DISCUSSION

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Many points of discussion resulted from this textbook review. Objects were a regular part of traditional articulation therapy according to Van Riper and the writers of the fourteen textbooks reviewed, and to suggest otherwise is historically inaccurate. Van Riper called this the phonetic placement method, and he himself used a wide variety of objects for this purpose. The main purpose of using an object was to teach dissociation, direction, and grading of oral movements for phoneme position/placement. To dissociate means to "separate" (Jewell & Abate, 2001, p. 494). In the case of speech articulation, this usually means to separate jaw, lip, tongue, and velar movements from one another. For example, the production of /ʃ/ requires distinct movements in each articulator: The jaw sits high, the lips round, the tongue elevates its lateral borders, and the velopharyngeal port closes. Authors of these historical texts used objects to assist these independent movements when a client could not accomplish them without assistance.

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Van Riper taught that objects were to be used only after a client had failed to imitate an auditory-visual model of the target phoneme. In other words, he posited that one should not begin teaching a phoneme with an object. Van Riper explained that phoneme training begins with auditory training. Once the client is aware of the phoneme, can identify it, and can discriminate it from other similar phonemes, the actual process of teaching production begins with modeling the phoneme for the client to imitate--the stimulation method. However, according to Van Riper, if auditory training and a therapist's auditory-visual model do not stimulate a better production of the target phoneme with accurate movement and positioning right away, other methods, including the phonetic placement method and the objects it employs, should be used to teach place, manner, and voicing. Van Riper wrote: "When the stimulation method fails...they [phonetic placement methods/objects] must be used" (Van Riper, 1947, p. 146).

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None of the writers in the textbook reviews suggested that an object alone would bring about phoneme emergence or correction. Objects were to be used to stimulate appropriate dissociation, grading, or direction of movement, and then these movements were to be used to teach target phonemes. This is a two-step process that Van Riper described as follows: "The therapist...is attempting to give [the client] the appropriate location and formation. As soon as this has been achieved, the therapist stimulates [the client] with the correct sound" (Van Riper, 1954, p. 147). Therefore, according to this traditional view, objects may be used and in fact are recommended to teach approximations of speech movements.

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A misunderstanding of the basic phonetic placement process may be causing some of the recent concern among speech-language pathologists about using objects in articulation therapy. Some academics and clinicians who condemn the use of objects or tools (including the hands and fingers) in speech therapy, by calling these activities NSOME/NSOMT, have implied that therapists are attempting to use objects alone to cause phonemes to emerge or correct. According to Powell for example, "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... they employ nonspeech tasks as an indirect means of modifying speech production" (Powell, 2008, p. 374).

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If it is true that SLPs are using objects alone to correct phonemes, this runs counter to the historic use of objects as presented by the authors reviewed. As explained by Van Riper, an object is used to teach a specific movement and then this movement is used to teach the phoneme that requires the movement. All of this is done only after a client has failed to imitate the phoneme with auditory-visual modeling and direct instruction. The key to using objects in this view is to have clients attempt to produce the correct sound during or immediately after stimulation.

One of the current arguments against using objects is that there has been no demonstrable relationship between speech and "nonspeech" activity (e.g., Wilson, Green, Yunusova, & Moore, 2008). Some authors are warning that it is inappropriate to have clients chew gum to get the jaw to move up and down, to bite on a bite block to stabilize the jaw at various heights, to blow whistles to learn lip rounding, or to press the tongue-tip against a spoon to learn tongue-tip elevation. Those clinicians who disapprove of such measures fail to consider the sample of clients with oral sensory-motor delays/deficiencies who may require help in producing appropriate jaw, lip, tongue, or velar movements as preparatory skill development before specific phoneme training is possible. Van Riper called these clients "clumsy-tongued individuals" and "the slow of tongue" (Van Riper, 1947, p. 132). The need to develop some basic movement skills in order to control structures associated with speech has merit. In Van Riper's words: "In modern speech correction, the emphasis on tongue exercises has almost disappeared. Yet for certain of the clumsy tongued individuals with whom we work, modern forms of these exercises are very valuable" (p. 132).

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Van Riper's texts clearly point to and recommend that speech-language pathologists engage in these routines in order to attain preliminary movement approximations for speech. He wrote: "Whenever possible the articulatory exercises given should proceed out of the movements used in the biological functions" (Van Riper, 1939, p. 242). Van Riper even recommended the use of "non-speech" activity itself when working with young children: "With smaller children it is often necessary to begin by training them in imitation of non-speech movements" (Van Riper & Irwin, 1958, p. 144). Modern SLPs are trying to reconcile these basic Van Riper methods with recent cautions about the use of objects or tools in so-called "non-speech" activity. Much confusion about why and how to use objects in articulation therapy appears to be the result.

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It also has been argued that articulation improvement cannot be achieved if therapists focus on the individual parts of phonemes instead of the whole phoneme in a syllable or word (e.g., Bowen, 2005; Bunton, 2008; Forest, 2002; Lof, 2003; Kahmi, 2008). For example, when teaching /k/, the warning is to leave jaw, lip, and tongue control alone, and just teach /k/ within the language context. This procedure ignores clients with oral sensory-motor issues who simply cannot elevate the back of the tongue on demand. How long must a speech-language pathologist model /k/ in syllables or words with no success before he or she decides to do something directly to help the client lift the back of the tongue? Van Riper and the other authors reviewed suggested that this help should be given right away. In 1993, Van Riper explained that the reason he wrote his first text (Van Riper, 1939) was to counter the then common practice of simply having clients repeat words over and over again as a way to correct phonemes. In his words: "All the clinician would do was to ask the client to repeat [words] after her... That would go on for an hour. They felt that such a bombardment would lead to error elimination. Can you imagine that?" (Secord, et al, 2007, p. viii).

According to each of the reviewed textbooks, word drilling often is not enough to correct the articulation of phonemes. The early authors of articulation texts in this review concluded that therapy should switch quickly to the individual phoneme (or syllable) when failure occurs, and further assistance on place, manner, and voice features should be given right away. Objects may be used to teach these features if necessary. This recommendation represents basic articulation therapy as taught by the authors under discussion.

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The reader will note that some of these authors utilized unsanitary and potentially harmful or dangerous object activities that are not compatible with current safety requirements. For example, Nemoy and Davis (1937) recommended placing small bits of paper on the back of the tongue to teach posterior tongue elevation, and the aspiration of such objects represents a risk that was not identified. Berry and Eisenson (1956) used masking and adhesive tape next to or below the lips to inhibit or to draw attention to their movement. Scripture (1912) and Anderson (1953) both recommended producing phonemes in front of lit flames to monitor airflow. Froeschels (1948) used fragile and easily breakable glass pipettes to teach oral airflow. Scripture (1912) also used electrical impulses to stimulate velar movement. Even Van Riper (1954) used long wooden matches to mark the palate for tongue placement, and he used pencils to move the tongue, to groove the tongue, to round the lips, and to stabilize the jaw.

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Some may claim that Van Riper modified his views about the use of objects in articulation therapy later in life. A review of his final thoughts on the subject may shed light on this conjecture. Examination of the last edition of Van Riper's textbook revealed that he had continued discussing these methods as a regular part of therapy (Van Riper, 1978). It is therefore apparent that Van Riper advocated the use of objects in articulation therapy for at least four decades, from 1939 through 1978.

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Beginning in 1984, however, Van Riper collaborated with a colleague (Erickson) in writing another basic text, An Introduction to Speech Pathology and Audiology (Van Riper & Erickson, 1984). In the introduction, Van Riper noted that the very purpose of the text had changed from being a collection of methods for speech-language pathologists, to a general introductory text for undergraduate speech and other students. The section of the text on articulation was highly influenced by this transformation. The authors made more generalized statements about articulation therapy, they introduced phonological theory, and they dropped almost all of Van Riper's specific phonetic placement methods along with the discussion of the objects he used to accomplish them. This seems to have become the model for many articulation/phonology textbooks published since that time.

Modern textbooks on articulation and phonology continue to acknowledge the phonetic placement method as one viable option in articulation therapy, but the many details of how to utilize objects generally are not included. As examples, Bernthal and Bankson (2004), Bauman-Waengler (2004), and Pena-Brooks and Hegde (2000) present general statements about the phonetic placement method, offering a few sample methods as illustrations. Likewise these texts acknowledge the motokinesthetic method (Stinchfield & Young, 1938; Young & Hawk, 1955), but the great details of the ways in which these therapists used their hands and fingers to teach positioning of the speech structures are absent. The reduction of phonetic placement techniques and motokinesthetic methods into simplified paragraph descriptions has left generations of therapists lacking specific knowledge about the vast array of objects, including the hands and fingers, which were used to influence oral movement in Van Riper's time. Perhaps the misunderstanding and misuse of objects today has been the inevitable result.

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Phonetic placement methods and the objects used to accomplish them endured into the 1980s in a few books including Vaughn and Clark (1979), Bosley (1981) and Hanson (1983). In the 21st century, the details of object use for phonetic placement and motokinesthetics have survived and thrived by shifting them away from main introductory textbooks designed for students, and into practical instructional manuals designed for working professionals. A number of modern guidebooks contain procedures for using objects in the process of speech movement instruction. These include Bahr (2001), Bleile (2006), Gilbert and Swiney (2007), Marshalla (2004 and 2007), Rosenfeld-Johnson (2001 and 2005), and Secord et al (2007). Although the term "oral motor" (simply meaning "mouth movement") has been attached to some of them, many of the techniques contained in these manuals are updated versions of what Van Riper called "the old traditional methods." As an example, Van Riper (1947) used a pencil to teach lip rounding, and he called it a phonetic placement method, while Gilbert and Swiney (2007) used a gummy worm to teach lip rounding, and they called it an oral motor technique. The goal and procedures are the same, but the tool has been modernized and the vocabulary updated. This is a reflection of a basic principle of articulation therapy taught by Van Riper and Irwin: "There are no doubt almost as many ways of carrying out these basic principles as there are clinicians" (Van Riper & Irwin, 1958, p. 118).

Phonetic placement techniques and their objects are employed when a client simply cannot learn a specific speech movement in any other way. Secord, a protégé of Van Riper, wrote that one uses these and other methods "when the client cannot produce a target sound at all" (Secord, et al., 2007, p. 3). He continued: "In a manner of speaking, the clinician needs to 'roll up her sleeves' and actually teach the client how to say the target sound" (p. 3). This is a process of teaching the mechanics of sound production (phonetics), not the use of a phoneme within a language (phonology). Professional speech-language pathologists today welcome these ideas in manuals and continuing education programs because the rich assortment of phonetic placement techniques that formerly appeared in articulation therapy textbooks are no longer included in modern texts.

CONCLUSIONS AND IMPLICATIONS FOR THERAPY

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This textbook review strongly suggests that objects can and should continue to be used to teach speech movements in articulation therapy when the phonetic placement method is employed. To claim that this is a new idea, to ban the use of objects in articulation therapy, or to assert that this is "non-speech" activity ignores the fact that practicing clinicians have been using objects continuously in speech training in the United States since at least 1912. Using objects to teach speech movement is exactly what Van Riper and other traditional therapists often did when a client could not produce a target phoneme by imitating it. Speech-language pathology students would benefit from being taught to appreciate the historic value served by objects in speech movement training instead of being taught to ignore or condemn this process. Seasoned professionals would benefit from considering how these ideas might apply to clients who do not respond well to model-and-imitate methods of phoneme stimulation.

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The traditional therapists of these textbooks used tongue depressors and other "sticks" more than any other tools in articulation therapy. SLPs today continue to use tongue depressors, but some problems exist. The present author has found that tongue depressors are too wide, too thick or too thin, the wrong shape, and simply too clumsy for many of the delicate oral adjustments necessary in articulation training. Additionally, wood can have an unpleasant taste and feel in the mouth even when it is flavored, and an adult-sized tongue depressor can splinter fairly easily when a client bites down hard on its thin edge. Alternatives to the tongue depressor are welcome for these reasons. For example, a modern flexible plastic dental pick often can be slipped between the upper central incisors and placed so that it sits between the tongue-tip and the alveolar ridge. This tiny tool allows for more direct instruction about tongue-tip placement for /s/, /z/ and the other lingua-alveolar phonemes than does the much larger tongue depressor.

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SLPs also find that they cannot use their hands and fingers as easily as the therapists in this review because of new restrictions regarding sanitary procedures. SLPs often do not have sinks for proper hand sanitation in their therapy spaces, they may not be provided with gloves, and they may have clients who do not respond well to gloves or commercially available hand sanitizers. SLPs in the schools often work in groups and cannot sanitize their hands simultaneously for every student. Therapists in many environments find they cannot manipulate the papers, toys, and games of therapy while keeping their hands sanitized. They also cannot touch clients with the hands when working via on-line video services. Some SLPs work for employers who prohibit them, for legal reasons, from touching clients with the hands and fingers. An obvious solution to each of these situations is to employ a variety of sanitized objects the therapist can use or the client can use on himself.

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Van Riper wrote that "every available device" should be used for phonetic placement. Speech-language pathologists who employ phonetic placement techniques today have a much wider range of tools from which to choose due largely to the invention of synthetic materials. For example, Van Riper may have used matches, pencils, toothpicks, and sticks to adjust jaw position, but a modern therapist can use a set of sanitary and professionally designed bite blocks. Many appropriate objects are being used today for phonetic placement:

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• Inexpensive household items: Including plastic straws, tubes, swizzle sticks, spoons, and eyedroppers. Metal spoons can be used as well.

• Inexpensive items designed to improve oral hygiene: Including toothbrushes, toothettes, tongue scrapers, dental picks, dental floss, and dental floss handles.

• Inexpensive toys: Including plastic horns, whistles, bubble wands, kazoos, and harmonicas.

• Professionally designed oral/nasal tools: For example, the Lip Retractor, Z-Vibe, LifteR, Oral Probe, Lip Gym, Nasal Clamp, ChewyTube, Maroon Spoon, Jaw Grading Bite Blocks, and Progressive Jaw Closure Tubes.

• Safe and sanitary tapes: Including latex-free and nonabrasive Kinesio Tape.

Objects are used in therapy today when auditory bombardment, modeling, phonological awareness activities, reading programs, minimal pairs, and other linguistic and cognitive means are not enough to teach correct phoneme production. Phonetic placement techniques are employed as a last resort when a client needs to learn the specific movements of place, manner, voice, and resonance for particular phonemes, and there is nothing "nonspeech" about that. Nor is there anything new about it. Using objects is one of the traditional ways to teach speech movements in articulation therapy.