FOR THE SCIENCE OF ORAL MOTOR TREATMENT

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.

Figure 1: Percentage of SLPs Who Included Surveyed Areas in Their "Oral Motor Treatment" Definitions and Practices with Some ASHA Demographics (Bahr, 2008b; ASHA, 2007b); Percentages Rounded

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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.

Figure 2: Time SLPs Reported Spending on Feeding, Orofacial Myofunctional, and Motor Speech Treatment (Bahr, 2008b); Percentages Rounded

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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).

Figure 3: Time SLPs Reported Spending in Oral Awareness/Discrimination and Oral Activities/Exercises (Bahr, 2008b); Percentages Rounded

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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.

Figure 4: Oral Sensory-Motor Treatment Flow Chart

Click To Enlarge

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.

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American Speech-Language-Hearing Association (1993). Orofacial myofunctional disorders: Knowledge and skills, ASHA, 35 (Suppl. 10), 21-23.
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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.
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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.
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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:____________

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 "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.

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