If you’ve ever wondered what PROMPT therapy is all about, then this podcast is for you. In this episode you’ll get an overview of how speech therapists use PROMPT to look at all of the aspects of articulation, the order they develop, and how they integrate. 

—– Episode Links —–

The PROMPT Institute

What Is PROMPT Therapy? (video)

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

Transcript

Denise: And what PROMPT is, is a tactile approach. So you, you touch their face, help guide their jaw to where it should be, help guide their cheeks and lips to make the right movements. It’s easier to understand when someone gives you more cues, right. And a tactile cue is very powerful. It’s like my violin teacher, instead of telling me how to hold my bow actually putting my fingers on the bow.

Welcome to The Mindful SLP, the show that explores simple but powerful therapy techniques for optimal outcomes. I’m Denise Stratton, here with my co-host Dan. And today we’re talking about one of my all time favorite topics PROMPT therapy.

Dan: You’ve talked about PROMPT many times in the podcast, so today we’re going to do an overview of PROMPT and finally let people know what it is?

Denise: Yeah. I thought I should do that, since I talk about all the time and what PROMPT is, is a tactile approach. So you, you touch their face, help guide their jaw to where it should be, help guide their cheeks and lips to make the right movements. It’s easier to understand when someone gives you more cues, right. And a tactile cue is very powerful. It’s like my violin teacher, instead of telling me how to hold my bow, actually putting my fingers on the bow, you know?

Dan: Yeah. That makes sense. So is there much more to it than just that?

Denise: Oh, there’s so much more to prompt. It’s one of the many approaches used for apraxia and other motor speech disorders, but I just have to say some speech disorders, we would not look at him and say that that’s a motor speech disorder. PROMPT helps you see that if they’re not saying the sound right, most of the time, there’s some kind of motor component going on. So I took PROMPT initially, because I thought I really need to help these kids with apraxia. I really need to help my really severe clients, and I use it for so much. I use it for so many clients who have articulation goals.

Dan: When did you first hear about PROMPT?

Denise: I think it was at a conference, they went to on apraxia. I might’ve heard about it before, but really didn’t know what it was seeing advertisements and journals and things, but the presenter listed several different approaches of things we could do to help apraxic clients.

And PROMPT was just one of those. It was lumped in with various approaches and that led me to think, okay, I’ve got this other approach, so I don’t need PROMPT, and so it was a few more years before I actually took the PROMPT training and that training was life changing. I really have to tell you therapists, in my opinion, in which obviously my opinion is biased, but I think it is the best approach to treat motor speech disorders like apraxia.

Dan: How has it life changing? What has it changed about your therapy?

Denise: It showed me what I needed to pay attention to, what I needed to notice. I had noticed some things before about how important the jaw was, and I integrated that into my R book. What is really interesting is I had written the first draft of my book for Impossible R Made Possible, but I had noticed things about the jaw, and I had noticed things about how clients who didn’t have good jaw control, couldn’t get R, and I had started working towards that life(?). I took the PROMPT training, was like, oh, wow, this is all that and so much more . PROMPT showed me. I guess what we’d call the hierarchy. There, there is what they call a motor speech hierarchy.

My orchestra teacher always said orchestra is only strong as the weakest player. So if there is a speech system that is weak below what you’re trying to correct, you’re going to have a hard time correcting that, or it’s going to take a long time, or it may not even be ever corrected if you don’t fix what’s lower down. So PROMPT taught me all these hierarchies to look at, and that’s what we’re going to talk about.

Dan: So this PROMPT technique really makes you step back and take a look at things. Oh, boy, this sounds a lot like mindfulness and everything that you’ve been talking about is that where it all came from?

Denise: And observing, yeah, that kind of sent me on the road to really paying more attention to my clients. And I thought I was good at paying attention to them, but I wasn’t as good as I could’ve been.

Dan: Okay, what are we going to learn in today’s podcast? What are we going to cover?

Denise: I’m just going to cover those levels in the motor speech hierarchy. Obviously I can’t teach you all PROMPT, I would love it if everyone got trained in PROMPT who works with articulation disorders, um, but I’ll cover that. And I think anyone can benefit from it, even if you don’t take that PROMPT training, I think you can benefit from this mindset. So we’ll cover that and then a couple stories case histories.

Dan: So there are seven points that we’re going to look. We’re going to go over it real quick here, and then we’re going to dive in. So first look at structure. Second phonation. Third jaw. Four rounding and retraction. Five lingual. Six integration. And seven timing. So let’s get into it. Look at structure.

Denise: So it’s looking at the client’s oral structure. Do they have an overbite and underbite? Is their tongue free to move? Do they have a tethered oral tissue? Do they have a high palate? All that basic, but sometimes we therapists forget to look at that. In addition to that, I was really taught how to look at the body position, the tone of the client, even the ability to maintain some stillness.

So there are some clients who are just all over the place, and that’s just something to pay attention to. Do they have some sensory motor stuff going on? It’s really interesting, one of my clients I’ve been doing PROMPT with when he first came to me, he could not sit still. I mean normally developing seven year old, no other kind of thing going on.

When I asked him to put his feet flat on the ground, because we want a really stable body position where we’re giving prompts. We don’t want their body twisting, we want them sitting in the feet on the ground upright and that kind of brought tears to his eyes. Tears to his eyes to have to sit like that.

I was like, whoa, we got some work to do. So trying to look at that, trying to look at their tone. Some clients who might have something like Downs Syndrome, you are not going to change their muscle tone. Well, I’ve helped a lot of clients with Downs Syndrome get to a certain level in the hierarchy, but not all the way up because I can’t change the underlying muscle tone, but I can do some things to help them compensate.

Dan: Then you start looking at phonation?

Denise: Phonation. Now, before I took PROMPT training, I never understood why the sound H was so important.

Dan: The sound H?

Denise: Yeah. Phonation. Now mmm, H, and ahh are the things that you look at after you look at the structure and the tone. And I had had clients in the past, like little preschoolers who really struggled to say any word that began with H. They couldn’t say hat, it would be at. They just leave the H off. Okay. Well thinking about what H does, it gets your breath flowing.

Dan: Yeah, you’ve got to use quite a bit of muscles all the way down.

Denise: So, yeah, there are so many clients who come to me, apraxic or not…

Dan: Well, that really starts all the way down the diaphragm, which is a long ways away from your face.

Denise: Yeah, who have problems with H we get the H going, and so much good stuff starts to happen. So you look at the mmm, ahh, and hah, that’s the basics of phonation. Next is looking at how the jaw moves. Can clients open and close their mouth easily and can they open them to the degree you’d want them to open, um, for what we call the low vowels, meaning your jaw is low for ah, and that’s what we call grading the different, um, degrees you open your jaw is grading. So I kind of clued into that with my R course, and I even have exercises for grading. I just didn’t know that’s what I was doing. But so many clients, they lack that ability to open their mouth as wide as they should. When they do they lose stability, their jaw just slides out, so the lower jaw slides out. So now it’s anterior to the upper jaw, which we don’t make any sounds that way, or they get tens, all sorts of things happen. Anyway, so you look at the jaw.

Dan: And then rounding and retracting?

Denise: So this is where we get to the labial facial muscles. So you see we’re building, we’re building from just the whole body and muscle tone.

And we’re looking at phonation and we’ll look at how the jaw moves. So the lips and the cheeks, and it’s not just lips. So you will see some clients who don’t have a good control of their cheek muscles, the cheek muscles are not really, um, developed. Okay. So it’s interesting, um, and maybe they can’t round at all, or maybe when they try and round for sound like ooh or oh, they’re, um, they lose control of their jaw. And so their lips kind of over-round, they suck in, like one client’s mother call it granny lips. So can you kinda imagine licks lips, you’re kinda yeah, pulled inwards, inverted.

Dan: Yeah. For the video portion of this comic(?) podcast, you’ll be able to see this.

Denise: So that’s interesting. Um, sometimes when you start getting them to round, the round would just their lips and not their cheeks. Can you, you can kind of do that, maybe as you’re listening, we don’t… (garbled noises ensue)

Lips stick way out. You gotta use your cheek muscles too. Those cheek muscles are really important and lots of times they’re underdeveloped. And then you get clients who are in a state of what you would call over retraction. Um, a kind of a constant smile. That’s retraction, but if they don’t have good control of their jaw, in order to keep what we call a neutral resting posture. Now a neutral resting posture is being able to have your teeth and lips gently closed, but having them pop open. If you don’t have good control of your jaw, two things might happen.

You might just have an open mouth all the time. And some kids are like that. And sometimes they even drool, because their mouth is just open. Other kids subconsciously know they don’t have good control of their jaw and they don’t want it to hang open. So they give you this big grin and they’re in this sort of fixed grin all the time.

Now I had one client, I think he was ten and he had this sort of fixed grin. And when I asked him to relax his lips, close his teeth and close his lips gently and just hold that neutral resting posture, his mouth just dropped open. And he looked at me in amazement. He was like, like what, what just happened to me?

Because he hadn’t ever been, just hadn’t been used to having a neutral resting posture. He was using that big grin, that retraction of his muscles to keep his mouth from just hanging open. And it was really interesting. Um, I was still working at the school district when I took PROMPT training. I went back and I started noticing the little school pictures would pop up on our IEP software. Man, you’ve got a huge grin on your school picture. Man, you’ve got a huge grin on your school picture. Whoa, is that just a smile or is that over retraction?

Dan: Interesting. Okay, for those who are interested in seeing a little bit more about this and actually seeing what Denise is looking like here, uh, you can, she demonstrated this in her, her webinar that she did earlier this year. And you can get a replay of that at SLP proadvisor.com/spring-masterclass-2 the number two dash replay. If you go to that website, there, we’ll link it in the show notes, but that’s a SLP proadvisor.com/spring-masterclass-two-replay. She talks about these neutral resting postures and exactly what that looks like.

It’s a lot easier to show it on video than it is to just talk about it.

Denise: Well, yeah, I’m glad you remembered that because I do show that. So after the rounding and retracting, we get to lingual. Fancy word for tongue, right? We always have to have our fancy words. This is where most speech therapists start. And that’s where I used to start.

But look at that, that’s number five on the list, those lingual sounds, the anterior lingual sounds T D N S Z. We have a lot of errors with those. And then we get to the middle of the tongue, we have R and S H and C H, and oh man, those can be tricky. And in the back, K and G usually are not tricky, but sometimes they can be really tricky.

Dan: The tongue is really important to all of these sounds.

Denise: What has happened to me so often since I’ve been PROMPT trained as I worked on the lower subsystems, the other start fixing themselves.

Dan: Oh, that makes sense. Get the foundation right, then things can build correctly as they should.

Denise: Yeah, and I’m like, oh man, I didn’t have to work on that so much.

Dan: Conversely, if you don’t ever get the foundation set, you’re going to really struggle to get results that stick.

Denise: Yeah. You end up with some persistent articulation disorder sometimes, or it could just take a long time. So when you do start as a speech therapist with the lingual, it can take a lot longer to correct. As I said, um, it’s much more difficult with a client who has a motor speech disorder like apraxia or a significant motor speech disorder. It’s much more difficult to correct without addressing these subsystems. In fact, you may not be able to correct it without addressing these subsystems.

Dan: So now that we’ve got that going, then obviously the next step then is integration where you’re starting to pull everything together.

Denise: Yes. And I just want to mention that all along the way you are integrating, because once you get the phonation and you start to work on jaw movement, you’re integrating that. And you’re integrating that with rounding and retracting.

Dan: So what kind of integration is this then?

Denise: So this is being able to integrate lots of sounds across different planes of movement. So be able to say a word like strawberry. And so planes of movement, I guess I should just explain that real quickly. So we have the vertical plane of movement, that’s the jaw opening and closing. We have the horizontal plane of movement, which is the rounding and retracting. We have the anterior posterior plane of movement, which is the tongue we got the front tongue sounds the back tongue sounds, and the middle tongue sounds, okay. So now you’re being able to integrate words that have all those different planes mixed in, and you’ll be able to say blends S blends, L blends. So that’s integration.

Dan: And then timing.

Denise: Timing, and prosody is the very last on this PROMPT hierarchy. But I have to tell you, I almost never have to do that because if I’ve done my work in the other levels…

Dan: This just falls into place. Once the therapist has a picture of the entire motor system, what’s next?

Denise: So PROMPT has you write motor speech goals. You choose, um, you actually work on three levels at once and sometimes, sometimes you’re really just focusing on just two if the client’s really severe, but you choose some, um, phonemes from each of your goal areas that you’re working on and you write goals around it and you look at what’s most important. I just might mention if a client has what we call an attractor state, meaning they’re in that like fixed smile, their muscles naturally attract to that position. That’s going to be your number one priority, or if their jaw’s hanging open and that’s their natural attractor state, instead of having lips closed, that’s gonna be your number one priority.

So you set your priorities and you make goals from there. Then you start prompting them. Oh, you take a video. You always take a video of the client in conversation, if you can. Okay. Some of your clients are not going to be a conversation.

Dan: And what’s the video for?

Denise: So a three-minute video conversation to actually look at how their muscles are moving when you’re not right across from them. It’s so much easier to see, um, and not miss little things if you can review it and review it and review it.

Dan: You’re taking these videos and then you’re actually analyzing them to see what it is you’re looking for.

Denise: I’m looking for them as I fill out the hierarchy worksheet, but with the really little ones, kids who aren’t speaking yet only have a few sounds, you don’t really need to do that, but you do know where you are.

Dan: But if I’m not, if I’m not PROMPT trained, these are things I just would want to look for. And it may take a little bit of practice, and so that’s why you do a video so that you can review it because you’re not going to catch it when you’re right in front of the kid.

Denise: Yeah, there’s subtle things you see with the jaw shifting and moving sometimes that, um, you don’t notice.

Dan: Okay. So as you’re working with a client and they’re stuck and they can’t seem to be progressing. This might be something that you’ll want to look at.

Denise: Yeah. I mean, it’s really amazing what you can feel that you can’t see as I become more experienced at PROMPT, and I’ve learned how to be real effective at giving these tactile cues, with more experience, you can fill excess tension, even when you can see it, you can feel lack of freedom of movement in the jaw, even when you can’t see it, um, you can feel tension in the neck as they try and tilt their head back, even if you can’t see that. So it’s just really interesting. The things that happen, the progress they make when they even do something like release the tension in their neck, you never know.

Dan: I’m not PROMPT trained, should I be trying to do prompting with my fingers and hands now?

Denise: No, no PROMPT doesn’t recommend that, but I’m putting this out there because I would love people to understand all that goes into speech, the things we don’t look at. I would also just, I like to promote PROMPT. I mean, anytime a student clinician comes to observe me. I say, if you get PROMPT trained, you’ll never regret it. Yeah. So yeah, I guess I am saying it’s one of the best, I’ll say it, right. That’s one of the best trainings I’ve ever taken, but yes, you can learn from this even without taking PROMPT training, you think you can learn from looking at your clients this way.

Dan: Bring this all together, then let’s, let’s, let’s hear a success story. Something that you was able to use PROMPT on that really made a difference.

Denise: This is one of my most dramatic success stories. So a two-year-old came who could only say mum, mum, mum, mum, mum, mum, mama, like that. Without any inflection in his voice, it was just like that, mum, mum, mum, mum, mum. And he could. He couldn’t say mama or ma it was mum, mum, mum, mum, mum, mum, mum, until he just kind of ran out of steam.

Um, he, he couldn’t control his lips to round to say, oh, um, didn’t have any other words. Hmm. Um, so I diagnosed him as having apraxia, um, and we started with involuntary phonation. And what that means is he couldn’t access his, even his phonation. I mean, he couldn’t speak except for that mama, um, purposefully.

So I had to do some things to get him going. And one of the things that worked best was I have this big cauldron I use at Halloween, um, if he voiced into it and that echo did something that he could just start to talk into it. Interesting. But see, it was a little bit of tapping into the involuntary, um, speech, um, a little cup, if I put a cup to his mouth and we went all-lall-lall like that, you know how you kind of echo in a cup, that would work. In fact, there’s a really funny story, um, after he had kind of an experiment with phonating into a cup, um, they were at church where they have a little plastic cup that they take the sacrament in. He grabbed that right when it was quiet and started going ‘ahhhhhhhh’ very loudly.

Dan: That’s what kids do at church. That’s the responsibility of filling it.

Denise: Yeah. And it was just a gradual process from there to where he learned how to voluntarily phonate and the day he learned to say a word that began with H, you were cutting plastic food in half. And he learned to say, ha for half. That was the day his mom said everything changed. And I’ll have to tell you that he progressed so fast from there. It was like, that was all he needed. He needed a little bit of rounding and retraction, but he was like done in three months after that. No, not from the start to finish, but after he learned it, I was just kind of embarrassed that I diagnosed apraxia a little bit, cause I thought, um, he qualified for services through the school district, but he finished during the summer and thought he’s going to go back in the fall and they’re going to say why did she diagnose him as apraxic because it is a problem in our field, over-diagnosis of apraxia. But I have to tell you, he had all the symptoms at the beginning, of apraxia. Um, and now it usually doesn’t happen that way.

Dan: They’re not going to think of you as a miracle worker?

Denise: You usually don’t have results that startling, that dramatic, but yeah, he was the one, it was just like, whoa. I mean, he just, the language and everything just came pouring out.

Dan: So yeah, I know this is a pretty special story, but you have – over the years, you have told me a lot of good stories about PROMPT success. Give me another one.

Denise: Oh, this is a story with quite a different outcome. And maybe some people wouldn’t think of it as ideal, but a girl came to me, she was in her early teens, um, severely autistic.

She had rather recently learned to use a communication board, I think maybe it was like within two years. So she was pretty old when someone discovered that yeah, she can communicate. And the people who taught her how to use the communication board recommended PROMPT therapy. So she was really, really challenging.

A family member always came with her because sometimes she lost control and they needed to help her settle down. But you know, at the end of our three years together, and just mention that PROMPT says, once you’ve reached three years, you’ve probably maxed out on as much as PROMPT can do. Um, it works really, really, really well, but it doesn’t always perform the miracle, right? Just because some of the couldn’t totally correct some of her subsystems because she had so much tension, so much tension. If she relaxed too much she’d get sleepy, like she had no in between, I’ve got to be tense, or if I’m going to relax I’m going to fall asleep.

Dan: That was probably more a function of the autism.

Denise: Yeah. There’s only so much you could do. But at the end of the three years, there were some really good things happening as far as her participation in her family and her religious life, which is very important to the family. That improved so much. She could go to church and stay the whole time where she used to have to leave early.

She could go to activities with the other young women her age in church and stay the whole time. Even Girl’s Camp. She could stay the whole time. Of course, um, her grandmother went with her to Girl’s Camp. She was able to stay the whole time. And she was able to say family prayers for the whole family, big family gatherings.

And, um, and say her personal prayers, her grandmother would listen to her praying. Um, those were just really important things to the family. Um, she could say about three words together quite often. So they were little short sentences. She also had a communication board though, if she wanted to say something longer.

Dan: Because it was such a huge shift from where you started.

Denise: From having no words, no words at all, but it was kind of funny. I thought, Hey, you’ve been holding out on me because her grandmother who usually came with her, um, told me that she’d been naughty. And so, as a punishment or whatever, her grandpa was making her repeat the scout oath. And she was doing it. I was like, wait a minute, you can say the scout oath? Okay. Well, that’s a lot longer than what you’re saying in here.

Dan: But she did progress as far as you could go, and then…

Denise: Yes, and that was because of PROMPT. For her, I don’t think anything else would have worked. I really don’t. Um, and she was just so happy to have another avenue to communicate. I mean, sometimes she just didn’t want to use the communication board. She wanted to talk.

Dan: That’s terrific. Well, I imagine the big takeaway for this week is everyone should get PROMPT trained.

Denise: Well, I don’t think you’d regret it. If you got PROMPT trained, let’s put it that way.

Dan: Now Denise is not being paid to say this.

Denise: There’s a couple takeaways. One is our mantra: when you master the simple, the complex takes care of itself. So mastering the lower speech subsystems can take care of a lot of the more complex sounds that we teach. And as one of my PROMPT instructors said, all roads lead to Rome, um, and she said this when someone said, well, I’ve used this approach in this work, I’ve used this approach and it’s worked and there are other approaches out there for motor speech disorders.

But then she said for some clients, PROMPT is the only road that will work. And I have found that to be true.

Dan: Okay. Well, we want to thank you all for joining us this week. Next week, what are we going to talk about, Denise?

Denise: Those persistent stubborn lisps, and we are going to bring in PROMPT a little bit, because that has helped me be much more effective at correcting lisps.

Dan: All right, we look forward to that. In the meantime, if you enjoyed today’s podcast, please give us a five star rating on the podcast engine of your choice. That’ll help them steer this podcast to other speech therapists. We appreciate all the time you spend with us. And we look forward to talking with you again next week, thanks for joining us.

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.