To Motor or not to Motor: That is the Question

Join us as we discuss the oral motor controversy, and who can benefit from motor techniques in speech therapy.

Show Links & Notes

Prompt
https://promptinstitute.com/

Talk Tools
https://talktools.com/

Char Boshart’s Podcasts
https://speechdynamics.com/pages/podcasts (episodes 33-37 comprise The Perfect Oral Motor Storm: What Happened, Why, and Supportive Evidence of Oral Sensory-Motor Methods to Remediate Speech Sound Productions)

The Perfect Oral Motor Storm Articles
https://speechdynamics.com/pages/articles

Impossible R Made Possible
Online Course

Kathy Buckley Video
https://www.youtube.com/watch?v=1m-AqCo0IoY

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Dan: Welcome to The Mindful SLP, the podcast for SLPs looking for simple tools and optimal outcomes. Your host is Denise, experienced speech therapist specializing in all things pediatric, and Dan, business manager for her private clinic.

Welcome to today’s episode of The Mindful SLP. Today, we’re going to talk about a little bit of a spicy topic, a little controversy: To motor or not to motor, that is the question. We’re going to talk all about oral motor therapy today. Tell me a little bit about this controversy, Denise.

Denise: Well, let me give you an example. I was browsing on a speech therapy face group I belong to the other day and a therapist had posted some oral motor exercises. Another therapist in the comments put, uh, ‘research has proven there’s no link between speech and oral motor exercises’. And I see that difference of opinion over and over and over again. And I’m coming down in the oral motor side, but I want to explain why.

Okay. So to get closer to home. I got an interesting question. The other day about my Impossible R Made Possible technique. By the way Impossible R Made Possible is the name of my book about teaching R is now also an online video course. And we’ll put the links in the show notes for you.

Dan: We also talked about The Impossible R course in episode three, and in case you want to learn a little bit more of an overview of what that is, go ahead and listen to episode three, but getting back to today’s subject. What was the question that you received about The Impossible R made Possible?

Denise: A therapist asked whether my technique for teaching R was for children with apraxia or for children with more typical speech disorders or both.

Dan: For listeners who are, might be rusty on apraxia, and for me, who’s never, well, I don’t know what apraxia is at all, just tell us a little bit about what is apraxia.

Denise: So we’re talking about childhood apraxia speech, as opposed to acquired apraxia, that’s two different diagnoses, we’re just focusing on childhood apraxia. The Mayo clinic defines childhood apraxia speech as an uncommon speech disorder in which a child has difficulty making accurate movements when speaking.

The definition goes on to say the brain struggles to develop plans for speech movement, the speech muscles don’t perform normally because the brain has difficulty directing or coordinating movements. Now, do you spot a potential problem with that definition?

Dan: Not quite sure, but please keep going.

Denise: Can you name a single speech movement that isn’t directed by the brain?

Dan: Let me think of that for a second. Your brain pretty much controls all movement. If you’ve got movement happening that the brain isn’t directing, then I don’t know how you’d ever be able to control that enough to make speech.

Denise: Exactly the brain directs all motor movement. So to define the cause of an uncommon speech disorder like apraxia, as difficulty with making motor movements, that seems to exclude the role of motor movement in more typical speech disorders,

Dan: the Mayo clinic definition isn’t wrong, it is a problem with the brain and movement. But keep going on that. Where is the problem?

Denise: I think it’s some therapist’s interpretation of the motor connection in other speech disorders, all speech disorders, not just apraxia. I use the Mayo clinic definition for childhood apraxia of speech, rather than Ash’s, to drive home my point. So Ash’s definition is a little bit more precise. However, this controversy is driven by an artificial separation we have drawn between different speech disorders and how they should be treated. So I don’t see many people questioning a therapeutic motor approach for childhood apraxia, but I do see a lot of adamant statements about how a motor approach for more common speech disorders is not evidence-based and ineffective. People even go so far as to imply it’s unethical that those of us who are doing oral motor therapy are walking the bridge to unethical practices because research hasn’t proven it.

Dan: So if there’s a motor speech disorder, they’re saying it’s way over there in apraxia, but it’s not in everyday speech. So therefore you are not doing the ethical therapy if you’re addressing that in a normal speech disorder, only if you’re doing it in an apraxic situation.

Denise: Yeah. That’s it exactly. You figured that out.

Dan: Okay, so why should therapists consider a motor approach for speech disorders outside of apraxia then?

Denise: Because the foundation is the same. My speech anatomy professor told us over and over again, speech is an overlaid function and he said it over and over and over again, and I thought, okay, I understood it. I get what you mean, but I didn’t really get what he meant.

Dan: Okay. But I don’t get what he meant. What does he mean by an overlaid approach?

Denise: We all use the same muscles for eating and breathing for the functions that keep us alive. We then use the same muscles to speak. Uh, speech is movement made audible to quote Raymond Stetson, one of my favorite quotes. So muscle movement is an inescapable component of speech, therefore, to a greater or lesser degree, there is a motor component to all speech disorders. Some disorders have such a small degree of motor involvement compared to apraxia, that is difficult to think of them as having the same foundation, but they do have the same foundation we don’t put on a different set of muscles to speak.

Dan: I think I get that. Do you have some examples to illustrate that connection? It would help me get a bit of a clearer picture.

Denise: Yeah, I have a great example, it’s very funny. So Kathy Buckley is a deaf comedian who tells a very funny story about learning, to say that shh sound and a certain word beginning with shh.

Dan: Okay. It’s the four-letter word.

Denise: She talks about working for years with some of the best speech therapists in the country to learn ‘shh’. They had her blowing out candles to help her develop the breath control that she needed. That would be classified as an oral motor technique. We’ll link to that video in the show notes. And she’s hysterical by the way, that video is so funny,

Dan: Even for people who aren’t speech therapists, by the way, it is really funny. But I remember that because she was making, trying to make the ‘shh’ sound without having any air support behind it. It doesn’t work. You can’t do it. You have to have movement.

Denise: And it’s a, it’s a muscle movement to learn that control of breath, right? The bottom line is that she wasn’t apraxic, but she still needed to learn a motor skill for that sound. I see a lot of clients who have issues with breath control, who are not apraxic. It’s one of the aspects I address in Impossible R made Possible.

Dan: I get that because I’m a singer and there is a lot of breath control in singing, and if I don’t practice and I don’t have, my muscles get flabby, let’s face it. You know, if I don’t sing for awhile, my diaphragm starts to lose muscle tone. I can’t hold notes as long, I can’t have the support underneath it, and it sounds weak and thin. Why would it be any different? I don’t get why they wouldn’t think it would be motor.

Denise: Um, and it’s not any different. It is the same, it’s just degrees. We have a hard time sometimes seeing degrees. So if you think about autism, we used to separate autism and do what you might call classical autism. And Asperger’s, um, high functioning autism, because Asperger’s seemed so different than it needed a separate category.

They rewrote the definition and took away the name Asperger’s some people still use it, but realized that it was on a spectrum. Now I need to be clear here. I’m not saying that apraxia doesn’t exist because it does exist. But what I’m saying is the treatment doesn’t necessarily need to be in a different camp than other speech disorders, but apraxia is a real thing.

Also, we have pediatric feeding SLPs who would almost certainly tell you that deficits in motor skills for eating can carry over to speech and language. So those infants who have eating problems often end up with speech disorders. I mean, why is that, if they’re not related? Again, it’s an overlaid function.

It would be an interesting study to see how many children with speech disorders excluding apraxia can chew with their mouth closed compared to their peers. Hmm. Okay. I don’t always have snack time with all my clients, but we’ll do as some of them. And I’ve seen some really, really, um, sloppy eating, the, inability to chew with their mouth closed. I mean, parents say, Hey, chew with your mouth closed, I’m telling you some kids can’t do that. Really.

Dan: I think I owe my children an apology.

Denise: They didn’t have speech disorders, but I’m willing to bet the number would be significantly higher in the speech disorder camp. Even if you excluded apraxia. Can you see the connection I’m talking about?

Dan: Yeah, I do, I think that makes a lot of sense. And coming from the, outside, I don’t know how it wouldn’t be. Well, let me play devil’s advocate for a minute here. What are all the speech therapists doing who don’t necessarily see the need for oral motor therapy? Do they see their client’s progress and, and see their techniques work?

Denise: I love that question because I was that therapist for a long time. Well, I wasn’t adamantly opposed to oral motor therapy. I didn’t understand how to incorporate specific research-based oral motor techniques into my therapy, but I did see success, a lot of it teaching from a language and cognition based framework. But there were some clients that wasn’t able to help as much as I would’ve liked and who I now know would have made more progress with the addition of oral motor therapy.

In fact, I can think of a lot of clients who would have progressed faster with some oral motor therapy, but some of them just internalized it as we worked, it was like more like a top-down approach. And as we worked on worked on saying the sounds correctly, they internalized how to make those movements correctly, where it would have been faster for me to incorporate the oral motor therapy from the beginning and more a bottoms up approach.

Otherwise they filled in the missing building blocks on their own.

Dan: So is it fair to say that not all speech problems have an oral motor problem, but all oral motor problems have speech problems?

Denise: That’s a very interesting question. And I’m not exactly because I have had a few tongue-thrust clients whose speech didn’t really sound impaired, but the orthodontist said he needed to get that fixed.

So, an S for example, where the tongue is not coming out in between the teeth, but is just brushing the teeth. Some of those kids can still make it a pretty good S sound. And I don’t know how, um, but for the most part an oral motor problem affects your speech 90%, so, okay. But then we have language disorders too. We have a vast array of other, um, disorders we treat, they don’t have this oral motor component, but if it’s an articulation problem, there is, uh, some muscle movement that isn’t happening correctly because we shape our vocal tracts. We’re a musical instrument. You hit the key on the piano, the shape of the string changes, you get a different sound. We change, we use our muscles to change our vocal tract and we get a different sound. So of course, there’s muscle involved.

Dan: The next step then is that oral motor therapy is going to be useful in a lot of situations. Maybe not all situations, but it’s really, being able to do oral motor therapy with, uh, your clients is another tool in the toolbox because some don’t need it. Others, even with the same problem might need it because they have a different level of oral movement. Is that kind of what you’re saying?

Denise: There’s different degrees of severity. Um, I occasionally have some clients who are missing like final S’s, and so obviously the teeth aren’t closing for the S’s, that’s a motor movement or something, but the reason they’re missing it, is because it’s a morphing, it’s a, uh, morphing is what we use to change root words.

So it’s a plural S or it’s a possessive. And because our understanding the rules of language they’re leaving, those sounds off, I have some clients who the language component was their main component. It was just more efficient to teach them that because they could say S in other words, they could say the S in other positions and they could say it correctly.

And in that case, I don’t worry about the oral motor component because I’m just going to go from a language base and that’s the most efficient, most effective way to solve it. So you really need to problem solve, but you need to have the oral motor basis so that you know how severe it is. You know, if that’s something that you need to add in. So I haven’t thrown my other therapy techniques out. I’ve just added and rearrange the sequence in their approach. And I really problem solve what needs to happen here.

Dan: Okay. So where can I start if I want to learn more about using oral motor techniques in my therapy?

Denise: Well, you can take Prompt training. In fact, they’ve been offering online trainings since COVID-19 and that’s great if you live in a place, they don’t usually come to you. I mean, I flew to different places out of state to get my Prompt training, but I love, I love, Prompt training is on the top of my list for understanding how speech is motor. Talk Tools is also a motor based therapy approach, and they have some great online trainings.

I particularly like the training they have on tethered oral tissue. Tongue-tie in other words, and I learned to look at oral structures and functions in a really integrated way after that training. Also Char Boshart is an SLP who has written about oral motor therapy in depth, she wrote a series of five articles, The Perfect Oral Motor Storm, which is also a five-part podcast now to which he explains how the whole controversy came about.

Why do we have this controversy where we have some research studies that show that it doesn’t work, um, and she explains what the research is missing and I’m in the middle of listening to those podcasts, but I’m fascinated so far. I think that’s great.

Dan: We’ll link to those podcasts so that you can listen to them too.

Denise: And last but not least, there is my online course, Impossible R Made Possible, which has a very strong basis in oral motor therapy for your challenging R clients.

Dan: Your professor, back in the beginning, who said that speech is an overlaid function, it sounds like he had it right back then. What’s the takeaway? Where do we go from here?

Denise: I don’t want to overstate the obvious, but when we look at the whole child, we must look at them wholly. We must look at their motor, their cognition, their social needs. We’re really good at looking at cognition and social needs. Um, we’re not so good at looking at motor, but to exclude one of these areas means we aren’t seeing the whole picture.

How can you effectively treat a disorder if you don’t see the whole picture?

Dan: You can’t treat just two legs of a three-legged stool.

Denise: No, you can’t, and therefore you need to understand the third leg. If you see a research article that says we have proven the oral motor therapy is not effective, do you really understand why they’re saying that if you, like Char Boshart, has looked at some of that research and she’s like, well, here’s, what’s missing.

This is why the research study came out this way because they are missing this piece.

Dan: So therefore, if you see something in the controversy, don’t just accept the controversy, go and look at the research behind it, look at what they’re talking about and consider what they might be missing.

Denise: Yeah. And if you’re not into reading research articles, which is not my favorite thing to do, um, you know, take Prompt training or read up about it or talk to other therapists who Prompt trained and they will tell you how awesome it is.

Look at Talk Tools, read Char Boshart’s stuff. There’s a lot of random stuff out there, and you might stumble across something about oral motor therapy that is not as strength-based and not as grounded as what’s already out there. So that’s why I’m giving you some resources. And once you can see something, you can’t unsee it. I mean, I have seen the validity of oral motor therapy and I can’t unsee it. It’s just, it just is.

Dan: Alright, we appreciate everybody who’s listened to our podcast and we are grateful for your time and look forward to hearing what your comments are. Please join us over at SLP pro-advisor dot com. Look at the podcast there, there’ll be a comment section underneath it. Please, we’d like to hear what you think about the oral motor therapy controversy. Where do you come down? How do you work with it? Let us know. We’ll talk to you next time.

Thank you for listening to The Mindful SLP. We hope you found some simple tools that will have optimal outcomes in your practice. This podcast is sponsored by SLP pro advisor. Visit SLP pro-advisor dot com for more tools, including Impossible R Made Possible, denise’s highly effective course for treating those troublesome Rs.

A link is in the show notes. If you enjoyed this podcast, please give us a five-star rating and tell your fellow SLPs. And please let us know what you think. Join the conversation at SLP pro-advisor dot com.