When NOTHING works to elicit k or g, here’s a little something that may help. Join us as we discuss a client with a very complicated /k/.

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Simple Tools: Back Tongue Movement

Char Boshart’s blog on Back Tongue Movement

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

Transcript

Denise: Sometimes I heard it clearly and I did know, okay, you can say it, you have got the muscles back there, because as a speech therapist, sometimes you’re wondering where they born without these muscles? I don’t know. Sometimes you just wonder.

Welcome to The Mindful SLP, the show that explores simple but powerful therapy techniques for optimal outcomes. I’m Denise Stratton, a pediatric speech language pathologist of 30 years. I’m closer to the end of my career than the beginning, and along the way I’ve worked long and hard to become a better therapist.

Join me and I’ll do my best to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Joining me in the conversation is Dan, my technical wizard and office manager.

Dan: Welcome back to The Mindful SLP. This week, we are going to be discussing a very complicated case of K’s. Now Denise is an alliteration expert, obviously here, but let’s dive into this. When does it develop in language?

Denise: Everything I’m going to say about K pretty much applies to G too, but just to simplify things, we’re going to talk about K they’re very similar sounds or cognates. K can actually be a really difficult sound to produce, but it’s common for very young children to say it.

So there’s a wide range of development. So even though a very young child can say K, it’s perfectly normal and average for a preschooler not to have it yet or even a kindergartener perhaps not to have K yet. So there’s a wide range of normal development, if you think of your bell curve.

Dan: Is that unique in that they’ll get it sometimes, but they won’t get it all the time?

Denise: Is it unique in that it has such a wide range of development? You mean that’s a little bit unique that way? So the thing is, many preschoolers, we’ll work on K and speech therapy K and G, but it’s not a big deal if they can’t get it, but it’s usually resolved by kindergarten or by first grade at the very last. That’s usually when, okay, we’ve got this K and G thing figured out. So it doesn’t usually linger on like an R and S sound, which you can have even junior high kids or sometimes even high school kids working on still.

Dan: What is there to talk about with K then, if it usually is taken care of. Obviously if it’s not taken care of, that’s why you go to speech therapy.

Denise: Occasionally. So you get an older client, like maybe second or third grade who was not even stimulable for K and G. Like, no matter what you do, you can’t get them to say it. And so when they’re stuck there, they’re really stuck. Often they have no movement at the back of their tongue and the T and D substitution they make for K and G is really, really habitualized.

Dan: You did a Simple Tools video a while back called A Little Help With Back Tongue Movement to kind of help talk about how to stimulate this, right?

Denise: Yeah. And I found that technique to be really essential to help me with an older client that I have, who had no conscious control of back tongue movement, but that was only a piece of the puzzle.

So if that Simple Tools video had been the whole solution, I wouldn’t be doing this podcast, but I had to do some other steps too, and it was really a complicated case. So I thought, well, maybe someone out there can benefit from this.

Dan: Okay. Well, take us through this then. First let’s talk about the client. Give us a little description of this child.

Denise: Well, he was seven years old when he started with me, which is a bit old to be trying to figure out what K and G .He was not stimulable for K or G or R. Sometimes his S H sound was there, and sometimes it wasn’t. I noticed right away his body posture was not optimal. He had constant movement. Now, while I’m working with a kid on articulation, I want them to have 90 degree angles when they sit down with their body, and their feet are flat on the floor, they have good posture. Their head is level, all that stuff is really important. Um, he just could not do that. He was constantly moving.

He was sitting on his hands. When I would help him position his body to sit upright, with his feet flat on the floor, it made him so uncomfortable that tears actually came to his eyes. Wow. Yeah, it was just kind of a really unusual, he didn’t have any other diagnosis, not on the spectrum, nothing like that.

Just a lot of sensory stuff going on. He was really, really orally defensive.

Dan: What does orally defensive mean?

Denise: Meaning reacting negatively. If you touched his face, or put something in his mouth, like a tongue depressor just really made him uncomfortable. He had a forward resting tongue, so his tongue is pushing against his front teeth. Didn’t have good tongue or jaw control, no surprise there. He was really sensitive to being wrong and very intelligent.

Dan: Interesting. So what did you address first? This is obviously the sitting part.

Denise: The body posture, right? Yeah. He had to be able to tolerate, to be still, to have a still body and to be focused. And we couldn’t even begin to work on jaw or tongue control until he could control his body.

So we made some headway there and then I worked on jaw control and then I thought, okay, we’re far enough along, let’s try to elicit this K and G. Nothing doing, no progress there. And so I thought, well, let’s try R. Okay, he’s a little bit young to learn R, but I have had a client in the past who was younger, who learned R first and then K and G because she was able to take that back tongue movement. So you do get some back tongue movement with R, she was able to take that and from there I could shape the K and G. So I thought, well, let’s try this. Nothing doing, no progress with R.

Dan: So you didn’t make progress with R or K?

Denise: No, I didn’t. So I thought, okay, well let’s try tongue thrust therapy. And the reason I would do that, yes, he had a forward resting tongue, S and Z were not a concern, but sometimes if you can teach them to swallow correctly, not have the tongue thrust, they get the idea that their tongue is very tracted, the back tongue movement. The ton can rest on the palate like it’s supposed to, and then it won’t be low and forward.

Just getting the tongue to move around sometimes…

It’s getting the tongue to be in the correct resting position too, um, up on the palate, retracts it. But he could not place the body of his tongue on his palate. Nothing, no matter what I did.

And so, he just didn’t have the muscle movement, or the muscle coordination, or the strength, I don’t know what it was. And so we couldn’t really move forward in the tongue thrust program because that’s sort of a basic thing. You put the tip of your tongue on the spot. You, you roll the body of your tongue up and back across the pallet and swallow your food.

Couldn’t do that. So I thought, okay, what are we going to do? And even my beloved PROMPT didn’t work. I mean, it helped him get better, jaw and tongue control, but no K, no G, no R. Okay. What am I doing? Finally? I thought, well, this is the least of his problems, but he’s got this Sh that is sometimes there sometimes not.

So let’s work on the Sh. And that’s when he said his first R sound in the word short, I was like, okay, we got something going here. That S H where you spread the sides of your tongue, it helped him figure out just that one word short, but was really touch and go with that or come and go. Not really deliberate on his part until I started doing intro oral stimulation that Char Boshart wrote about and that’s what I cover in that Simple Tools video. So I’m not going to go into depth here, but she has some things you do with a tongue depressor, with a toothette, that, to get kids to understand and the sensation in their mouth even.

Dan: Which he didn’t like.

Denise: No, which he didn’t like, but once I did that intending to get K and G, we actually got conscious control of R. And we’re able to start working on R more directly. We able to start working on the R with more success.

Dan: Oh, that’s good. At least you got something going on here, but tell us about, more about Boshart’s technique.

Denise: So the rationale behind it is to develop sensory awareness. We’ve got a lot of sensory nerves, I guess, for lack of a better word in the oral area, and I mean a lot, okay. And some kids just have really, really low awareness of where their tongue is in their mouth, how it relates to the other parts of their mouth. And so you’re expecting them to move it a certain way and they don’t even feel it. So her rationale though is let’s increase this sensory awareness in your mouth.

Dan: Okay. Sorry. I can’t stop thinking about this because there was a cartoon yesterday in the newspaper, Pearls Before Swine, and in the cartoon, the cartoonist says, look, I got to make everybody in the world who reads this cartoon, think about their tongue and where it is in their mouth. And he did it, and sure enough you’re sitting there running your tongue around your mouth, just from the stimulus of the cartoon. I’ll link to this in the show notes, because it was such a cute one. I think I’ll bet speech therapists would love it.

Denise: Andtually, that was originally a peanuts comic too. Yeah. Linus and Lucy or something about now. I can’t stop thinking about where my tongue is, but anyway, yeah, that is kind of funny.

Dan: How did he react to this with his oral defense in his problems?

Denise: He didn’t like it at all. I wrote up a desensitization protocol for him. So this week I said, we’re going to do this many repetitions and then we’ll move on to this next part. And then the next week we would up a little bit. I had to work up even to do the exercises as described because his tongue went wild as soon as you touched it with a toothette or a tongue depressor. Now I’ve seen this before. I mean, I have. But his was the most extreme case that I’ve seen for someone his age. So you touch something to his tongue and all of a sudden it’s just like it’s moving all over the place and in the muscles are just making it really tight and hump up instead of flattened down and spread out like we want.

This is interesting, he could not tolerate any of the flavored sprays or the flavored tongue depressors that you use to maybe make it more enjoyable for the kid, that was too much for him.

Dan: He was not making this easy for you at all.

Denise: So we just used water. Um, so his R continued to improve with this and I could bring in my usual R techniques. Still no K or G. Now what is interesting is he said it a very few times, almost accidentally. So I guess I shouldn’t say no K, but I don’t know if that was due to what I was doing with Char Boshart’s techniques, because the interesting thing about it is K happens really fast. Right. And sometimes he would say something like, thank you. I said thant you(?). And I’d be like, wait a minute. Did I hear that K? I’m not sure. And that kind of happened intermittently just very rarely. But if I said, Hey, I think you said, K and thank you. He would say, thant you. You know, he couldn’t do it again consciously, but sometimes I heard it clearly and I did know okay. You can say it, you have got the muscles back there because as a speech therapist, sometimes you’re wondering where they born without these muscles? I don’t know. Sometimes you just wonder. But at least I knew he could do it all the way. He could never pin it down. Almost never do it twice in a row.

He knew he was supposed to say it with a back of his tongue because of all this work we’d done, but the best he could do was to elevate the middle of his tongue. So he’s making kind of a T sound with the middle of his tongue, his, (funny noises) ’cause it’s like hey, I’m working on this K, I’m kind of moving it towards back and I’d be like, okay.

Dan: Well please tell me this story has a happy ending.

Denise: Yes. And this is what clenched it. And all that we did before was needed. But this is what finally elicited the sound. So first I had him just say H, right. Okay. And then I moved him to saying a glottal fricative.

Dan: Well that’s a big one, what’s a glottal fricative?

Denise: Almost like you’re clearing your throat, but it’s way back there, right. Okay. And by the way, that wasn’t really easy for him to summon. He would have to try a few times some times to get that glottal fricative going okay. And then I heard him say eee, you know the vowel E sound while he was holding his chin in to keep it from sliding out.

Because all this time, like I said, we continued to work on jaw control and this was the remaining control he needed to learn. I mean, his jaw didn’t slide out with every E, but sometimes it did and I thought, okay, that’s not gonna help you because E raises the back of the tongue, which is why I’m doing it. But if your jaw is slid forward, while you’re saying E your tongue’s not back like you want it.

Okay. So, um, to this point, he could control it himself. He could hold his own chin and say E, raised the back of his tongue. And so after those three steps, the huh and the chh and the say the E, with his jaw in, then we tried eek. So he went from saying eek once and as such and the first time he did it really consciously, I mean that was a really important moment. He couldn’t do it again, but he got this look on his face like I did that on purpose. And so it just, didn’t, wasn’t really fleeting where he couldn’t remember the sensation of where he’d done it. And he did remember he, that he had kept the tip of his tongue down. I was like, okay, come in on that.

Then he said it four times in a session, five times, and then he said at 30 times, wow. Which is super exciting. Then the next time he came, I was pretty sure he was going to remember it, not lose it after doing it 30 times in one session, but I said remember what you did, you said eek like 30 times last time.

Did you practice it all at home? And he says, no, I didn’t practice at home. But I said, lots of words with K all week long and he just settled like that. And I was like, okay. And he almost mastered K and G, I mean, he was saying G too once he figured it out, he was missing a few words, like box and like scream because yeah those are kind of tricky. But once I said it to him, I was like, oh yeah, I can say that. So pretty much once he figured out the motor movement.

Dan: You got it in there and slid right in and locked in and everything was good.

Denise: It was like, like mastery almost.

Dan: Oh, that’s great. How long did that take this last part?

Denise: A month.

Dan: A month after all that time beforehand. Well, I guess you had to kind of build up, don’t you?

Denise: Oh, from the outside, it might appear that he learned K and G in one month, an overnight success, but that wasn’t the case. It wasn’t a case of me finding this perfect elicitation technique for K, you know, go from H to the glottal fricative to the E with your jaw controlled and then eek. I had to address his body posture, his oral defensiveness, jaw and tongue control, ability to tolerate constructive, critical feedback. And that was important. I didn’t talk about the lot here, but, you know, he was very sensitive to that. Um, and learning R helped him with mid to back tongue control. So that had a part too, and self-monitoring.

Okay. So his jump from saying eek just like four or five times and to 30 times per session, that was facilitated by him tracking his own progression through these exercises with a sticky note, just like we talked about last time. Yeah. I gave him a sticky note and I said, okay, I want you to mark down. How many times do you say huh, and how many times you say chh, you know, and okay, the huh was no problem. But he had to think about what he was doing when he’s making that glottal fricative right. And he couldn’t make, he couldn’t make a little tally mark unless he’d done it correctly. That made him stop and really think about it. And then the eee, with his jaw moving, he started to really cue into those tiny little shifts when his jaw slid forward and he would stop myself and say, oh no, I didn’t do that right. My, my jaw slid forward, I can’t make a tally mark and all that made it so that he could do it like 30 times.

Dan: How long was he in therapy for this?

Denise: It took a year.

Dan: Oh, wow. So yeah, it did feel like an overnight success with a year’s worth of basic work.

Denise: That’s the longest I’ve ever had a client take to elicit K and G. Now I had one client who, I guess you could say she took that long. She had apraxia. But she was, she was younger. And so it wasn’t like a huge deal to me. We just kind of worked on a little bit. It might’ve taken her a year if I looked at it in that whole arc, but we weren’t working on it like that, you know, we were doing other things. So yeah, for someone who had no other issues going on, like apraxia just to learn K and G in a year, I was like, whoa, okay.

Dan: Sounds like a lot of tedious work, a lot of really, frustration. If this was his only thing, and you were working on this with him for a half an hour every week, that sounds like that had to have been really a challenge for the therapy. How do you keep you engaged for all that time?

Denise: Yeah, it was his only thing in addition to R. Right. Yeah, so you’re right. How did I keep him motivated? Well, that’s what we’re going to talk about next time. So come back next week. We’ll talk about how to keep clients motivated when you just need them to buckle down and work.

Dan: All right. Well, we’ve talked a lot today about some of the simple things that you have to work at, but when you master the simple, the complex takes care of itself.

Denise: Yeah, I figured out that complex K.

Dan: All right. Thanks for listening to us. And we will be back next week.

Thanks for listening to The Mindful SLP. We invite you to sign up for our free resource library at slpproadvisor.com slash free. You’ll get access to some of Denise’s best tracking tools, mindfulness activities, and other great resources to take your therapy to the next level. All this is for free at SLP proadvisor.com/free.

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