FOR THE SCIENCE OF ORAL MOTOR TREATMENT
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.
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.
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).
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).
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).
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).
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).
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).
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.
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.
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).
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.
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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Blakely, R. (1983). Treatment of developmental apraxia of speech. In W. H. Perkins (Ed.), Current therapy of communication disorders. New York: Thieme-Stratton.
Borden, G. (1984). Consideration of motor-sensory targets and a problem in perception. In Winitz, H. (Ed.), Treating articulation disorders: For clinicians by clinicians. Baltimore: University Park Press.
Borden, R. & Busse, A. (1925). Speech correction. New York: F. S. Crofts.
Caruso, A. J. & Strand, E. A. (1999). Motor speech disorders in children: Definitions, background and a theoretical framework. In Caruso, A. J. & Strand, E. A. (Eds.), Clinical management of motor speech disorders in children. New York: Thieme.
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Please cite this article as:
Marshalla, P. (2007). Oral Motor Techniques Are Not New. Oral Motor Institute, 1(1). Available from www.oralmotorinstitute.org.
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