Eating, drinking, and speaking involve several systems. Figure 4 is another very simplified, conceptual model of these systems. Intelligible speech requires adequate respiratory and vocal support in addition to control over the oral and nasal areas. Effective eating and drinking require oral, nasal, and respiratory control as well as adequate pharygeal and esophageal function. The arrows in Figure 4 indicate the general direction of movement through the various systems that support eating, drinking, and speaking.

Figures 3 and 4 provide the background for subsequent discussions on phonological and articulation disorders vs. motor speech disorders. These figures serve as a simple reference and reminder of the complex sensory-motor bases for the functional processes of eating, drinking, and speaking.

Phonological and Articulation Disorders vs. Childhood Apraxia of Speech (CAS) and Dysarthria

The “oral motor treatment” debate began with the discussion of children who had phonological and articulation disorders. It now includes children with dysarthria and CAS (two motor speech disorders). SLPs differentiate these disorders in order to make sound oral sensory-motor assessment and treatment decisions.

A phonological disorder can be defined as “a subset of sound production disorders in which linguistic and cognitive factors are thought to be central to the observed difficulties” (Strand, 2010, p. 4). “An articulation disorder is the atypical production of speech sounds characterized by substitutions, omissions, additions or distortions that may interfere with intelligibility” (ASHA, 1993b). Childhood dysarthria and apraxia of speech are motor speech disorders. Dysarthria “is a collective term for a group of related motor speech disorders resulting from disturbed muscular control of the speech mechanism” (Strand, 2010, p. 5). Childhood apraxia of speech (CAS) is currently defined as “a neurological childhood (pediatric) speech sound disorder, in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits” such as abnormal reflexes and muscle tone (ASHA, 2007a, p. 6).

Consider Figure 3 (“A Simplified Conceptual Model of the Components Involved in Oral Sensory-Motor Treatment”) relative to childhood dysarthria and CAS. Childhood dysarthria involves problems with muscle tone/function that can negatively impact motor plans/gestures. CAS involves the motor plans/gestures themselves. Children with dysarthria may benefit from activities that improve muscle tone/function, and many authors have agreed on this point.35 Children with CAS do not need activities to improve muscle tone/function unless they exhibit concurrent muscle tone/function concerns.

However, few children seem to have CAS in isolation. Many have co-occurring childhood dysarthria and other disorders (Hammer, 2007; Strand 2010). Therefore, muscle tone/function may need to be addressed prior to (or in addition to) motor planning/gestures in those children with concomitant muscle function concerns. The oral mechanism exam (in conjunction with speech production tests and behavioral observations) assists SLPs in determining the predominance of speech motor planning/gesture impairment vs. speech muscle function impairment vs. auditory and/or language-based speech disorder. Based on such assessment, appropriate treatment choices can be made. SLP treatment choices will vary based on the type of disorder and individual patient/client needs.

Relevant Speech Motor Programming Research

In an article on the use of NSOMEs in pediatric speech treatment (the apparent topic of the “oral motor treatment” debate), Watson and Lof (2008, p. 339) said,

A great deal of information is available to help clinicians understand the principles of motor speech learning and control, and how to apply those principles to clinical practice…. The results of many investigations have documented the difference between the…movement for speech and nonspeech tasks.

These authors were likely speaking of the body of research by C. Moore and his colleagues who continue to study oral movement via electromyography (Steeve, Moore, Green, Reilly, & McMurtrey, 2008; Steve & Moore, 2009). Moore and his colleagues repeatedly demonstrated that the neural mechanisms controlling speech are likely to be different from those controlling eating and drinking, particularly beyond the age of 2 years (Moore, Smith, & Ringel, 1988; Moore & Ruark, 1996; Ruark & Moore, 1997; Green, Moore, Ruark, Rodda, Morvee, & VanWitzenburg, 1997).

While Moore and his colleagues mostly compared feeding and speech behaviors, the following hypothesis is also probable: If feeding motor plans/gestures are unique from speech motor plans/gestures, then motor plans/gestures for nonspeech oral sensory-motor activities are likely to be unique from speech motor plans/gestures. Therefore, motor plans/gestures taught for each activity should be specific to that activity when possible (e.g., the action of licking the lips is specific to feeding, not speech). Yet, sometimes an activity is chosen as a successive approximation toward a target goal when a desired motor outcome cannot be otherwise attained (Bahr & Rosenfeld-Johnson, 2010). For example, blowing may help a client learn to direct air through the mouth (instead of the nose); voicing and speech oral movements are added as soon as possible to attain speech.

The Long-Standing Discussion on the Treatment of Phonological vs. Motor Speech Disorders

While indications were subtle, the “oral motor treatment” controversy seemed in some way related to a long-standing discussion on the treatment of phonological vs. motor speech disorders. Most of the outspoken opponents in the “oral motor treatment” controversy appeared to have expertise in phonological disorders and/or cleft palate (e.g., C. Bowen, A. Kamhi, G. Lof, N. Lass, M. Pannbacker, D. Ruscello).36 Yet, most of those actually named in the controversy (Part II, Table 1; Bahr, 2011b) had expertise in oral sensory-motor disorders (e.g., motor speech, feeding, orofacial myofunctional, etc.).

The “oral motor treatment” controversy originally seemed to surround the use of NSOMTs37 and NSOMEs38 in the treatment of typically developing children with articulation and phonological disorders (Parts I & II; Bahr, 2011 a & b). Children with motor speech disorders (i.e., childhood dysarthria and CAS) did not appear to be part of the original discussion. These populations were eventually discussed (relative to NSOME) by Clark (2008), McCauley and Strand (2008b), and McCauley, et al. (2009).

An article by Muttiah, Georges, and Brackenbury (2011) also indicated that the “oral motor treatment” controversy was related to the discussion of phonological disorders. These authors compared the perceptions of 11 clinicians (who used NSOMTs) with 11 “child phonology” researchers (p. 47), not motor speech researchers.39 The clinicians treated an average of 47 percent of children with articulation or phonological disorders; they also treated children with motor speech disorders. Muttiah, et al. found that both clinicians and “child phonology” researchers “applied features of EBP toward NSOMTs,” “were aware that others had different views,” and based “their final decision” on “their experiences and work environment” (p. 58). Therefore, phonology researchers and clinicians likely used different frameworks when approaching the information on the use of NSOMTs, which led to different conclusions by each group.

Additionally, Kamhi (an expert in phonology) discussed trends in SLP treatment. He indicated a trend away from language-based speech treatment and toward motor speech treatment. He said (2005, p. 226),

What has occurred in the early 1990s to the present is the pendulum seems to have swung back to the motor side after spending 10-15 years on the side of language-based phonology. This is seen in the heightened interest in oral-motor approaches and the increasing number of children diagnosed with DAS [developmental apraxia of speech].

The trends observed by Kamhi may reflect consumer needs (an important aspect of EBP). According to ASHA demographics (2007b), 64 percent of certified SLPs treated “motor speech disorders.” In addition, 62 percent of certified SLPs treated “autism/pervasive developmental disorder” and 58 percent treated “mental retardation/developmental disability” (two disorders that frequently co-occur with motor speech disorders).

CONCLUSIONS

The “oral motor treatment” debate has been multifaceted, extremely complex, and very uncomfortable for SLPs. It has been complicated by inaccurate general statements, definition and terminology problems, potential underlying agendas, and other factors. In particular, the topic of EBP seemed to be a point of contention between academics and clinicians throughout the debate. Academics (speaking and writing about the controversy) seemed most concerned about the availability of “best current evidence,” while clinicians seemed most concerned about value being placed on their “clinical expertise.”

Muttiah, et al. (2011) commented on the “oral motor treatment” debate relative to EBP. They said,

If we are to progress in this area [EBP], we need to be respectful and considerate of the research evidence as it currently exists, the successes and failures that clinicians have experienced, and the experiences and viewpoints of our clients. All of these pieces of information should be considered within the alternative frameworks that different professionals and clients might bring to the topic. By doing so, we can have informed discussions that may help us work through these disagreements.

Resolutions for the “oral-motor treatment” controversy were explored relative to EBP in Part III. Suggested models for collaborative research and coordinated training resulted. Collaborative research (where academics and clinicians combine their efforts and talents) would likely generate greatly needed “best current evidence” (one aspect of EBP). Coordinated training processes from undergraduate through continuing education would provide clinicians with essential knowledge to make appropriate clinical decisions and better serve SLP consumers (the two other aspects of EBP).

In a January 2011 interview, Dr. Paul R. Rao (ASHA President) reminded the SLP community of the famous words, “United we stand, divided we fall.” He also said, “We need to keep our eyes on client/patient care as the keystone of our practice; once we realize our work is not about us but about those we serve, our personal concern will take a back seat and we can see the power of our discipline” (Moore, p. 20). While Dr. Rao was not specifically discussing the “oral motor treatment” debate, his words were practical advice for those involved in the controversy.

Here are a few other practical lessons from the debate:

General statements are often inaccurate. Specificity is needed when describing populations and treatments under discussion.
Criticism of others’ ideas/experiences/work and “taking” sides (when the complete truth is unknown) is likely to escalate problems and decrease opportunities for discussion and resolution.
It is unlikely that those with strong biases will readily change their opinions. However, sharing and discussing cases, ideas, and concerns may help apparent opponents find common ground from which to work.40
Showing respect for colleagues and openly discussing differences is likely to reveal that each side of a debate/controversy has important information that may lead to a complete discussion of the topic, new ideas to explore, and advancement of the field.
Insufficient empirical evidence to support or refute treatments does not mean they are ineffective. It demonstrates the need for empirical treatment research (one aspect of EBP) to support clinical decision-making. Hand washing is a famous example. Prominent physicians (Holmes and Semmelweiss) suggested that doctors were passing disease from patient to patient in the mid-1800s. However, most physicians did not begin to use hand-washing procedures until Lister and Pasteur proved the theory (Kihlstrom, 2000).

The “oral motor treatment” controversy resulted in significant confusion, misunderstanding, and disharmony within the SLP field. Powell said there was “an urgent need for some degree of consensus” (2008a, p. 274) regarding the debate. Much professional time and effort have been spent on the theoretical discussion of one very narrow aspect of SLP practice (i.e., the use of nonspeech oral exercises/activities in the treatment of children with speech disorders). With so many SLPs treating children with speech disorders, well-designed research projects that focus on specific speech treatments (e.g., “bottom-up,” “hierarchical,” “auditory-visual,” “tactile-proprioceptive,” etc.) and populations (e.g., CAS, childhood dysarthria, articulation disorders, phonological disorders, etc.) are essential. Evidence-based assessment and treatment materials have the potential to evolve from such empirical research.

RELATED INFORMATION

Acknowledgements

Many SLPs participated in the surveys, data compilation, and feedback for this article. The masked peer-reviewers donated their time independent of the OMI.

Declarations of Interest

Diane Bahr co-owns Ages and Stages, LLC (a continuing education company and private practice) in Las Vegas, NV. She voluntarily co-chairs the OMI study group. She has authored two books: Nobody Ever Told Me (or My Mother) That! Everything from Bottles and Breathing to Healthy Speech Development (Sensory World, 2010) and Oral Motor Assessment and Treatment: Ages and Stages (Allyn & Bacon, 2001).

Rhonda J. Banford is the owner of Tip of the Tongue Speech and Language, LLC (a private practice) in Ballwin, MO. She collated and summarized the data collected via the “Survey for Future Research” (Appendix C). In addition to being the co-author of Part III, she edited the entire three-part series on the “oral motor treatment” debate.

Financial Support

Individuals participating in the surveys, data compilation, article review, and writing of this article series received no remuneration. Rhonda J. Banford, M.A.T., CCC-SLP and Maigen Bundy, M. Cl. Sc., Reg. CASLPO voluntarily edited and provided feedback (independent of the OMI) for the series. The OMI is an all-volunteer study group and does not advertise or endorse particular groups or individuals. The OMI website is donated by Marshalla Speech and Language.

Author Information

Diane Bahr, MS, CCC-SLP, CIMI is a certified speech-language pathologist and infant massage instructor in private practice in Las Vegas, NV. She has practiced speech-language pathology since 1980 and has been a feeding therapist since 1983. Her experiences include teaching graduate, undergraduate, and continuing education courses; working with children and adults who exhibit a variety of speech, language, feeding, and swallowing disorders; and publishing/presenting (e.g., ASHA, 2008 & 2009) information on oral motor function, assessment, and treatment. She has taught university and/or continuing education courses on the topics of neurology, childhood language and reading disorders, adult disorders, and augmentative communication as well as feeding, motor speech, and mouth function. Email questions and comments regarding this article series to dibahr@cox.net.

Rhonda J. Banford, M.A.T., CCC-SLP is a certified speech-language pathologist and early childhood special educator in private practice in Ballwin, MO. She is currently working toward certification in the area of orofacial myology. She started her career as a self-contained classroom teacher for children with severe language and speech disorders. Over her many years as a speech-language pathologist, she has worked as a diagnostician, clinician, home health therapist, and school therapist. While working for her local school district, she designed and implemented a successful intensive speech classroom program for unintelligible preschoolers. Many of her students demonstrated childhood apraxia of speech and related disorders. She continues to provide similar services to private clients in the form of a camp program in the summer months. She can be reached at rjb.slp@charter.net.

REFERENCES

Agency for Healthcare Research and Quality. (2002a). Rating the strength of scientific research findings. AHRQ Publication No. 02-P022. Rockville, MD: Agency for Healthcare Research and Quality. Available from www.ahrq.gov/clinic/epcsums/strenfact.htm.
Agency for Healthcare Research and Quality. (2002b). Systems to rate the strength of scientific evidence. Summary, evidence report/technology assessment: Number 47. AHRQ Publication No. 02-E015. Rockville, MD: Agency for Healthcare Research and Quality. Available from www.ahrq.gov/clinic/epcsums/strengthsum.htm.
Alexander, R., Boehm, R., & Cupps, B. (1993). Normal development of functional motor skills: The first year of life. Tucson, AZ: Therapy Skill Builders.
American Psychological Association (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: American Psychological Association.
American Speech-Language-Hearing Association (1991). The role of the speech-language pathologist in management of oral myofunctional disorders, ASHA, 33 (Suppl. 5), 7.
American Speech-Language-Hearing Association (1993a). Orofacial myofunctional disorders: Knowledge and skills, ASHA, 35 (Suppl. 10), 21-23.
American Speech-Language-Hearing Association (1993b). Definitions of Communication Disorders and Variations [Relevant Paper]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association (2004). Evidence-Based Practice in Communication Disorders: An Introduction [Technical Report]. Available from www.asha.org/policy
American Speech-Language-Hearing Association. (Year-end 2006). Annual Counts of the ASHA Membership and Affiliation. [ASHA’s Surveys and Information Team].
American Speech-Language-Hearing Association. (2007a). Childhood Apraxia of Speech [Technical Report]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association. (2007b). 2008 ASHA Marketing Planner. Obtained from www.asha.org.
American Speech-Language-Hearing Association (2009). 2009 SLP Healthcare Survey. Available from www.asha.org/research/memberdata/HealthcareSurvey09.htm.
American Speech-Language-Hearing Association. (2010a). 2010 Schools Survey-SLP Caseload Characteristics Report. Available from www.asha.org/uploadedFiles/Schools10Caseload.pdf.
American Speech-Language-Hearing Association (2010b). Code of Ethics [Ethics]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association. (n.d.-a). Strategic Pathway to Excellence. Retrieved March 24, 2009 from http://www.asha.org.
American Speech-Language-Hearing Association. (n.d.-b). Introduction to Evidence-Based Practice. Retrieved May 27, 2011 from http://www.asha.org/members/ebp/intro.htm.
American Speech-Language-Hearing Association. (n.d.-c). ASHA’s 2009-2010 Academic Year State-by-State Data on Graduate Education in Communication Sciences and Disorders. Retrieved May 28, 2011 from www.asha.org/academic/HES/HESDataReports.htm.
American Speech-Language-Hearing Association (n.d.-d). Curriculum Resources. Retrieved September 16, 2011 from www.asha.org/academic/curriculum.
Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010a, November). Evidence-Based systematic review: The effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of Speech-Language Pathology, 19, 321-340.
Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010b, November). The effects of oral-motor exercises on swallowing in children: An evidence-based systematic review. Developmental Medicine & Child Neurology, 52(11). 1000-1013.
Ashford, J., McCabe, D., Wheeler-Hegland, K., Frymark, T., Mullen, R., Musson, N., Schooling, T., & Hammond, C. S. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part III – Impact of dysphagia treatments on populations with neurological disorders. Journal of Rehabilitation Research & Development, 46(2), 195-204.
Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston, MA: Allyn & Bacon.
Bahr, D. (2008a). A topical bibliography on oral motor assessment and treatment. Oral Motor Institute, 2(1). Retrieved October 30, 2010 from www.oralmotorinstitute.org/mons/v2n1_bahr.html.
Bahr, D. (2008b, November). The oral motor debate: Where do we go from here? Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL. (Full handout available from http://convention.asha.org/handouts/1420_2054 Bahr_Diane_124883_Nov03_2008_Time_103047AM.doc)
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 2: Exploring terminology and practice patterns. Oral Motor Institute 3(2). Available from www.oralmotorinstitute.org.
Bahr, D., & Rosenfeld-Johnson, S. (2010, February). Treatment of children with speech oral placement disorders (OPDs): A paradigm emerges. Communication Disorders Quarterly, 31, 131-138.
Bunton, K. (2008). Speech versus nonspeech: Different tasks, different neural organization. Seminars in Speech and Language, 29, 267-275.
Caruso, A. J., & Strand, E. A. (1999). Motor speech disorders in children: Definitions, background, and a theoretical framework. In A. J. Caruso and E. A. Strand (Eds.). Clinical management of motor speech disorders in children. New York: Thieme, 1-27.
Clark, H. M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12, 400-415.
Clark, H. M. (2008). The role of strength training in speech sound disorders. Seminars in Speech and Language, 29, 276-283.
Clark, H., Lazarus, C., Arvedson, J., Schooling, T., & Frymark, T. (2009, November). Evidence-Based systematic review: Effects of neuromuscular electrical stimulation on swallowing and neural activation. American Journal of Speech-Language Pathology, 18(4), 361-375.
Davis, B., & Velleman, S. (2008). Establishing a basic speech repertoire without using NSOME: Means, motive, and opportunity. Seminars in Speech and Language, 29, 312-319.
Duffy, J. R. (1995). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis: Mosby Year Book.
Forrest, K., & Iuzzini, J. (2008). A comparison of oral motor and production training for children with speech sound disorders. Seminars in Speech and Language, 29, 304-311.
Frymark, T., Schooling, T., Mullen, R., Wheeler-Hegland, K., Ashford, J., McCabe, D., Musson, N., & Hammond, C. S. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part I – Background and methodology. Journal of Rehabilitation Research & Development, 46(2), 175-184.
Green, J. R., Moore, C. A., Ruark, J. L., Rodda, P. R., Morvee, W. T., & VanWitzenburg, M. J. (1997). Development of chewing in children from 12 to 48 months: Longitudinal study of EMG patterns. Journal of Neurophysiology, 77, 2704-2716.
Hammer, D. (2007). Childhood apraxia of speech: New perspectives on assessment and treatment. Workshop presented in Las Vegas, NV: The Childhood Apraxia of Speech Association.
Hayden, D. A. (2006). The PROMPT model: Use and application for children with mixed phonological-motor impairment. Advances in Speech-Language Pathology, 8(3), 265-281.
Hayden, D. A. (2004). PROMPT: A tactually grounded treatment approach to speech production disorders. In I. Stockman (Ed.), Movement and action in learning and development: Clinical implications for pervasive developmental disorders (pp. 255-297). San Diego: Elsevier-Academic Press.
Hayden, D., & Square, P. (1999). Verbal motor production assessment for children. San Antonio, TX: The Psychological Corporation.
Hillis, A. E., & Bahr, D. C. (2001). Neurological and anatomical bases. In D. C. Bahr. Oral motor assessment and treatment: Ages and stages. Boston, MA: Allyn & Bacon.
Justice, L. M., & Fey, M. E. (2004, September 21). Evidence-Based practice in schools: Integrating craft and theory with science and data. The ASHA Leader, [Electronic version]. Retrieved February 25, 2011, from http://www.asha.org/Publications/leader/2004/040921/f040921a.htm.
Justice, L. M., Nye, C., Schwarz, J., McGinty, A., & Rivera, A. (2008). Methodological quality of intervention research in speech-language pathology: Analysis of ten years of group design studies. Evidence-Based Communication Assessment and Intervention, 2, 46-59.
Kamhi, A. G. (2005). Summary, reflections, and future directions. In A. G. Kamhi and K. E. Pollock (Eds.). Phonological disorders in children: Clinical decision making in assessment and intervention. Baltimore: Paul H. Brooks Publishing Company, 211-228.
Kamhi, A. G. (2008). A meme’s-eye view of nonspeech oral-motor exercises. Seminars in Speech and Language, 29, 331-338.
Kihlstrom, J. F. (2000). Doctors are reminded: Wash up! Institute for the Study of Healthcare Organizations & Transactions. Retrieved March 12, 2011 from www.institute-shot.com/hand_washing_by_health_care_providers.htm.
Lass, N. J., & Pannbacker, M. (2008, July). The application of evidence-based practice to nonspeech oral motor treatments. Language, Speech, and Hearing Services in Schools, 39, 408-421.
Lass, N., Pannbacker, M., Carroll, A., & Fox, J. (2006, November). Speech-language pathologists’ use of oral motor treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Miami, FL.
Lof, G. L. (2003). Oral motor exercises and treatment outcomes. Perspectives on Language Learning and Education, 10, 7-11.
Lof, G. L. (2006, November). Logic, theory and evidence against the use of non-speech oral motor exercises to change speech sound productions. Session presented at the annual meeting of the American Speech-Language-Hearing Association, Miami Beach, FL.
Lof, G. L. (2007, November). Reasons why non-speech oral motor exercises should not be used for speech sound disorders. Session presented at the annual meeting of the American Speech-Language-Hearing Association, Boston, MA.
Lof, G. L. (2008a, November). Evidence-Driven speech sound intervention: Alternatives to nonspeech motor exercises. Session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL.
Lof, G. L. (2008b). Introduction: Controversies surrounding nonspeech oral motor exercises for childhood speech disorders. Seminars in Speech and Language, 29, 253-256.
Lof. G. L. (2009, November). Nonspeech oral motor exercises: An update on the controversy. Session presented at the annual meeting of the American Speech-Language-Hearing Association, New Orleans, LA.
Lof, G. L., & Watson, M. (2005, November). Survey of universities’ teaching: Oral motor exercises & other procedures. Session presented at the annual meeting of the American Speech-Language-Hearing Association, San Diego, CA.
Lof, G. L., & Watson, M. (2008, July). A nationwide survey of nonspeech oral motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing Services in Schools, 39, 392-407.
Lohr, K. N. (2004). Rating the strength of scientific evidence: Relevance for quality improvement programs. International Journal for Quality in Health Care, 16(1): 9-18.
Maas, E., Robin, D. A., Austermann Hula, S. N., Freedman, S. E., Wulf, G., Ballard, K., & Schmidt, R. A. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology, 17(3), 277-298.
McCabe, D., Ashford, J., Wheeler-Hegland, K., Frymark, T., Mullen, R., Musson, N., Hammond, C. S., & Schooling, T. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part IV – Impact of dysphagia treatment on individuals’ postcancer treatments. Journal of Rehabilitation Research & Development, 46(2), 205-214.
McCauley, R. J., & Strand, E. A. (2008a). A review of standardized tests of nonverbal oral and speech motor performance in children. American Journal of Speech-Language Pathology, 17, 81-91.
McCauley, R. J., & Strand, E. A. (2008b). Treatment of childhood apraxia of speech: Clinical decision making in the use of nonspeech oral motor exercises. Seminars in Speech and Language, 29, 284-293.
McCauley, R. J., Strand, E., Lof, G. L., Schooling, T., & Frymark, T. (2009, November). Evidence-Based systematic review: Effects of nonspeech oral motor exercises on speech. American Journal of Speech-Language Pathology, 18(4), 343-360.
McNeilly, L. (2010, November 23). ASHA will roll out associates program in 2011. The ASHA Leader, 15(14), 7.
Moore, C. A., Smith, A., & Ringel, R. L. (1988). Task-specific organization of activity in human jaw muscles. Journal of Speech and Hearing Research, 31, 670-680.
Moore, C. A., & Ruark, J. L. (1996). Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research, 39, 1034-1047.
Moore, M. (2011, January 18). “ASHA rocks” – and so does Paul R. Rao. The ASHA Leader, 16(1), 20-23.
Morris, S. E. (1989). Development of oral-motor skills in the neurologically impaired child receiving non-oral feedings. Dysphagia, 3(3). 135-154.
Mullen, R. (2006, December). Conducting a systematic review of the research literature. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 15(4), 15-19.
Muttiah, N., Georges, K., & Brackenbury, T. (2011, February). Clinical and research perspectives on nonspeech oral motor treatments and evidence-based practice. American Journal of Speech-Language Pathology, 20, 47-59.
Pannbacker, M., & Lass, N. (2002, November). The use of oral motor therapy in speech-language pathology. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Atlanta, GA.
Pannbacker, M., & Lass, N. (2003, November). Effectiveness of oral motor treatment in Slp. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL.
Pannbacker, M., & Lass, N. (2004, November). Ethical issues in oral motor treatment. Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Philadelphia, PA.
Pierce, R., & Taylor, P. (2001). Rationale for including orofacial myofunctional therapy in university training programs. International Journal of Orofacial Myology, 28, 24-32.
Rao, P. R. (2011, March). Special interest groups: An integral part of our ASHA family. The ASHA Leader, 16(3), 23.
Rao, P. R. (2011, June 7). Evidence-Based practice: The coin of the realm in CSD. The ASHA Leader, 16(7), 7.
Rao, P. R. (2011, August 30). From the president: Mentorship: The price of membership. The ASHA Leader, [Electronic Version]. Retrieved October 5, 2011 from www.asha.org/Publications/leader/2011.
Robey, R. R. (2004, April 13). Levels of evidence. The ASHA Leader, [Electronic Version]. Retrieved February 19, 2011 from www.asha.org/Publications/leader/2004.
Robey, R. R., & Dalebout, S. D. (1998, December). A tutorial on conducting meta-analyses of clinical outcome research. Journal of Speech, Language, and Hearing Research, 41, 1227-1241.
Ruscello, D. M. (2008). An examination of nonspeech oral motor exercises for children with velopharyngeal inadequacy. Seminars in Speech and Language, 29, 294-303.
Ruark, J. L., & Moore, C. A. (1997). Coordination of lip muscle activity by 2-year-old children during speech and nonspeech tasks. Journal of Speech, Language, and Hearing Research, 40, 1373-1385.
Scottish Intercollegiate Guidelines Network. (2002). Glossary of key terms. Available at www.sign.ac.uk.
Scott, K. S., Bahr, D., & Reardon-Reeves, N. (2009, November). Creating effective and efficient research teams. Session presented at the annual meeting of the American Speech-Language-Hearing Association, New Orleans, LA (Full handout available from www.asha.org/Events/convention/handouts/2009/1926_Scaler_Scott_Kathleen.htm.)
Steeve, R. W., & Moore, C. A. (2009). Mandibular motor control during early development of speech and nonspeech behaviors. Journal of Speech, Language, and Hearing Research, 52, 1530-1554.
Steeve, R. W., Moore, C. A., Green, J. R., Reilly, K. J., & McMurtrey, J. R. (2008, December). Babbling, chewing, and sucking: Oromandibular coordination at 9 months. Journal of Speech, Language, and Hearing Research, 51, 1390-1404.
Strand, E., Stoeckel, R., & Baas, B. (2006). Treatment of severe childhood apraxia of speech: A treatment efficacy study. Journal of Medical Speech Pathology, 14, 297-307.
Strand, E. A. (2010). Differential diagnosis and treatment of childhood apraxia of speech. Workshop presented in Las Vegas, NV: The Childhood Apraxia of Speech Association.
United States Department of Labor. (2010). Occupational Outlook Handbook, 2010-11 Edition, Speech-Language Pathology. Bureau of Labor Statistics (Available from http://www.bls.gov/oco/ocos099.htm#empty).
Watson, M. M., & Lof, G. L. (2008). Epilogue: What we know about nonspeech oral motor exercises. Seminars in Speech and Language, 29, 339-344.
Wheeler-Hegland, K., Ashford, J., Frymark, T., McCabe, D., Mullen, R., Musson, N., Hammond, C. S., & Schooling, T. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part II – Impact of dysphagia treatment on normal swallow function. Journal of Rehabilitation Research & Development, 46(2), 185-194.
Wheeler-Hegland, K., Frymark, T., Schooling, T., McCabe, D., Ashford, J., Mullen, R., Hammond, C. S., & Musson, N. (2009). Evidence-Based systematic review: Oropharyngeal dysphagia behavioral treatments. Part V – Applications for clinicians and researchers. Journal of Rehabilitation Research & Development, 46(2), 215-222.
Wilson, E. M., Green, J. R., Yunusova, Y., & Moore, C. A. (2008). Task specificity in early oral motor development. Seminars in Speech and Language, 29, 257-266.
Woolf, H. B. (Ed.). (1980). Webster’s new collegiate dictionary. Springfield, MA: G. & C. Merriam Company.

APPENDIX A

Summary of ASHA’s N-CEP EBSRs on Nonspeech and Behavioral/Nonfeeding/Nonswallowing Oral Sensory-Motor Treatment

APPENDIX B

Summary of ASHA’s N-CEP EBSRs on Nonspeech and Behavioral/Nonfeeding/Nonswallowing Oral Sensory-Motor Treatment

APPENDIX C

Survey for Future Research:State of Residence:________
Diane Bahr, MS, CCC-SLPToday’s Date:____________

Circle questions important to you. Write other questions you have.

Would a clear definition of oral motor function and the many aspects of oral motor treatment (i.e., feeding/oral phase swallowing, motor speech, orofacial myofunctional treatment, oral awareness/discrimination, and oral activities/exercises) help researchers and clinicians use the terminology more accurately?
How can SLPs become more cohesive as a profession? Could group-design research projects combining the efforts of researchers (often doctoral level SLPs) with SLPs who carry active caseloads (often master’s level SLPs) be developed?
What is being taught at the undergraduate and graduate levels on feeding, motor speech, and mouth function? Are students still being taught how to adequately conduct, interpret, and use the results of an oral examination?
How can continuing education better meet the needs of working therapists? Is there a way to better coordinate undergraduate, graduate, and continuing education on the topic of oral motor assessment and treatment as well as other topics?
Is there a professional interest in an updated text on oral motor assessment and treatment? Should researchers and practicing clinicians collaborate on this?
Is there an appropriate place and use of nonspeech and/or nonfeeding oral treatments with appropriate populations? What is this place and use?
What other related questions do you have?

ENDNOTES

1 Ages and Stages, LLC; Las Vegas, NV

2 Tip of the Tongue Speech and Language, LLC; Ballwin, MO

3 Academics are “member[s] of an institute of learning” (Woolf, 1980, p. 6).

4 “Narrow” is a descriptive term meaning “to decrease the scope or sphere of” (Woolf, 1980, p. 758).

5 The Oral Motor Institute (OMI) studies the “oral sensory and motor components of articulation, motor speech, and feeding development, disorders, assessment, and treatment.” Retrieved October 30, 2010 from www.oralmotorinstitute.org/index.html. The all-volunteer OMI study group had over 1100 members as of February 24, 2011 (S. Marshalla, personal communication).

6 T. Schooling, personal communication; March 14, 2011.

7 Schooling, personal communication; March 14, 2011.

8 Robey and Dalebout (1998) described meta-analysis as “a mathematical synthesis of independent research findings scattered throughout a body of literature” (p. 1228).

9 LSHSS is ASHA’s Language, Speech, and Hearing Services in Schools journal.

10 It may also be helpful to survey the populations this small percentage of SLPs treat. Do they treat children with phonological and articulation disorders, children with motor speech disorders, etc.?

11 Retrieved October 30, 2010 from www.oralmotorinstitute.org/index.html.

12 Most of the OMI board members are experienced master clinicians and 2 have PhDs.

13 One of the items listed by Lass and Pannbacker (2008, p. 416, Table 6) was Bahr’s peer-reviewed textbook (Oral Motor Assessment and Treatment: Ages and Stages, 2001). The textbook covers a full range of oral sensory-motor assessment and treatment topics including anatomy, physiology, neurology, feeding, and motor speech. Another item listed was a clinical article “Development of Oral-Motor Skills in the Neurologically Impaired Child Receiving Non-Oral Feedings” by Suzanne Evans Morris (1989). These items did not appear to fit with the other items in the Lass and Pannbacker list.

14 “SPEECH-MOTOR ACTIVITY – any therapy activity involving the use of the oral musculature (e.g., lips,…mandible, cheeks, [and] velum) that INCLUDES the production of speech sounds at the same time” (P. Flipsen, personal communication, February 17, 2011).

15 “NSOMTs focus on nonspeech movements of the speech mechanism such as exercise, massage, blowing, positioning, icing, sucking, swallowing, cheek puffing, and other nonspeech activities” (Lass & Pannbacker, 2008, p. 411). Therefore, techniques incorporating speech sound production are not considered NSOMTs.

16 NSOMEs were defined as “any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities” (Lof & Watson, 2008, p. 394). Therefore, techniques incorporating speech sound production are not considered NSOMEs.

17 Prompts for Restructuring Oral Muscular Phonetic Targets (Hayden, 2004, 2006)

18 Definitions listed and discussed in Part II (Bahr, 2011b).

19 AJSLP is AHSA’s American Journal of Speech-Language Pathology.

20 JSLHR is ASHA’s Journal of Speech, Language, and Hearing Research.

21 Dr. Paul R. Rao (2011 ASHA president) recently wrote about the importance of “mentorship” in the SLP field (August 30, 2011; ASHA Leader).

22 Oral Motor Assessment and Treatment: Ages and Stages (Bahr, 2001) seemed to be the only textbook covering the many aspects of oral sensory-motor assessment and treatment in one source.

23 Consumers are SLP students, clients, patients, and appropriate others.

24 A number of clinical textbooks have been recently published on motor speech and swallowing disorders. Recent tutorials (applicable to oral sensory motor assessment and treatment) were published by Clark (2003) and Maas, Robin, Austermann Hula, Freedman, Wulf, Ballard, and Schmidt (2008).

25 Dynamic Temporal and Tactile Cueing (DTTC) is a recent example of a motor speech intervention with an empirical evidence base (Strand, Stoeckel, & Bass, 2006). The Verbal Motor Production Assessment for Children (VMPAC, Hayden & Square, 1999) is a recent example of a pediatric, motor speech assessment with an empirical evidence base (as discussed by McCauley and Strand in 2008a). However, data is needed on SLPs’ clinical experiences and the value patients and clients place on these techniques to complete the EBP requirements.

26 Available from www.asha.org/academic/curriculum (ASHA, n.d.-d); no motor speech curriculum resources were provided in this document.

27 ASHA’s 2011 president Dr. Paul R. Rao (March 2011, p. 23) expressed the following benefits of SIGs which could apply to all training levels: “There is benefit in connecting with colleagues who share our interests and expertise, but we gain much more when we also use our collective knowledge to advance the goals and objectives of the entire organization.”

28 Personal communications from E. Palumbo (October 30, 2011) and P. Taylor (October 29, 2011)

29 McNeilly (2010); L. McNeilly, personal communication (July 5, 2011)

30 ASHA’s 2009-2010 Academic Year State-by-State Data on Graduate Education in Communication Sciences and Disorders revealed 266 SLP master’s programs and 83 doctoral SLP programs in the USA (n.d.-c, p. 17, Retrieved May 28, 2011 from www.asha.org/academic/HES/HESDataReports.htm).

31 Normal Development of Functional Motor Skills: The First Year of Life (Alexander, Boehme, & Cupps, 1993) contains topics that may be taught in such a course.

32 Orofacial myofunctional treatment focuses on normal tongue resting posture and oral phase swallowing as well as related dental and speech concerns. ASHA (1991, 1993a) published official guidelines for this type of treatment.

33 The use of the terminology “motor plans/gestures” reflects recent discussions on motor learning theories (Bahr & Rosenfeld-Johnson, 2010).

34 Leslie Faye Davis; personal communication; July 15, 2011

35 See Part II (Bahr, 2011b).

36 Areas of expertise based on published information by these individuals.

37 “NSOMTs focus on nonspeech movements of the speech mechanism such as exercise, massage, blowing, positioning, icing, sucking, swallowing, cheek puffing, and other nonspeech activities” (Lass & Pannbacker, 2008, p. 411). Therefore, techniques incorporating speech sound production are not considered NSOMTs.

38 NSOMEs were defined as “any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities” (Lof & Watson, 2008, p. 394). Therefore, techniques incorporating speech sound production are not considered NSOMEs.

39 Different outcomes may have been found if motor speech researchers were matched with clinicians treating mostly children with motor speech disorders and if phonology researchers were matched with clinicians treating mostly phonological disorders.

40 For example, D. Bahr and G. Lof were both instructors in SLP graduate training programs when Bahr wrote the textbook Oral Motor Assessment and Treatment: Ages and Stages (2001) and Lof began expressing his concerns regarding NSOME (2003). Both appeared to want parameters for the use of oral sensory-motor activities/exercises. This may have been common ground from which these two SLPs could have worked.

Please cite this article as:

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.

Permalink URL: www.oralmotorinstitute.org/v4n1_walsh

HORNS, WHISTLES, BITE BLOCKS, AND STRAWS

Oral Motor Institute

Volume 4, Monograph No. 2, 3 April 2012

HORNS, WHISTLES, BITE BLOCKS, AND STRAWS

A REVIEW OF TOOLS/OBJECTS USED IN ARTICULATION THERAPY BY VAN RIPER AND OTHER TRADITIONAL THERAPISTS

By Pam Marshalla, MA, CCC-SLP

Keywords: Articulation therapy, phonetic placement method, oral motor techniques, nonspeech oral motor exercise, nonspeech oral motor treatment, oral sensory-motor techniques, traditional articulation therapy, motokinesthetic method, orofacial myofunctional disorders, oromotor, speech tools, horns, whistles, bite blocks, straws, tongue depressors

ABSTRACT

Problem

The use of tools and other objects in articulation therapy has been bundled into new groups of activities called “nonspeech oral motor exercises” (NSOME) and “nonspeech oral motor treatments” (NSOMT) by some authors. The purveyors of these new terms suggest that there is no proof that such objects aid speech learning, and they have cautioned students and professionals about their use. Speech-language pathologists are trying to reconcile these cautions with basic Van Riper type therapy routines.

Purpose

The purpose of this literature review was to summarize the ways in which tools/objects were used by Van Riper and other speech professionals between 1939 and 1968.

Method

Fourteen textbooks were selected for review. Data were recorded on the number, types, and purposes of tools and other objects used to influence speech movements.

Results

Van Riper and fourteen other authors used 86 different objects, or types of objects, to teach dissociation, direction, and grading of speech movements in articulation therapy. Objects included regular household items, medical equipment, and specially designed oral tools. These objects were used to teach an extensive array of jaw, lip, cheek, tongue, and velar movements while training every consonant, vowel, and diphthong of Standard North American English. Van Riper stated that objects must be used when auditory training, auditory-visual modeling, and verbal instruction proved inadequate in teaching correct phoneme productions. He called this method the phonetic placement method.

Conclusions

Van Riper and other developers of traditional articulation therapy regularly used a wide variety of tools/objects in articulation therapy when teaching dissociation, grading, direction, and positioning of the articulators for phonetic placement. Tools/objects were used when other auditory, linguistic, and cognitive means failed to stimulate correct phoneme productions. To call these activities “non-speech” methods seems to misrepresent the historic purpose objects have served in articulation therapy. Student clinicians need to be taught how tools/objects were used in phonetic placement, and professionals need to consider how these methods might help their clients with oral sensory-motor delay/dysfunction. More empirical research is required in this area.

BACKGROUND

Some speech-language pathologists (SLPs) have cautioned against the use of objects such as horns, whistles, bite blocks, and straws in articulation training (Bowen, 2005; Lof, 2008; Lof & Watson, 2008; Powell, 2008; Forest & Iuzzini, 2008; Muttiah, Georges, & Brackenbury, 2011). Activities that employ these types of tools have been bundled into categories called nonspeech oral motor exercises (NSOME; Lof & Watson, 2008) and nonspeech oral motor treatments (NSOMT; Lass & Pannbacker, 2008). Employing the term “nonspeech” suggests that using an object in articulation therapy is unrelated to classic processes of speech correction and therefore should be avoided. One writer even stated that it would be a progressive step if these types of activities were condemned (Bowen, 2005). Some arguments against the use of objects in speech treatment have been:

There is insufficient evidence to support the use of objects in articulation therapy.
There has been no demonstrable relationship between so-called “nonspeech” activity and speech.
Articulation improvement cannot be gained if therapists focus on the individual parts of phoneme productions instead of whole phonemes or syllables.
Speech-language pathologists may be using objects indiscriminately in articulation therapy.

Despite objections such as these, Lof and Watson (2008) also demonstrated that the use of NSOME seems to be widespread in North America. The following samples are illustrative of the types of activities being employed. They have been abstracted from five manuals published in the U.S. since 2001:

Straws: Rosenfeld-Johnson (2001) recommended a hierarchy of straws to help clients attain tongue retraction and lip rounding when these skills could not be elicited through auditory-visual modeling and verbal instruction for consonant and vowel productions.
Dental floss holder: Marshalla (2004) recommended the aid of a dental floss holder to teach the tongue-tip to curl up and back when clients could not attain that movement for a retroflex /r/.
Peanut butter: Bleile (2006) recommended placing peanut butter on the maxillary anterior alveolar ridge to help teach tongue-tip elevation when that skill was lacking in production of /l/.
Gummy worm: Gilbert and Swiney (2007) recommended the use of a gummy worm between the lips to teach lip rounding when that skill was lacking and otherwise unattainable in production of selected phonemes.
Flavored cotton swab: Secord, Boyce, Donohue, Fox, and Shine (2007) recommended using a cotton swab to touch the soft palate in order to teach tongue-back placement when clients were unable to achieve that movement during production of /k/ and /g/.

CENTRAL QUESTIONS

The central questions to be answered in this paper are:

How did Van Riper and other architects of traditional articulation therapy use objects in articulation therapy?
What was their rationale for using objects in articulation therapy?
What types of objects did they use?
For what purpose did they use these objects?

METHOD

Textbooks published between 1939 and 1968 were reviewed. 1939 was the year Van Riper published his first textbook (Van Riper, 1939), and he is widely considered to be the main architect of traditional articulation therapy. The final year, 1968, was selected as the year that the first principal works about phonological concepts entered the English literature (Chomsky & Halle, 1968; Jacobson, 1968). Phonological theory facilitated a radical shift in the way speech-language pathologists analyze and treat speech impairment.

Ten textbooks were selected for review (Appendix A). These books were chosen because they met the following criteria:

They were used to train students studying the assessment and treatment of speech disorders.
They were published between 1939 and 1968.
Their titles contained the words speech, speech therapy, speech correction, speech disorders, articulation, articulation therapy, or articulation disorders.

Three other books published before 1939, and one from 1955, were added to this group because Van Riper consistently recommended them as resources for additional methods (Appendix B). Therefore, a total of fourteen textbooks were reviewed. Altogether fifteen speech professionals authored these texts. Four of the writers served as Presidents of the American Speech-Language-Hearing Association (ASHA), and six received ASHA’s prestigious Honors of the Association (Appendix C). Van Riper wrote four of the books under review.

Once the review of these fourteen books was completed, three of Van Riper’s later texts (Van Riper, 1978; Van Riper & Erickson, 1984, 1996) were surveyed for comparison to the earlier volumes used in the review. One letter Van Riper wrote in 1993 also was reviewed for comments he made about his early work in articulation therapy (Secord, et al, 2007, p. viii).

Each text was read, and findings were recorded on worksheets designed specially for this purpose (Appendix D). Each object named as a tool to teach the movements or positions of phoneme production was added to the list. The page on which the object appeared was noted and its purposes were described. Objects also were classified according to the following types: Animal product (A), Body part (B), Cold object (C), Eating utensil (E), Food (F), Glass object (G), Heated object (H), Liquid (L), Metal object (M), Musical instrument (MI), Paper object (P), Plant-based object (PB), Rubber object (R), Toy (T), Wooden object (W), Other specified object (OS), and Other non-specified object (ONS).

RESULTS

A total of 86 different objects, or types of objects, were mentioned in the fourteen textbooks reviewed (Appendix E). Careful scrutiny of Appendix E reveals that many of these objects were regular household items such as spoons, toothpicks, lollipops, mirrors, tissue paper, and ping-pong balls. Several items were common medical/laboratory items such as nasal bulbs, pipettes, and tongue depressors. Some items appear to be alternate names for the same object. For example, the following terms were found: “applicator,” “applicator stick,” “thin applicator,” “wooden applicator,” “stick,” “thin stick,” “thick stick,” “rounded stick,” and “tongue depressor.” It is possible that all of these were terms for the tongue depressor, but the texts did not make that clear so these objects were listed separately. The reader also will notice objects identified by generic names such as “probes,” “wedges,” “tooth props of various sizes,” “other objects,” and “every available device.” There was no way to determine from the texts what these objects actually were, so they were listed exactly as named by the original authors. Van Riper referred to all of these tools as “various instruments and applicators.”

Additional study of Appendix E reveals several objects that will be unfamiliar to the modern reader including: “Fricator,” “Fraenum Fork,” “Ladator,” “S-Concentrator,” and “Ruvinator.” These were specialized wire tools that were developed by Borden and Busse (1925) at the New York University Speech Clinic. Each tool was designed to teach a particular speech movement. The “Fricator” was designed to hold the tongue-tip down. The “Ladator” was designed to hold the lower lip down. The “Fraenum Fork” was designed to teach the tongue to groove for the sibilants. The “S-Concentrator” was designed to teach a smaller and tighter groove at the tongue-tip (a more “concentrated” groove). The “Ruvinator” was designed to push the tongue into a high back position for the lingua-velar phonemes. Van Riper referred to all of these objects as “curious wire contrivances.”

Other unfamiliar items also will be found in Appendix E. The “Velar Hook” was a tool made out of

“a rubber pen holder” (Scripture, 1912, pp. 153-155). The object was placed in the mouth and hooked

onto the back of the velum. The instructor then used the tool to exert slight forward pressure against the soft palate. The client worked to lift his soft palate up and back against this resistance to close off the nasal port. Froeschels (1948) named three other unusual objects:

“Kerr’s Modeling Compound,” “Stents Wax,” and

“Stents Plate.” These products are used today for making

dental impressions and models, but the purposes for using them in articulation therapy were not described in Froeschels’ text.

Detail from Sctipture (1912) showing the use of a tissue flag for teaching nasal airflow.

Manipulation of oral structures with the hands and fingers was recommended by all but one of the authors, and they were the main tools recommended in the two books written about the motokinesthetic method (Stinchfield & Young, 1938; Young & Hawk, 1955). The hands and fingers were treated as one single object and recorded as “hands/fingers” because authors often did not differentiate between them. Some authors specified a thumb or finger to be used, but generally the hands and fingers were treated generically. Van Riper used his hands and fingers in various ways to stimulate oral positions for phoneme productions; however, with Irwin he hinted that the motokinesthetic method probably relied too heavily on the hands and fingers (Van Riper & Irwin, 1958, p. 147). Van Riper and Irwin preferred to have clients use their own hands and fingers as feedback mechanisms to supplement the auditory and visual sensations they experienced while learning phonemes.

The authors also referred to the teeth as “objects” relative to jaw, lip, cheek, and tongue manipulation. The upper central incisors were used to stimulate lower lip elevation, and the side teeth were used to stimulate lateral tongue elevation. The side teeth also were used as objects against which the cheeks could brace.

The 86 objects were organized according to the authors who discussed them (Appendix F). The appendix reveals that all fifteen authors employed objects in the process of articulation therapy. Some authors recommended only a few objects while others named a wide variety. The number of objects mentioned and/or discussed by each writer ranged from 2 to 24. Authors who named the most items included Van Riper (1954) who named 22 and Scripture (1912) who named 24. Authors who described how to employ a small number of objects relied upon wooden objects (tongue depressors and other “sticks”), the hands and fingers, household mirrors, and hand-drawn diagrams and palatograms as their main tools of articulation training. Some writers described how they utilized objects in great detail (e.g., Nemoy & Davis, 1937; Young & Hawk, 1955). Other authors described the use of objects only in passing (e.g., Eisenson & Ogilvie, 1963; Carrell, 1968).

Van Riper termed the process of using objects in articulation training the phonetic placement method. He wrote:

“For centuries, speech correctionists have used diagrams, applicators, and instruments to ensure appropriate tongue, jaw, and lip placement… [These] phonetic placement methods are indispensable tools in the speech correctionist’s kit… Every available device should be used to make the student understand clearly what positions of tongue, jaw, and lips are to be assumed” (Van Riper, 1954, pp. 236-8).

Appendix G contains a summary of the stated purposes served by the 86 objects by category. A quick scan of this appendix reveals that tongue depressors and other wooden objects were used for far more purposes than any other single item. The hands and fingers were the next most widely used items. The reader also can verify that while a few objects were used for only one purpose, most objects were used for multiple purposes. The overall purpose of using objects was “to manipulate the tongue, lips, and jaw [and] to touch mouth surfaces for showing tongue placement” (Carrell, 1968, p. 99).

Appendix H lists the 86 objects according to the goal they served, organized by subsystem and structure. The appendix reveals that the objects were used for a variety of goals, from attaining lip rounding for /w/ to gaining tongue-back elevation for /k/ and /g/. No objects were used to teach whole phonemes; therefore, there was no one tool for /p/, or /l/, or /k/, and so forth. Instead, it was found that objects were used to teach component speech movements, and the objects varied according to the targeted goal. Thus one tool might be used to teach the velum to rise while another was used to encourage the tongue to groove. Objects were used to facilitate changes in each of the four primary speech subsystems: respiration, phonation, resonation, and articulation.

These textbooks collectively described methods for using objects to teach a total of 72 distinct movement skills, or types of movements, named in Appendix H and summarized here:

Jaw: Objects were used to teach dissociation, grading, and direction of the lower jaw’s vertical (up and down) movements. Objects were used to stabilize the lower jaw’s vertical position in order to achieve appropriate amounts of mouth openness and closure (i.e., grading). Objects were used to guide the jaw left, right, forward, or back in order to achieve a midline position. Objects also were used to inhibit unnecessary jaw movements.
Lips: Objects were used to teach bilabial and labio-dental contact, as well as lip rounding and retracting. Objects also were used to inhibit unnecessary lip movements and to reduce tension in the lips both before and during phoneme productions.
Cheeks: Objects, especially the hands and fingers, were used to hold the cheeks in position against the lateral dentition (side teeth) during phoneme production.
Tongue: Objects were used to stimulate general gross tongue movement as well as to prevent unnecessary tongue movement. Objects were used to elevate the tongue-tip to the maxillary anterior alveolar ridge. They also were used to hold the tongue-tip against the alveolar ridge, to prevent the tongue-tip from reaching the alveolar ridge, and to tease the tongue-tip away from the alveolar ridge. Objects were used to elevate the tongue-back to the soft palate as well as to elevate the sides of the tongue to the upper side teeth and gums. Objects were used to create both wide and narrow central grooves in the tongue, as well as to create a tiny central groove at the tongue-tip. Objects were used to teach the tongue-tip to curl up and back for the retroflex /r/. Objects also were used to push the tongue back into the mouth when it habitually postured in an anterior or interdental position.
Palate: Objects were used to stimulate specific locations on the palate at points where the tongue was to make contact. For example, the anterior portion of the alveolar ridge was stroked with an object at the point Van Riper called “the spot” in order to teach lingua-alveolar contact (Van Riper, 1947, p. 191).
Respiration: Objects were placed on and around the chest, and in front of the mouth and nose, in order to teach clients to become aware of their own patterns of inhalation and exhalation. Objects also were used to teach prolongation of exhalation. Small objects and tubes were used to teach the discrete differences in airflow for each of the fricatives and affricates.
Phonation: Objects, especially the hands and fingers, were placed on the face and throat to educate clients about several facets of voice. They were used to teach clients how to produce phonemes with and without voicing as well as how to produce voiced sounds and words without tension.
Nasal Resonance/Velum: Objects, especially the hands and fingers, were placed on the face to help clients become aware of, to modify, and to control their own oral and nasal resonance. Paper and tissue “flags” were held in front of the mouth and nose to help clients control the direction of oral and nasal airflow. Objects also were placed directly against the velum to teach it to raise and lower.
Prosody/Fluency: Objects, especially megaphones and wind instruments, were mentioned on occasion as aids in the teaching of certain aspects of prosody and fluency including pitch, stress, loudness, rate, and intonation modulation.

Review of the textbooks revealed that collectively the authors had devised activities using objects to teach every component movement necessary for production of all Standard North American English consonants, vowels, and diphthongs. Nemoy and Davis (1937) were the only authors to discuss a variety of specific object techniques for every consonant. Scripture (1912) described how to use objects to teach every consonant except /h/. Young and Hawk (1955) were the only authors to describe how to apply these ideas specifically for every consonant as well as for every vowel. The other writers concentrated on methods to address movements for only the more problematic consonants, including /l/, /r/, /k/, /g/, and the fricatives/affricates. Examples of selected procedures to teach the movements and positioning required for /s/ from the texts are presented in Appendix I.

In regard to the logistics of using objects in articulation therapy, each of these authors recommended that objects should be employed after a client has failed to produce a correct phoneme from an auditory-visual model and from direct verbal instruction. In each of his texts, Van Riper claimed that the training of any phoneme begins with stimulating the auditory system (auditory training), and then proceeds to providing an auditory-visual model for the client to imitate (stimulation method). He contended that if auditory training and the therapist’s model alone did not teach the client to produce the correct phoneme right away, then other methods needed to be employed. These other methods included the phonetic placement method and those objects employed in its application (Illustration 1). Nemoy and Davis (1937) suggested that object manipulation be considered “a last resort [used] only after all other methods have failed” (p. 36). Objects were used by various authors both before and during phoneme attempts.

Illustration 1: A selected portion of Van Riper’s model of articulation therapy showing the relationship between auditory training, the stimulation method, and the use of objects when teaching phonemes.

DISCUSSION

Many points of discussion resulted from this textbook review. Objects were a regular part of traditional articulation therapy according to Van Riper and the writers of the fourteen textbooks reviewed, and to suggest otherwise is historically inaccurate. Van Riper called this the phonetic placement method, and he himself used a wide variety of objects for this purpose. The main purpose of using an object was to teach dissociation, direction, and grading of oral movements for phoneme position/placement. To dissociate means to “separate” (Jewell & Abate, 2001, p. 494). In the case of speech articulation, this usually means to separate jaw, lip, tongue, and velar movements from one another. For example, the production of /ʃ/ requires distinct movements in each articulator: The jaw sits high, the lips round, the tongue elevates its lateral borders, and the velopharyngeal port closes. Authors of these historical texts used objects to assist these independent movements when a client could not accomplish them without assistance.

Van Riper taught that objects were to be used only after a client had failed to imitate an auditory-visual model of the target phoneme. In other words, he posited that one should not begin teaching a phoneme with an object. Van Riper explained that phoneme training begins with auditory training. Once the client is aware of the phoneme, can identify it, and can discriminate it from other similar phonemes, the actual process of teaching production begins with modeling the phoneme for the client to imitate–the stimulation method. However, according to Van Riper, if auditory training and a therapist’s auditory-visual model do not stimulate a better production of the target phoneme with accurate movement and positioning right away, other methods, including the phonetic placement method and the objects it employs, should be used to teach place, manner, and voicing. Van Riper wrote: “When the stimulation method fails…they [phonetic placement methods/objects] must be used” (Van Riper, 1947, p. 146).

None of the writers in the textbook reviews suggested that an object alone would bring about phoneme emergence or correction. Objects were to be used to stimulate appropriate dissociation, grading, or direction of movement, and then these movements were to be used to teach target phonemes. This is a two-step process that Van Riper described as follows: “The therapist…is attempting to give [the client] the appropriate location and formation. As soon as this has been achieved, the therapist stimulates [the client] with the correct sound” (Van Riper, 1954, p. 147). Therefore, according to this traditional view, objects may be used and in fact are recommended to teach approximations of speech movements.

A misunderstanding of the basic phonetic placement process may be causing some of the recent concern among speech-language pathologists about using objects in articulation therapy. Some academics and clinicians who condemn the use of objects or tools (including the hands and fingers) in speech therapy, by calling these activities NSOME/NSOMT, have implied that therapists are attempting to use objects alone to cause phonemes to emerge or correct. According to Powell for example, “Party horns… blow ticklers… bubbles… straws… Items such as these are being used by speech-language pathologists (SLPs) across America to treat a wide range of communication disorders… they employ nonspeech tasks as an indirect means of modifying speech production” (Powell, 2008, p. 374).

If it is true that SLPs are using objects alone to correct phonemes, this runs counter to the historic use of objects as presented by the authors reviewed. As explained by Van Riper, an object is used to teach a specific movement and then this movement is used to teach the phoneme that requires the movement. All of this is done only after a client has failed to imitate the phoneme with auditory-visual modeling and direct instruction. The key to using objects in this view is to have clients attempt to produce the correct sound during or immediately after stimulation.

One of the current arguments against using objects is that there has been no demonstrable relationship between speech and “nonspeech” activity (e.g., Wilson, Green, Yunusova, & Moore, 2008). Some authors are warning that it is inappropriate to have clients chew gum to get the jaw to move up and down, to bite on a bite block to stabilize the jaw at various heights, to blow whistles to learn lip rounding, or to press the tongue-tip against a spoon to learn tongue-tip elevation. Those clinicians who disapprove of such measures fail to consider the sample of clients with oral sensory-motor delays/deficiencies who may require help in producing appropriate jaw, lip, tongue, or velar movements as preparatory skill development before specific phoneme training is possible. Van Riper called these clients “clumsy-tongued individuals” and “the slow of tongue” (Van Riper, 1947, p. 132). The need to develop some basic movement skills in order to control structures associated with speech has merit. In Van Riper’s words: “In modern speech correction, the emphasis on tongue exercises has almost disappeared. Yet for certain of the clumsy tongued individuals with whom we work, modern forms of these exercises are very valuable” (p. 132).

Van Riper’s texts clearly point to and recommend that speech-language pathologists engage in these routines in order to attain preliminary movement approximations for speech. He wrote: “Whenever possible the articulatory exercises given should proceed out of the movements used in the biological functions” (Van Riper, 1939, p. 242). Van Riper even recommended the use of “non-speech” activity itself when working with young children: “With smaller children it is often necessary to begin by training them in imitation of non-speech movements” (Van Riper & Irwin, 1958, p. 144). Modern SLPs are trying to reconcile these basic Van Riper methods with recent cautions about the use of objects or tools in so-called “non-speech” activity. Much confusion about why and how to use objects in articulation therapy appears to be the result.

It also has been argued that articulation improvement cannot be achieved if therapists focus on the individual parts of phonemes instead of the whole phoneme in a syllable or word (e.g., Bowen, 2005; Bunton, 2008; Forest, 2002; Lof, 2003; Kahmi, 2008). For example, when teaching /k/, the warning is to leave jaw, lip, and tongue control alone, and just teach /k/ within the language context. This procedure ignores clients with oral sensory-motor issues who simply cannot elevate the back of the tongue on demand. How long must a speech-language pathologist model /k/ in syllables or words with no success before he or she decides to do something directly to help the client lift the back of the tongue? Van Riper and the other authors reviewed suggested that this help should be given right away. In 1993, Van Riper explained that the reason he wrote his first text (Van Riper, 1939) was to counter the then common practice of simply having clients repeat words over and over again as a way to correct phonemes. In his words: “All the clinician would do was to ask the client to repeat [words] after her… That would go on for an hour. They felt that such a bombardment would lead to error elimination. Can you imagine that?” (Secord, et al, 2007, p. viii).

According to each of the reviewed textbooks, word drilling often is not enough to correct the articulation of phonemes. The early authors of articulation texts in this review concluded that therapy should switch quickly to the individual phoneme (or syllable) when failure occurs, and further assistance on place, manner, and voice features should be given right away. Objects may be used to teach these features if necessary. This recommendation represents basic articulation therapy as taught by the authors under discussion.

The reader will note that some of these authors utilized unsanitary and potentially harmful or dangerous object activities that are not compatible with current safety requirements. For example, Nemoy and Davis (1937) recommended placing small bits of paper on the back of the tongue to teach posterior tongue elevation, and the aspiration of such objects represents a risk that was not identified. Berry and Eisenson (1956) used masking and adhesive tape next to or below the lips to inhibit or to draw attention to their movement. Scripture (1912) and Anderson (1953) both recommended producing phonemes in front of lit flames to monitor airflow. Froeschels (1948) used fragile and easily breakable glass pipettes to teach oral airflow. Scripture (1912) also used electrical impulses to stimulate velar movement. Even Van Riper (1954) used long wooden matches to mark the palate for tongue placement, and he used pencils to move the tongue, to groove the tongue, to round the lips, and to stabilize the jaw.

Some may claim that Van Riper modified his views about the use of objects in articulation therapy later in life. A review of his final thoughts on the subject may shed light on this conjecture. Examination of the last edition of Van Riper’s textbook revealed that he had continued discussing these methods as a regular part of therapy (Van Riper, 1978). It is therefore apparent that Van Riper advocated the use of objects in articulation therapy for at least four decades, from 1939 through 1978.

Beginning in 1984, however, Van Riper collaborated with a colleague (Erickson) in writing another basic text, An Introduction to Speech Pathology and Audiology (Van Riper & Erickson, 1984). In the introduction, Van Riper noted that the very purpose of the text had changed from being a collection of methods for speech-language pathologists, to a general introductory text for undergraduate speech and other students. The section of the text on articulation was highly influenced by this transformation. The authors made more generalized statements about articulation therapy, they introduced phonological theory, and they dropped almost all of Van Riper’s specific phonetic placement methods along with the discussion of the objects he used to accomplish them. This seems to have become the model for many articulation/phonology textbooks published since that time.

Modern textbooks on articulation and phonology continue to acknowledge the phonetic placement method as one viable option in articulation therapy, but the many details of how to utilize objects generally are not included. As examples, Bernthal and Bankson (2004), Bauman-Waengler (2004), and Pena-Brooks and Hegde (2000) present general statements about the phonetic placement method, offering a few sample methods as illustrations. Likewise these texts acknowledge the motokinesthetic method (Stinchfield & Young, 1938; Young & Hawk, 1955), but the great details of the ways in which these therapists used their hands and fingers to teach positioning of the speech structures are absent. The reduction of phonetic placement techniques and motokinesthetic methods into simplified paragraph descriptions has left generations of therapists lacking specific knowledge about the vast array of objects, including the hands and fingers, which were used to influence oral movement in Van Riper’s time. Perhaps the misunderstanding and misuse of objects today has been the inevitable result.

Phonetic placement methods and the objects used to accomplish them endured into the 1980s in a few books including Vaughn and Clark (1979), Bosley (1981) and Hanson (1983). In the 21st century, the details of object use for phonetic placement and motokinesthetics have survived and thrived by shifting them away from main introductory textbooks designed for students, and into practical instructional manuals designed for working professionals. A number of modern guidebooks contain procedures for using objects in the process of speech movement instruction. These include Bahr (2001), Bleile (2006), Gilbert and Swiney (2007), Marshalla (2004 and 2007), Rosenfeld-Johnson (2001 and 2005), and Secord et al (2007). Although the term “oral motor” (simply meaning “mouth movement”) has been attached to some of them, many of the techniques contained in these manuals are updated versions of what Van Riper called “the old traditional methods.” As an example, Van Riper (1947) used a pencil to teach lip rounding, and he called it a phonetic placement method, while Gilbert and Swiney (2007) used a gummy worm to teach lip rounding, and they called it an oral motor technique. The goal and procedures are the same, but the tool has been modernized and the vocabulary updated. This is a reflection of a basic principle of articulation therapy taught by Van Riper and Irwin: “There are no doubt almost as many ways of carrying out these basic principles as there are clinicians” (Van Riper & Irwin, 1958, p. 118).

Phonetic placement techniques and their objects are employed when a client simply cannot learn a specific speech movement in any other way. Secord, a protégé of Van Riper, wrote that one uses these and other methods “when the client cannot produce a target sound at all” (Secord, et al., 2007, p. 3). He continued: “In a manner of speaking, the clinician needs to ‘roll up her sleeves’ and actually teach the client how to say the target sound” (p. 3). This is a process of teaching the mechanics of sound production (phonetics), not the use of a phoneme within a language (phonology). Professional speech-language pathologists today welcome these ideas in manuals and continuing education programs because the rich assortment of phonetic placement techniques that formerly appeared in articulation therapy textbooks are no longer included in modern texts.

CONCLUSIONS AND IMPLICATIONS FOR THERAPY

This textbook review strongly suggests that objects can and should continue to be used to teach speech movements in articulation therapy when the phonetic placement method is employed. To claim that this is a new idea, to ban the use of objects in articulation therapy, or to assert that this is “non-speech” activity ignores the fact that practicing clinicians have been using objects continuously in speech training in the United States since at least 1912. Using objects to teach speech movement is exactly what Van Riper and other traditional therapists often did when a client could not produce a target phoneme by imitating it. Speech-language pathology students would benefit from being taught to appreciate the historic value served by objects in speech movement training instead of being taught to ignore or condemn this process. Seasoned professionals would benefit from considering how these ideas might apply to clients who do not respond well to model-and-imitate methods of phoneme stimulation.

The traditional therapists of these textbooks used tongue depressors and other “sticks” more than any other tools in articulation therapy. SLPs today continue to use tongue depressors, but some problems exist. The present author has found that tongue depressors are too wide, too thick or too thin, the wrong shape, and simply too clumsy for many of the delicate oral adjustments necessary in articulation training. Additionally, wood can have an unpleasant taste and feel in the mouth even when it is flavored, and an adult-sized tongue depressor can splinter fairly easily when a client bites down hard on its thin edge. Alternatives to the tongue depressor are welcome for these reasons. For example, a modern flexible plastic dental pick often can be slipped between the upper central incisors and placed so that it sits between the tongue-tip and the alveolar ridge. This tiny tool allows for more direct instruction about tongue-tip placement for /s/, /z/ and the other lingua-alveolar phonemes than does the much larger tongue depressor.

SLPs also find that they cannot use their hands and fingers as easily as the therapists in this review because of new restrictions regarding sanitary procedures. SLPs often do not have sinks for proper hand sanitation in their therapy spaces, they may not be provided with gloves, and they may have clients who do not respond well to gloves or commercially available hand sanitizers. SLPs in the schools often work in groups and cannot sanitize their hands simultaneously for every student. Therapists in many environments find they cannot manipulate the papers, toys, and games of therapy while keeping their hands sanitized. They also cannot touch clients with the hands when working via on-line video services. Some SLPs work for employers who prohibit them, for legal reasons, from touching clients with the hands and fingers. An obvious solution to each of these situations is to employ a variety of sanitized objects the therapist can use or the client can use on himself.

Van Riper wrote that “every available device” should be used for phonetic placement. Speech-language pathologists who employ phonetic placement techniques today have a much wider range of tools from which to choose due largely to the invention of synthetic materials. For example, Van Riper may have used matches, pencils, toothpicks, and sticks to adjust jaw position, but a modern therapist can use a set of sanitary and professionally designed bite blocks. Many appropriate objects are being used today for phonetic placement:

Inexpensive household items: Including plastic straws, tubes, swizzle sticks, spoons, and eyedroppers. Metal spoons can be used as well.
Inexpensive items designed to improve oral hygiene: Including toothbrushes, toothettes, tongue scrapers, dental picks, dental floss, and dental floss handles.
Inexpensive toys: Including plastic horns, whistles, bubble wands, kazoos, and harmonicas.
Professionally designed oral/nasal tools: For example, the Lip Retractor, Z-Vibe, LifteR, Oral Probe, Lip Gym, Nasal Clamp, ChewyTube, Maroon Spoon, Jaw Grading Bite Blocks, and Progressive Jaw Closure Tubes.
Safe and sanitary tapes: Including latex-free and nonabrasive Kinesio Tape.

Objects are used in therapy today when auditory bombardment, modeling, phonological awareness activities, reading programs, minimal pairs, and other linguistic and cognitive means are not enough to teach correct phoneme production. Phonetic placement techniques are employed as a last resort when a client needs to learn the specific movements of place, manner, voice, and resonance for particular phonemes, and there is nothing “nonspeech” about that. Nor is there anything new about it. Using objects is one of the traditional ways to teach speech movements in articulation therapy.

NEED FOR RESEARCH

Most of the activities utilizing objects that are recommended by the textbook writers of this review have not been tested using modern tools or research methodologies. Theoretical and opinion pieces on whether objects should or should not be used in treatment provide no evidence that these practices are ineffective. While this literature review does not prove that they are effective, the longevity and persistent presence of these methods over the past century, as demonstrated in this article, suggests that these methods have clinical value and warrant further investigation.

Some research on the use of objects for training phonetic placement has been initiated. The electropalatometer is being used to assess and guide tongue placement for sound production today (e.g., McLeod & Singh, 2009; Gibbon, 1999; Dagenais, Critz-Crosby & Adams, 1994; Fletcher, 1992). An appliance for training /r/ was shown to been effective when combined with auditory stimulation (Clark, Schwarz & Blakely, 1993). Research on SpeechBuddies suggests that tactile biofeedback on tongue position for /r/, /l/, /s/, /ʃ/, and /tʃ/ reduces treatment time in some clients (Rogers, 2010; Rogers & Galgano, 2011). These projects are a beginning, but they address tongue movements only and some of this equipment is beyond a typical therapy budget. Therapists need research on the traditional roles that simple inexpensive objects have played and continue to play in learning all the speech movements of respiration, phonation, resonation, and articulation advocated by Van Riper and these other traditional writers. Ultrasound, magnetic resonance imaging, and even film or videotape could demonstrate these changes. The question to be asked is whether or not the object made learning correct movement and position for target phonemes easier, faster, or more efficient.

SUMMARY

A review of fourteen selected textbooks written in the first half of the 20th century revealed that traditional therapists considered it standard practice to use objects when teaching dissociation, grading, direction, and positioning of the articulators for phoneme production. To call these activities “non-speech” methods seems to misrepresent the historic purpose objects have served in articulation therapy. Van Riper recommended that every device available should be used to help clients learn specific speech movements when imitation of an auditory-visual model of a phoneme proved unsuccessful. He used the term phonetic placement method to describe this process, and he discussed the role that non-speech activity plays in articulation therapy. Speech-language pathologists who are implementing basic Van Riper routines continue to use objects to teach phonetic placement and oral control. Student clinicians need to be taught to appreciate the role objects have played in articulation therapy throughout the past century. Professionals need to consider how the implementation of such activities might help clients who do not respond well to simple model-and-imitate phoneme teaching routines. Empirical research on the effectiveness of using objects to teach oral movement for phoneme production is needed.

ACKNOWLEDGEMENTS

Nine masked peer-reviewers participated in the pre-publication process for this article. This group was a mix of academics and clinicians. Five of the nine reviewers were from outside of the Oral Motor Institute (OMI) study group, and four were OMI board members. The masked peer-reviewers were and are unknown to the author. Feedback from masked peer-reviewers and many others helped refine the article.

RELATED INFORMATION

Declarations of Interest

Pamela Marshalla owns Marshalla Speech and Language through which she writes and publishes books, serves as an instructor of continuing education seminars, and provides consultation on children with speech disorders. She voluntarily co-chairs the OMI study group. Marshalla’s books include: Carryover Techniques in Articulation and Phonological Therapy (2010), Frontal Lisp, Lateral Lisp (2007), Apraxia Uncovered: The Seven Stages of Phoneme Development (2007), Successful R Therapy (2004), Becoming Verbal with Childhood Apraxia (2001), How to Stop Drooling (2001), How to Stop Thumbsucking (2001), and Oral-Motor Techniques (1992). She has developed one standardized test, Marshalla Oral Sensorimotor Test (2007), and she has produced one children’s music CD, Do You Like Pie? (2008). Several of her seminars have been recorded and made available for purchase and/or online continuing education training.

Financial Support

Pamela Marshalla received no remuneration for the study of this topic or the writing of this article. Rhonda J. Banford, MAT, CCC-SLP, Donna Ridley, MEd, CCC-SLP, and Diane Bahr, MS, CCC-SLP, voluntarily edited and provided feedback throughout the process. The OMI is an all-volunteer study group and does not advertise or endorse particular groups or individuals. The OMI website is donated by Marshalla Speech and Language. Neither Pam Marshalla nor the OMI receives financial benefit from the sale of any tools or objects named in this article.

Author Information

Pam Marshalla, MA, CCC-SLP, has been a certified speech-language pathologist since 1976. She completed a Master’s Thesis in phonology at the University of Illinois under the direction of Elaine Pagel Paden and Barbara Williams Hodson. She has provided assessment, treatment, and consultation to clients of all ages and ability levels in schools, hospitals, university clinics, parent-infant programs, residential facilities, and her own private practice. Pam is the author of nine books, one standardized assessment tool, and one children’s music CD. She has taught hundreds of continuing education courses in the United States and Canada, including numerous invited local, state, regional, and national conventions. Email questions and comments regarding this article to pam@pammarshalla.com. [Edited 2015: Pam Marshalla passed away in June, 2015. Please direct questions to Marshalla Speech & Language.]

REFERENCES

Anderson, V. A. (1953). Improving the child’s speech. New York: Oxford University.
Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston: Allyn and Bacon.
Bauman-Waengler, J. (2004). Articulatory and phonological impairment: A clinical focus. Boston: Pearson.
Bernthal, J. E., & Bankson, N. W. (2004). Articulation and phonological disorders. Boston: Pearson.
Berry, M. F., & Eisenson, J. (1956). Speech disorders: Principles and practices of therapy. NY: Appleton-Century-Crofts.
Bleile, K. (2006). The late eight. San Diego: Plural.
Borden, R. C., & Busse, A. C. (1925). Speech correction. New York: Crofts.
Bosley, E. C. (1981). Techniques for articulatory disorders. Springfield: Charles C. Thomas.
Bowen, C. (2005). What is the evidence for oral motor therapy? Acquiring Knowledge in Speech, Language and Hearing, 7(3) 144-147.
Bunton, K. (2008). Speech versus nonspeech: Different tasks, different neural organization. Seminars in Speech and Language, 29(4) 267-275.
Carrell, J. A. (1968). Disorders of articulation. Englewood Cliffs: Prentice-Hall.
Chomsky, N., & Halle, M. (1968). The sound pattern of English. NY: Harper & Row.
Clark, C. C., Schwarz, I. E., & Blakely, R. W. (1993). The removable r-appliance as a practice device to facilitate correct production of /r/. American Journal of Speech Language Pathology, 2, 84-92.
Dagenais, P. A., Critz-Crosby, P., & Adams, J. B. (1994). Defining and remediating persistent lateral lisps in children using electropalatography: Preliminary findings. American Journal of Speech Language Pathology, 3, 67-76.
Eisenson, J. & Ogilvie, M. (1963). Speech correction in the schools. NY: MacMillan.
Fletcher, S. G. (1992). Articulation: A physiological approach. San Diego: Singular.
Forest, K. (2002). Are oral-motor exercises useful in the treatment of phonological/articulatory disorders? Seminars in Speech and Language, 23(1) 15-25.
Forrest, K., & Iuzzini, J. (2008). A comparison of oral motor and production training for children with speech sound disorders. Seminars in Speech and Language 29(4) 304-311.
Froeschels, E. (Ed.) (1948). Twentieth century speech and voice correction. NY: Philosophical Library.
Gibbon, F. E. (1999). Undifferentiated lingual gestures in children with articulation/phonological disorders. Journal of Speech and Hearing Research, 42, 382-397.
Gilbert, D. W., & Swiney, K. A. (2007). Sound strategies for sound production. Austin: Pro-Ed.
Hanson, M. L. (1983). Articulation. Philadelphia: W. B. Saunders.
Jacobson, R. (1968). Child language aphasia and phonological universals. The Hague: Mouton.
Jewell, E. J., & Abate, F. (2001). The New Oxford American Dictionary. NY: Oxford University.
Lass, N. J., & Pannbacker, M. (2008). The application of evidence-based practice to nonspeech oral motor treatments. Language, Speech and Hearing Services in Schools, 39, 408-421.
Lof, G. L. (2008). Controversies surrounding nonspeech oral motor exercises for childhood speech disorders. Seminars in Speech and Language 29(4) 253-255.
Lof, G. (2003). Oral motor exercises and treatment outcomes. Perspectives on Language Learning and Education, 10(1) 7-11.
Lof, G. L., & Watson, M. M. (2008). A nationwide survey of nonspeech oral motor exercise use: Implications for evidence-based practice. Language, Speech, and Hearing Services in Schools, 39(4) 392-407.
Marshalla, P. (2007). Frontal lisp, lateral lisp. Mill Creek: Marshalla Speech and Language.
Marshalla, P. (2004). Successful r therapy. Mill Creek: Marshalla Speech and Language.
McLeod, S. & Singh, S. (2009). Speech sounds: A pictoral guide to typical and atypical speech. San Diego: Plural.
Muttiah, N., Georges, K., & Brackenbury, Y. (2011). Clinical and research perspectives on nonspeech oral motor treatments and evidence-based practice. American Journal of Speech-Language Pathology, 20, 47-59.
Nemoy, E. M., & Davis, S. F. (1937). The correction of defective consonant sounds. Magnolia, MA: Expression.
Pena-Brooks, A., & Hegde, M. N. (2000). Assessment and treatment of articulation and phonological disorders in children. Austin: Pro-Ed.
Powell, T. W. (2008). The use of nonspeech oral motor treatments for developmental speech sound production disorders: Interventions and interactions. Language, Speech and Hearing Services in Schools, 39, 374-379.
Rogers, G. (2010, November). Treating articulation disorders with Speech Buddies. Session presented at the annual meeting of the American Speech-Language-Hearing Association Convention, Philadelphia, PA.
Rogers, G. & Galgano, J. (2011, November). Evaluating the efficacy of treating misarticulated /s/ using tactile biofeedback. Session presented at the annual meeting of the American Speech-Language-Hearing Association Convention, San Diego, CA.
Rosenfeld-Johnson, S. (2005). Assessment and treatment of the jaw: Putting it all together/sensory, feeding and speech. Tucson: Talk Tools.
Rosenfeld-Johnson, S. (2001). Oral-motor exercises for speech clarity. Tucson: Talk Tools.
Scripture, E. W. (1912). Stuttering and lisping. NY: Macmillan.
Secord, W. A., Boyce, S., Donohue, J., Fox, R., & Shine, R. (2007). Eliciting sounds: Techniques and strategies for clinicians. NY: Thomson Delmar Learning.
Stinchfield, S. M., & Young, E. H. (1938). Children with delayed or defective speech: Motor-kinesthetic factors in their training. Stanford: Stanford University Press.
Vaughn, G. R., & Clark, R. M. (1979). Speech facilitation: Extraoral and intraoral stimulation technique for improvement of articulation skills. Springfield: Charles C. Thomas.
Van Riper, C. (1978, 1958, 1954, 1947, 1939). Speech correction: Principles and methods. Englewood Cliffs: Prentice-Hall.
Van Riper, C. & Erickson, R. L. (1996, 1984). Speech correction: An introduction to speech pathology and audiology. Boston: Allyn and Bacon.
Van Riper, C. & Irwin, J. (1958). Voice and articulation. Englewood Cliffs: Prentice-Hall.
Wilson, E. M., Green, J. R., Yunusova, Y., & Moore, C. A. (2008). Task specificity in early oral motor development. Seminars in Speech and Language, 29(4) 257-266.
Young, E. H., & Hawk, S. S. (1955). Moto-kinesthetic speech training. Stanford: Stanford University Press.

APPENDIX A

ten textbooks originally selected for the review

Anderson, V. A. (1953). Improving the child’s speech. New York: Oxford University.
Berry, M. F., & Eisenson, J. (1956). Speech disorders: Principles and practices of therapy. NY: Appleton-Century-Crofts.
Carrell, J. A. (1968). Disorders of articulation. Englewood Cliffs: Prentice-Hall.
Eisenson, J. & Ogilvie, M. (1963). Speech correction in the schools. NY: MacMillan.
Froeschels, E. (Ed.) (1948). Twentieth century speech and voice correction. NY: Philosophical Library.
Stinchfield, S. M., & Young, E. H. (1938). Children with delayed or defective speech: Motor-kinesthetic factors in their training. Stanford: Stanford University Press.
Van Riper, C. (1939). Speech correction: Principles and methods. Englewood Cliffs: Prentice-Hall.
Van Riper, C. (1947). Speech correction: Principles and methods. Englewood Cliffs: Prentice-Hall.
Van Riper, C. (1954). Speech correction: Principles and methods. Englewood Cliffs: Prentice-Hall.
Van Riper, C. & Irwin, J. (1958). Voice and articulation. Englewood Cliffs: Prentice-Hall.

APPENDIX B

four textbooks recommended by van riper and therefore added
to the review

Borden, R. C., & Busse, A. C. (1925). Speech correction. NY: Crofts.
Nemoy, E. M., & Davis, S. F. (1937). The correction of defective consonant sounds. Magnolia, MA: Expression.
Scripture, E. W. (1912). Stuttering and lisping. NY: Macmillan.
Young, E. H., & Hawk, S. S. (1955). Moto-kinesthetic speech training. Stanford: Stanford University Press.

APPENDIX C

authors from the textbook review who served as president of the american speech-language-hearing association, and/or who received asha’s prestigious honors of the association

Mildred F. Berry received ASHA’s Honors of the Association in 1971.
James A. Carrell served as ASHA president in 1956, and he received ASHA’s Honors of the Association in 1974.
Jon Eisenson served as ASHA president in 1958, and he received ASHA’s Honors of the Association in 1967.
Sara Stinchfield Hawk served as ASHA president in 1939 and 1940, and she received ASHA’s Honors of the Association in 1953.
Charles Van Riper received ASHA’s Honors of the Association in 1957. Van Riper is widely considered to be the main architect of modern day articulation therapy.
John V. Irwin served as ASHA president in 1968, and he received ASHA’s Honors of the Association in 1970.

APPENDIX D

sample data collection worksheet

Types: Animal product (A), Body part (B), Cold object (C), Eating utensil (E), Food (F), Glass object (G), Heated object (H), Liquid (L), Metal object (M), Musical instrument (MI), Paper object (P), Plant-based object (PB), Rubber object (R), Toy (T), Wooden object (W), Other specified object (OS), and Other non-specified object (ONS).

APPENDIX E
the 86 objects, or types of objects, recommended in the texts

APPENDIX F
a summary of the 86 objects organized by authors

APPENDIX G
a summary of the stated purposes for all 86 objects by category

APPENDIX H
the 72 goals served, organized by subsystem and structure

APPENDIX I
quoted examples of how objects were used to teach specific movements, postures, and positions for /s/ in the reviewed textbooks

Please cite this article as:

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). Available from www.oralmotorinstitute.org.

URL: www.oralmotorinstitute.org/v4n2_marshalla

SELF-LIMITED DIETS IN CHILDREN WITH A DIAGNOSIS OF AUTISM SPECTRUM DISORDERS

Oral Motor Institute
Volume 5, Monograph No. 1, January 2016

SELF-LIMITED DIETS IN CHILDREN WITH A DIAGNOSIS OF AUTISM SPECTRUM DISORDERS

TALK TOOLS: CHARLESTON, SOUTH CAROLINA

By Robyn Merkel-Walsh MA, CCC-SLP
and Lori L. Overland MS, CCC-SLP/NDT-C

ABSTRACT

The CDC (2014) reports, that Autism Spectrum Disorder (ASD) impacts 1 in 68 children in the United States. They also indicate that in “cluster” states such as New Jersey, as many as 1 in 28 boys are affected. Children with ASD often present with comorbid feeding issues. Studies show that up to seventy percent of children with ASD are selective eaters and up to ninety percent have feeding problems (Volkert & M Vaz, 2010). Researchers at Marcus Autism Center and the Department of Pediatrics at Emory University School of Medicine conducted a comprehensive meta-analysis of all published, peer-reviewed research relating to feeding problems and autism. Examination of dietary nutrients showed significantly lower intake of calcium and protein and a higher number of nutritional deficits overall among children with autism (Korschun & Edwards, 2013).

Researchers are exploring the possible causes of ASD, but thus far there are many theories regarding this complex disorder, ranging from genetics to autoimmune dysregulation (Merkel-Walsh, 2012). There is also debate regarding methods of treatment for children with autism. Applied Behavioral Analysis (ABA) has the most empirical research to date. Behavior analysis is a scientifically validated approach to understanding behavior and how it is affected by the environment (Autism Speaks, 2014). It has been endorsed by a number of state and federal agencies, including the U.S. Surgeon General and the New York State Department of Health. (Iovannone, Dunlap, Huber, & Kincaid , 2003). Research has shown that ABA therapy is effective at increasing appropriate behaviors and decreasing inappropriate behaviors (Kodak & Piazza, 2008). Therefore, it is reasonable to believe the principles on which ABA techniques are based can help with feeding issues (Volkert & M Vaz, 2010). The problem is that behavioral therapies however, do not often take into account the complexity of the sensory-motor system or medical issues, and how they relate to self-limited diets in children with ASD.

Purpose

This article explores 1) the sensory-motor system as it relates to feeding, 2) the importance of a thorough assessment; 3) biomedical treatment approaches for children with ASD, 4) Applied Behavioral Analysis (ABA) and its’ relevance when treating sensory-motor based feeding disorders in children with ASD.

Method

Numerous texts, journal articles, print articles, internet articles and clinical presentations were reviewed in order to collect information on the etiology, treatment and outcomes of feeding therapy for self-limited diets with children on the autism spectrum, who have comorbid feeding issues. The authors explored current research in speech – language pathology, biomedical and holistic medicine, nutrition, and Applied Behavioral Analysis (ABA). The authors also looked at case studies and the factors that may have influenced the diets of three children with ASD, who seemingly had behavioral issues, but when assessed presented with structural, medical and /or sensory-motor issues.

Results

The authors found that self-limited diets are often not purely behavioral in nature, and there is a future need for more peer reviewed research on this topic.

DISCUSSION

Based on the review of the literature, there are several important factors to consider when a speech-language pathologist (SLP) receives a referral for a child who presents with ASD and a self-limited diet. These factors include:

The sensory-motor system

Assessment protocols
Biomedical treatments
Applied Behavioral Analysis

1-The Sensory-Motor System:

Sensory processing refers to our ability to take in information from our internal environment and the world around us, organize this information and use it to respond in a well-organized way. An infant’s first job in life is self-regulation to calm him or herself, and to become attentive to the environment. Many people with a diagnosis of autism have difficulty with self -regulation and maintaining optimal levels of arousal (Barthels, 2014). Children with a diagnosis of autism also have a wide range of sensory processing difficulties, which may impact safe, effective, nutritive feeding.

Sensory discrimination is the ability to differentiate between sensations. When a person cannot discriminate, issues with modulation of incoming information and sensory-based motor deficits may occur. Individuals with autism may have qualitative differences in motor skills, especially with posture and alignment (Teitelbaum, Teitelbaum, Nye, Fryman & Mauer 1998). Since the sensory and motor systems cannot be separated, issues with posture and alignment may impact the sensory system (Overland & Merkel-Walsh, 2013).

People with intact sensory discrimination skills can differentiate tastes, textures, smells. They are also able to differentiate locations of food in the mouth or on the face. Secondary to deficits in sensory discrimination, children with ASD may not be able to differentiate these sensations, and as a result, may self-limit their diets because eating has become a negative experience. The sensory and motor systems function as a feedback loop. Sensory input impacts motor skills and movement impacts sensory perception. If a child has difficulty differentiating taste, texture, temperature, or locations of food in the mouth it may be difficult to handle food safely (Bahr, 2001). Holding food in the mouth for long periods of time, swallowing foods that are not adequately masticated, eating non-food items, etc. may result in gagging, choking, and vomiting. Food refusal and self-limited diets are often the result of compromised oral sensory-motor skills and negative experiences which result in behavioral responses.

Children with modulation issues may be over -responsive or under- responsive to incoming sensory information (i.e., taste, texture, temperature, sound, etc.) and therefore, their responses do not match the incoming information. For example, a typically developing toddler may react surprised, interested, or slightly dismayed at the introduction of a new food taste. A toddler with a diagnosis of ASD may become hysterical, turn red, and start gagging.

2- Assessment:

When an individual with autism is referred to a Speech-Language Pathologist (SLP) for self-limited diet, a comprehensive feeding assessment is required, including: review of child’s medical status; gross, fine, and oral-motor development; nutritional status; and sensory processing (Arvedson & Brodsky, 2001). Since the sensory and motor systems cannot be separated (Overland & Merkel-Walsh, 2013), it is very important to task analyze the child’s motor skills and determine how they relate to feeding, before assuming that a self-limited diet is purely behavioral (Overland, 2010; Merkel-Walsh, 2012). When interviewing parents of children with ASD in an initial intake, “red flags” may often be present in the feeding history such as “he never progressed from purees to solids,” or “she threw up at the sight of any new food,” or “he eats anything and everything even if it is not food.”

As previously mentioned, sensory processing issues can contribute to feeding disorders (Twachtman-Reilly, Amaral, & Zebrowski, 2008). Children with sensory regulation disorders may not be able to organize themselves for feeding (Morris & Klein, 2000). Those with oral sensory-motor issues may not feel the food in their mouths, or they may be overly sensitive to the feeling of the food in their mouths. They may not feel hunger or satiation. Sensory defensiveness can produce a neurochemical reaction of fear that can quickly become a hardwired automatic response (Overland, 2010). The nervous system triggers a “fright-flight-fight” response even if it is irrational. In addition, once a behavior is inadvertently reinforced, the behavior is likely to reoccur (Brophy, 2013). Seemingly well-meaning parents and therapists may not realize that by reacting to food refusals they are actually increasing the chance for this behavior to reoccur (Brophy, 2013; Overland & Merkel-Walsh, 2013). It is important to remember that every behavior means something (Barthels, 2014). While children with autism are referred for what appears to be behavioral feeding problems, the underlying etiology is often sensory-motor.

In order to understand a child’s diet profile, it is important to collect the necessary data and analyze that data in conjunction with information collected on the child’s oral sensory-motor skill development (Overland & Merkel-Walsh, 2013). To thoroughly understand a child’s taste, temperature and texture preferences, it is helpful to have the caregivers fill out a form reporting all foods consumed over a five day period. When possible, name brands of foods may be helpful in addition to the amount consumed, and the utensils that were used. This helps the therapist establish a “home base” which is a profile of taste, texture, and temperature in a child’s diet. Diet shaping starts with a child’s existing profile and slowly expands taste and texture.

5 Day Baseline Diet

Here is Case Study #1: (all names have been changed for privacy)

Jonathan was referred by Dr. Mary Tatum of Quest Learning Group. Chief complaints were speech clarity and feeding issues. Jonathan was diagnosed with mild Autism Spectrum Disorder by Dr. Jones at County General Hospital. Jonathan just started the Spectrum Program, (with regular education in the afternoon with a 1:1 aide), and had previous Early Intervention and ABA therapy with Quest Learning Group. The parents provided the most recent Developmental Pediatric study, along with an evaluation from Dr. Tatum for review.

Family History:

Jonathan resides at home with his mother Colleen (age 30) a homemaker, father Michael (age 38) a financial analyst, and sister Ella (11 months). English is spoken in the home. Jonathan’s maternal aunt was a late talker.

Birth History:

Jonathan was born at 35.5 weeks gestation via vaginal delivery without complications. Though a month early he was 7 pounds, 9 ounces and healthy. He had some difficulty latching for breast feeding and a lactation specialist was consulted. After some unspecified massage techniques feeding improved.

Medical History:

At four days of age, Jonathan was readmitted to the hospital for jaundice and received light therapy. From 6 months to 2.5 years he had a “constant cold. “ He also suffered from constipation. When dairy (milk only) was removed from the diet, his colds and constipation were minimal, and he continues to do well. His hearing and vision were tested in June of 2011 and were normal. He had one ear infection at 19 months.

Developmental History:

Developmental milestones are as follows:

Oral Motor/ Sensory History:
By parent report, Jonathan is an “extremely picky eater.” He only eats : macaroni and cheese, grilled cheese, Eggo frozen plain waffles (dry), store brand frozen pizza, one brand of chicken nuggets, a homemade fruit smoothie (specific to almond milk, banana and strawberry), almond milk, water, potato chips, and graham crackers. He will not tolerate new brands or any small changes in the presentation of these foods. For example, he eats the frozen “square” pizza, but will not eat a slice of pizza in a restaurant. He never sucked his thumb or used a pacifier. He weaned from the bottle at 13 months old, but did use a sippy cup for more than 3 to 6 months. He can drink from a straw. He grinds his teeth when excited. He has a history of being sensitive to sounds. He is right handed. He sleeps from 6:30 PM to 7:00 AM. He naps on weekends. He is verbal, but only intelligible 50% of the time. He understands most of what is said to him.

Social History:
Jonathan was described as a “pleasant, happy child.” He smiles and greets others. He is quiet with new people and needs to be prompted to say “Hi.” He wants to play with other children, but it is hard for others to understand him. He enjoys playing with play dough, riding his bike, swimming, matching games and puzzles. He has an average activity level and likes to be outside and playing.

Testing Observations:
Jonathan entered the clinic with his mother willingly. He had a tantrum when he was asked to stop playing with the blocks and move into the chair for work. His mother reported he has not had these behaviors in quite some time, and it was thought to be due to the presence of food in the room for the assessment. He transitioned to the chair when his behavior was ignored. His mother also employed ABA strategies throughout the testing to regulate his behavior, such as using her iPhone as a timer, and setting clear expectations. His father came to the assessment a bit later and Jonathan’s behavior improved in his presence.

Jonathan exhibited several preservative behaviors such as the need to complete a building task and to clean up all items before sitting down. Jonathan spoke in sentences throughout, but his responses at times seemed rehearsed or memorized as opposed to spontaneous. Never the less he was able to answer most questions and keep up with the conversation. He had several anxieties, one being the fear of flushing toilets. When he needed to go to the bathroom he would not go with his mother but quickly agreed to go with his father because he thought there will be urinals as opposed to a regular toilet. When upset he would talk about returning to the minivan and going home. He seemed to have his own strategies to self-sooth which help him engage in therapeutic activities.

After a thorough assessment the following summary, diagnosis, and recommendations were made:

Summary:
Jonathan was a 3 year, 1 month old male who recently started a preschool program and had a diagnosis of Mild Autism Spectrum Disorder. He has done very well in ABA and in therapies, but has issues with speech clarity and feeding which prompted this evaluation.

Jonathan had some strengths including: adequate orofacial tone for speech and feeding, positive self-regulation skills even when upset, positive social interaction with the examiner and recent language expansion. Areas of weakness noted in this assessment included: limited lingual mobility, tongue thrusting, and motor planning deficits. Jonathan fixed his jaw in a high posture and often had retracted lips which impaired his overall clarity and resonance.

Feeding issues were the result of a breakdown in the sensory-motor system. One cannot separate one from the other. He had difficulties with latching at birth and this is directly related to the possibility of a restricted lingual frenulum. If a child has reduced lingual mobility this also impacts the ability to handle the bolus when solids are first introduced. Between structural, sensory-motor issues and behavioral challenges associated with ASD, it is not surprising that he has a self-limited diet. Jonathan also met the criteria for Childhood Apraxia of Speech based on his inability to execute non-speech oral postures, blow on command and imitate oral postures. He also presented with atypical and erratic speech sound errors that have not responded to traditional therapy methods.

Jonathan would benefit from a speech therapy treatment protocol that addresses both his feeding and speech issues.

Diagnostic Impressions:
(784.69) Childhood Apraxia of Speech
(783.3) Feeding Mismanagement
(750.0) Rule Out Ankyloglossia (tongue-tie)

Recommendations:

Oral Placement/Feeding/PROMPT therapy by a speech pathologist with post graduate training in oral sensory-motor and feeding disorders.

Parents will need training to implement carryover in the home. The home ABA team is also welcome to help with this program.

ENT evaluation to entertain the possibility of Ankyloglossia (tongue-tie) secondary to limited lingual mobility. Referrals were given to the parents during the assessment.

This case study highlights a few key points when assessing feeding issues in children with ASD. First, there can be concurrent structural issues. This was seen in Jonathan’s case, as the lactation specialist may have missed the possibility of a tongue tie when latching issues occurred. Second, just because a child has a diagnosis of autism does not automatically imply that the feeding issues are purely behavioral. Consider that feeding mismanagement often starts in infancy long before the autism diagnosis (Gillberg, Nordin & Ehlers, 1996). Finally, global sensory-motor issues can spill over into feeding issues. In Jonathan’s case, his sensitivities to sound, and perseverations clearly were reflected in his eating habits.Â For example, sensitivity to sounds in the environment impacted his comfort level and subsequently reduced his food intake.

In clinical practice the speech-language pathologist needs to look at how the child with ASD reacts to touch of the extremities, the face, and oral cavity as well as oral habits such as teeth grinding, mouthing objects, and eating items other than foods (Pica). A diet analysis is needed to assess if the child has intolerances to certain tastes, temperatures and textures. This will establish the child’s home base and provide a starting point for diet expansion. The therapist must look at the underlying oral sensory-motor skills to support safe, effective nutritive feeding.

3- Biomedical Treatments:

Biomedical treatments are becoming more popular within the ASD community. Since these treatments often involve the diet, the evaluating and/or treating therapist should also be aware of diet restrictions and supplement therapies with which the client is involved. Many of the clients with whom an SLP comes in contact are now on these specialized diets (Defeat Autism Now, 2013).

The Defeat Autism Now (DAN) protocol believes that human genetics haven’t changed over the years. What has changed are environmental factors, including the increasing number of chemicals to whichÂ we are exposed from pesticides, flame retardants, plasticizers, solvents, personal care products, medicines, artificial sweeteners, and flavors. These varied factors may have an impact on the expression of our genes. This coincides with the theory of epigenetics of ASD, in which it appears that autism often results from a combination of genetic susceptibility and environmental triggers (Haliday, 2014). The way these environmental factors impact one person may be different than the way they are expressed in another person even if two people are related (Magaziner Center for Wellness, 2014). It is believed that many children with autism have a defect in their ability to excrete certain chemicals; therefore, they were more genetically susceptible to chemicals’ effects.

The DAN philosophy is very centered on the gut-brain connection. This theory supports that toxins in the gut can greatly impact the brain and certain substances such as gluten (wheat protein) and casein (milk protein), are triggers that negatively impact functions of the brain and increase undesirable behaviors in children with ASD. Therefore, according to the DAN protocol, gluten and casein should always be removed from the diets of children on the autism spectrum (Bock, 2011). Beyond that, there may be additional foods that the child is sensitive to, that require elimination.

The DAN protocol also involves diagnosis and treatment of the gastrointestinal system, treatment of immune system abnormalities, assessment of possible metabolic and genetic abnormalities, and nutrition treatment (Pangborn & Baker, 2005). Suggestions by DAN Physicians may include:

Nutritional supplements including certain vitamins, minerals, amino acids, and essential fatty acids
Testing for hidden food allergies and avoidance of allergenic foods
Treatment of intestinal bacterial/yeast overgrowth (with pro-biotics, supplements and other non-pharmaceutical medications)
Detoxification of heavy metals through chelation, a potentially hazardous medical procedure (Willingham, 2012).

While the DAN protocol is commonly known there other biomedical protocols which may be considered controversial, yet antidotal evidence and parent feedback have raised more awareness of alternative treatment methods in the field of biomedical approaches. For example, Stan Kurtz developed the therapeutic use of Valtrex and methylcobalamin (mB12, methyl B12) that reportedly has helped children with autism when other therapies did not. Valtrex is related to acyclovir and has shown efficacy against many but not all strains of some herpes viruses, including HSV1, HSV2, and VZV (chickenpox), with lesser degrees of effectiveness against Epstein Barr Virus, HHV6, and possibly Cytomegalovirus. The use of Valtrex is based on the theory that children with autism have high titers of these viruses (Autism Society of Larimer County, 2008).

Dr. Michael Goldberg, an autism specialist, argues that ASD is actually a neuro-immune disorder, as opposed to being a psychological or a genetic one (Goldberg, 2011). His treatment is a five- step process that considers possible stresses on the neuro-immune system including: food intolerances, respiratory allergies, activated viruses, and overgrowths of bacteria or yeast. Step one includes an evaluation and workup. Step two involves allergy testing to assess food intolerances and triggers in the diet. Step three targets immune stressors such as yeast overgrowth. Step four looks at the brain through a Nuero Single Photon-Emission Computed Tomography (NeuroSPECT) scan and considers blood flow and the need for Selective Serotonin Reuptake Inhibitors (SSRIs) to restore the correct balance needed for proper neural functioning. Step five involves rehabilitative therapies to work toward recovery. (Goldberg, 2010-2014).

Nutritional supplements are very much a part of biomedical interventions. While speech-language pathologists should not be taking the lead in these biomedical treatments, professionals in our field may be asked to assist with diet conversion, and supplement administration, as well as for professional opinions on these treatments. It is always important to follow the American Speech-Language Hearing Association (ASHA) Code of Ethics in regard to evidenced-based practices, and to be familiar with the latest research available when becoming involved with biomedical protocols. It is not within the scope of practice of an SLP to offer medical advice. We can however, refer to the appropriate specialist when warranted and present the latest research on this information.

For example, the Nourishlife Speakâ„¢ supplemental has been widely controversial amongst biomedical professionals. While originally developed to help apraxia of speech, many parents of children with ASD children started using this supplemental with their non-verbal children. A widely published letter from the Food and Drug Administration cited three issues with Speakâ„¢ (Schneeman, 2013):

First, the supplement is being marketed as a treatment for childhood speech delays, such as apraxia, without proper approval by the FDA and without proper substantiation.

Second, Speak’s labeling contains false and misleading claims and does not have adequate instructions for use or warnings.

Third, the amount of vitamin E contained in Speak far exceeds the tolerable upper intake level set by the Food and Nutrition Board, and may be hazardous to the health of children.

Therapists need to be educated on biomedical theories because when families and their physicians are implementing a biomedical protocol, SLPs may need to consider those parameters as part of a feeding program. Biomedical theories support the concept that self-limited diets can be more than just a behavior, because biomedical interventionists look at the whole child and issues with the gut-brain connection. Behaviors, including self-limited diets, are treated holistically and not just with behavior modification (Bock, 2011).

4 – Applied Behavioral Analysis:

Consideration of a child’s sensory-motor and medical issues is necessary; however, Applied Behavioral Analysis (ABA) is very useful. ABA is a method of behavioral intervention developed by Ivan Lovaas PhD and Tristan Smith PhD (Lovaas & Smith 1989; Cure Autism Now, 2005). It consists of teaching skills by breaking them down into small steps, while rewarding the correct responses. It is data driven and quite intensive. ABA is often associated with Discrete Trial Teaching (DTT) which uses instruction-prompt-response-reward to help children with ASD complete complex tasks. The principles of ABA can be successful in feeding therapy sessions (Volkert & M Vaz, 2010), as long as pre-feeding and feeding skills are task analyzed and appropriate food choices are made based on a child’s “home base” (Overland & Merkel-Walsh, 2013). Positive reinforcers, as well as restoring the “joy of eating”, can be automatically reinforcing to a child, if the right food choices are selected to present. Random food choices or advancing textures too quickly can result in negative food experiences. By changing foods by only one element at a time, children can expand their diet slowly and successfully.

An example of this procedure was used in Case Study #2:

Daniel was a three year old male with ASD. When he came to the clinic he was only eating a few select purees. Any progression in taste or texture led to emesis. He was previously assessed by a local feeding clinic, as well as a gastroenterologist and dietician. Modified Barium Swallow Study ruled out dysphagia. Upper endoscopy ruled out esophageal dysfunction, but proved positive for mild gastroesophageal reflux disease (GERD). Blood samples proved positive for a mild dairy allergy, which was thought to be linked to his reflux issues.

The initial assessment revealed that Daniel did not have adequate control of a pureed bolus. When a spoon was presented to the lips, he raked the puree off of the spoon and used tongue protrusion in an immature pattern to swallow the bolus. When the examiner attempted to present that same puree to the lateral margins of his tongue he immediately began to gag and his eyes started to water. He kept repeating the words “all done.” Lateral tongue movements were absent. He was not able to compress a Chewy TubeÂ®. Daniel did not have the pre-feeding skills to handle advanced textures, and previous attempts at feedings resulted in gagging and vomiting. These reactions are now habitual anytime he feels a bolus in an area of the mouth that he feels he cannot clear.

Daniel was placed on an intense pre-feeding therapy plan, working on normalizing the oral cavity beginning with the facial area and working from his lips into his mouth. He learned to tolerate non-food stimulation such as a vibrating therapy tool on the lateral margins of the tongue. Jaw strength, lip closure, and tongue lateralization were target goals.

As his pre-feeding skills improved, his accepted purees were added to his treatment plan. This included: side spoon feeding to improve lip closure and syringe feeding to improve tongue lateralization. In addition pre-feeding mastication programs began with the use of “The Chewing Hierarchy” developed by Lori L. Overland. Daniel began to improve jaw strength and developed a munch chew.

Daniel’s ABA therapist helped with the success of the therapy sessions. He was placed on a fixed ratio reinforcement schedule to increase positive behaviors. First, Daniel received reinforcement for every attempt at a sensory-motor task, or with the acceptance of the pureed food. As time progressed and his refusals decreased, Daniel could work with the therapist for longer intervals. If Daniel refused the task, he was ignored for 5 seconds, and then the task was represented with the positive reinforcer present. He usually chose small figurines to hold, or timed breaks with the iPad.

As his sensory-motor skills for feeding improved, Daniel’s anxiety surrounding feedings started to lessen. He was open to the acceptance of a variety of pureed foods and started to accept crushed cookies and crackers in his mouth with a Zvibe, a vibrating oral-sensory tool. The activities themselves became rewarding, and he needed less tangible reinforcers throughout the sessions. He started to accept the combination of textures and various flavors, which eventually led to tasting small bites of easy to melt solids such as GerberÂ® Puffs, cheese puffs, toddler snacks and small pieces of canned fruit. He is currently working on accepting more solids into the diet.

Daniel’s case study is just one example of sensory- based diet shaping, within an ABA context. Diet-shaping requires the therapist to look at temperature, texture and taste. Changing these elements in regimented, sequential steps may expand the diet. In addition following an ABA program, on a fixed ratio schedule, can also help with progress (Brophy, 2013).

To properly utilize diet-shaping in an ABA context, the therapist should be careful to only change one element at a time. For example, by chilling or freezing fruits, the textures also changes. By mixing foods together, the therapist is changing taste and texture simultaneously and this may be too much for a child with ASD to handle. Many parents will try to “hide” a new food in a preferred food only to find that this causes a major regression in a child’s diet. Children with sensory processing issues can be quite sensitive, and will not be easily fooled by trying to “disguise” new foods.

The following are examples of diet shaping:

In contrast to diet-shaping, purely behavioral feeding programs use preferred foods, toys, books, or television to reinforce children for eating challenging foods. They do not account for the sensory and motor challenges children may be experiencing. Behavioral components may be essential in a feeding program; however, they should be implemented in conjunction with a sensory-motor approach to provide the most positive outcomes (Roche, Eicher, Martorana, Berkowitz, Petronchak, Dzioba & Vitello, 2011). For example as suggested by Volkert & M Vaz (2010) and Addison, Piazza & Patel (2012), when a child tries a new food and accepts it the child should be praised and reinforced with tangibles. In contrast when a child has a negative reaction to food, it is best to ignore this behavior so it is not inadvertently reinforced. Â Since behaviors never occur without reason, feeding therapy must consider that both positive and negative reinforcers can cause a behavior to reoccur (Brophy, 2013).

For example, Case Study #3:

Emmett is 3 years old with ASD. He is labeled a very “picky eater” by parent description. The parents also reported that Emmett seemed to avoid eating to “get a rise out of people.” At mealtime he would smash food on the table, throw it on the floor, pocket foods, and refuse to eat. The parents often would yell, bribe him with candy and/or leave him sitting at the table for hours. Â Sometimes he was missing his home- based Early Intervention sessions, because his parents would not let him leave the table without eating.

Emmett’s parents actually reinforced his feeding problems by letting him escape work. He also knew if he held out from eating, he would eventually be awarded with candy. In a thorough assessment it was also revealed that he has some mild sensory-motor weaknesses that were impacting bolus management.

The best course of action in Emmett’s case was to work on oral sensory-motor goals and reinforce his feeding positively with tokens and his favorite TV shows as opposed to edibles. The therapist also made sure all of his foods were cut into small foods and placed with a small fork to the back molar to help improve mastication and motility. A timer was set for meals and if he did not eat he had to work and return to the same meal when the therapy was completed. Over time his negative relationship with food decreased and his intake also improved.

SUMMARY:

In summary, children on the Autism Spectrum can often have sensory processing issues and oral sensory-motor deficits that lead to self-limited diets. It is rare that food refusals stem from a purely behavioral etiology. Careful evaluation of the sensory-motor system along with medical history is crucial in successfully treating self-limited diets. Biomedical theories are now more mainstreamed and may be integrated into a feeding program. Applied Behavioral Analysis can be a very useful model for executing the therapy plan; however, the choice of foods selected to be goals for the child must be based on their flavor, texture and temperature preferences to have successful therapeutic outcomes. The principles of “diet shaping” are multifaceted and ever changing based on clinical evidence, current research and anecdotal data. The speech-language pathologist leading a feeding program for a child with ASD must be versed on a variety of treatment methodologies.

REFERENCES

Addison, L.R., Piazza, C. & Patel, M. (2012). Journal of Applied Behavioral Analysis Fall; 45(3), 455-471.
American Speech-Language-Hearing Association. (2009). Roles of Speech language pathologists in swallowing and feeding disorders [Technical Report]. Available from www.asha.org/policy
Arvedson, J. C., & Brodksy, L. (2001). Pediatric swallowing and feeding: Assessment and management (2nd Ed.). Albany, NY: Singular.
Autism Society of Larimer County, (2008). Retrieved from: http://www.autismlarimer.org/biomedical.html
Autism Speaks (2014). ABCs of applied behavioral analysis.
Retrieved from: http://www.autismspeaks.org/resource/abcs-applied-behavior-analysis
Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston, MA: Allyn & Bacon.
Barthels, K. (2014). There is always a reason for behavior: is it sensory or is it behavior? (Live presentation), New York, NY.
Bock, K. (2011). The gut brain connection. Living Without Magazine. Belvoir Media Group, LLC.
Brophy, N. (2013). Behavior plan implementation in the classroom. (Power point slides), Ridgefield, NJ.
Center for Disease Control (2014). Autism Spectrum Disorders (ASDs). Retrieved fromÂ http://www.cdc.gov/ncbddd/autism/data.html
Cure Autism Now, (2005). Applied behavioral analysis and other skills-based therapies, www.cureautismnow.org.
Defeat Autism Now (2013). Therapy. Retrieved from http://specialeducationresource.weebly.com/therapy.html.
Fisher, A. G., Murray, E. A., & Bundy, A. C. (1991). Sensory Integration: Theory and practice. Philadelphia, PA: F. A. Davis.
Gillberg, C., Nordin, V. & Ehlers, S. (1996) Early detection of autism: diagnostic instruments for clinicians. European Child & Adolescent Psychiatry, 5:67-74.
Gisel, E. G. (1994). Oral-motor skills following sensorimotor Intervention in the moderately eating impaired child withÂ cerebral palsy. Dysphagia, 9, 180-192.
Goldberg. M. (2011). The myth of autism. How a misunderstood epidemic is destroying our children. New York, New York: Skyhorse Publishing.
Goldberg,M. (2010-2014). Neuro-immune dysfunction syndrome. Retrieved from: http://www.nids.net/
Haliday, A. (2014). What is epigenetics, and what does it have to do with autism? Retrieved: from http://www.autismspeaks.org/node/123021Â
Iovannone, R., Dunlap, G., Huber, H., & Kincaid, D. (2003).
Effective Educational Practices for Students with Autism Spectrum Disorders Focus on Autism and Other Developmental Disabilities, 10883576, 18, 3.
Korschun, H., & Edwards, C. (2013.) Retrieved from http://www.news.emory.edu/stories/2013/02/autism_nutritional_deficits/
Kodak, T. & Piazza, C.C. Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorder. Behavior Modification, 33: 520-536.
Lovaas, O. I. & Smith, T. (1989). A comprehensive behavioral theory of autistic children: Paradigm for research and treatment. Journal of Behavioral Therapy and Experimental Psychiatry, 20, 17-29
Magaziner Center for Wellness (2014) Retrieved from http://www.drmagaziner.com/autism-dan-protocol/
Merkel-Walsh, R. (2012), TalkTools (producer). Solving the puzzle of autism: using tactile therapy techniques [DVD]. Charleston, SC.
Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development. San Antonio, TX: Therapy Skill Builders.
Overland & Merkel-Walsh (2013). A sensory-motor approach to feeding. Charleston, SC: TalkTools.
Overland, L. (2010). A sensory-motor approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20, 3, 60-64.
Pangborn, J. & Baker, S., et al. (2005). Autism: Have we done everything we can for this child? effective biomedical treatments. San Diego, California: Autism Research Institute.
Roche, W.T., Eicher, P.S., Martorana, P., Berkowitz, M., Petronchak, J., Dzioba, J. & Vitello, L. (2011) AN oral,motor, medical, andÂ behavioral approach to pediatric feeding and swallowing disorders: an interdisciplinary model. Perspectives on Swallowing and Swallowing Â Disorders(Dysphagia), 20, 3, 65-74.
Schneeman,B. (2013). Complaint letter to the FDA. Retrieved from: https://www.truthinadvertising.org/letter-to-the-fda/
Teitelbaum, P., Teitelbaum, O., Nye, J., Fryman, J.& Mauer, R., (1998). Movement analysis in infancy may be useful for early diagnosis of autism. Psychology, 95:23, 13982-13987
Twachtman-Reilly, J., Amaral, S. C., & Zebrowski, P. P. (2008). Addressing feeding disorders in children on the autistic spectrum in school based settings: Physiological and behavioral issues. Language Speech and Hearing Services in Schools, 39, 261-272.
Volkert, V.M. & M Vaz, P.C. (2010). Recent studies on feeding problems in children with autism. Journal of Applied Behavioral Analysis, 43 (1), 155-159.

Please cite this article as:

Merkel-Walsh, R., & Overland, L.L.. (2016). Self-Limited Diets in Children with a Diagnosis of Autism Spectrum Disorder. Oral Motor Institute, 5(1). Available from www.oralmotorinstitute.org.

Permalink URL: www.oralmotorinstitute.org/v5n1-walsh