Question & Answer - Speech-Language Disorders and Treatment

Why is assessment and treatment of oral sensory-motor skills important when treating the “r” sound?

Answer from Lisa Wright, Speech-Language Pathologist in Glen Allen, VA, USA

Every year, I receive several cases of children of all ages who cannot accurately produce an “r” sound.  Many have already had years of therapy with limited success. The first thing I do with these children is assess their oral sensory-motor skills. I assess the stability of the jaw using the Talktools’ bite blocks and ARK Grabbers. I look for adequate jaw strength, grading, and direction of movement. Can they maintain a bite for 15 seconds? And if so, do they fatigue or complain that it hurts/stings/is hard? I watch as they bite looking for a grinding pattern to sustain the bite or a lateral jaw slide as they repetitively bite on the Grabbers. Any discomfort, fatigue, or inappropriate jaw movement is a sign of a weakened, ungraded, and/or un-dissociated jaw.

I also look at their ability to move their tongues to various places within the mouth as they stabilize the jaw, as well as dissociate the tongue from the jaw and grade tongue movement. The tongue should move to a designated spot quickly and precisely without tremor or jaw movement. This is indicative of structure isolation (i.e., dissociation and grading) which is critical for speech clarity.

The mentalis muscles go from the bottom lip down to the chin. These muscles play a role in everting the lower lip which some people do when producing the “r” sound. I assess this muscle by having the child hold a tongue depressor between the lips horizontally. What I often see is tremoring, crinkling, or dimpling in the chin indicating the mentalis muscles are working overtime to support the tongue depressor. These muscles shouldn’t have to work so hard.

Poor jaw stabilization (involving the jaw elevator and depressor muscles), imprecise tongue movements, and poorly dissociated and graded mentalis and lip muscles make it difficult for a child to produce a crisp “r sound. In traditional therapy, children are shown placement and expected to learn to say the sound. But, sometimes the oral mechanism is not graded, dissociated, or coordinated enough to support the placement. If that is the case, then the multiple trials of do as I say practice will simply not achieve the goal of accuracy.

I recently had the opportunity to assess, via tele-practice, a 10-year-old boy who lives in a different country from me. This child has been unsuccessful at achieving a production of “r” sound despite working with several different speech therapists in his country.

I am new to tele-practice, but I am not new to assessing oral sensory-motor skills. So, I needed a way to assess this child’s oral sensory-motor skills without being present to probe, watch, and listen. For our first evaluation session, I asked his mother to gather a spring loaded clothes pin, a tongue depressor (or Popsicle stick) and a clean pencil. 

To assess his jaw stability, I had the child put the clothes pin on his molars and bite it closed 15 times on the left and then on the right. He could do the first 10 or so bites but struggled for the remaining 5. He told me this was hard and that it made his cheeks sting. While biting on a clothes pin involves different motor plans than jaw grading for speech, this task can be indicative of poor jaw stability, grading, and endurance. Fifteen to 25 repetitions is used in exercise physiology by physical and other therapists.

The child’s mom was unable to find a tongue depressor or Popsicle stick, so I assessed lip closure and his mentalis muscles by telling him to make fish lips and hold the pencil between his lips horizontally without using his teeth. He could not hold it for 2 seconds and there was significant tremor in his chin.  Even through the computer monitor, I could see it was dimpled and puckered possibly indicating a problem with lip grading, dissociation from the jaw, strength, and endurance.

I assessed the child’s tongue movement by giving him verbal directions such as “move your tongue tip to the top left back molar.” He was able to do all of these movements with relative ease. Therefore, he had some good tongue and jaw dissociation.

His homework for the first week was:

*Bite the clothes pin 15 times a day on both sides (working the jaw elevator and depressor muscles in a graded manner). This activity may also work the back and base of tongue needed for tongue retraction. 

*Hold the pencil between fish lips for 10 seconds daily (working on his buccinator, orbicularis, and mentalis muscles).

*Drink 1 milkshake or smoothie every day using a challenging straw (also working his buccinators, orbicularis, and mentalis muscles). I gave instructions on proper, therapeutic straw usage. Because of this, he declared I was the best speech therapist ever!

Session 2 was one week later. The child was able to bite the clothes pin without fatigue. His mother had ordered the ARK purple and green “P” Grabbers, and he was practicing with those as well. The child was still unable to hold the pencil between his lips, so I moved him to holding a piece of folded paper between his lips. This was easier, and he was successful.

Additionally, the child enjoyed the milkshakes and smoothies and told me he thought he needed to do that homework more often. Since he now had the Grabbers, I had him put the long part of each one between his lips, blow hard, pop the tube out of his mouth, and vocalize while popping. This produced a perfect “r” sound likely because he everted his lower lip, retracted and elevated his back and base of tongue, and had appropriate intraoral pressure.

I drew a road on the screen and asked him to draw one on the paper in front of him. I told him to put his tongue behind his front teeth and lick the roof of his mouth as if peanut butter were stuck and he needed to clear it away. We did that a few times. He was instructed to “freeze” his whole mouth when his tongue reached the back. Then, I asked him to make a sound. He produced a perfect retroflex “r” sound. We did numerous trials of “r” while running his finger along the road. We put stop signs on the road and practiced stopping the “r” at the stops signs and then starting again.

Finally, I added vowels to the end of the road, and he was able to produce the “r” sound in syllables accurately and with ease. Without palatometry or ultrasound, we were unable to know if his “r” sound was produced in retroflex (i.e., tongue curled) or with the sides and back of tongue raised. The retroflex “r” sound is often used to establish the sound until the sound can be produced with the back of the tongue.

The child’s homework for week 2 was to continue with the ARK Grabbers and straws, as well as to practice the “r” sound in syllables. Therapy continued weekly via tele-practice. Each session lasted 30 minutes. We did a quick warm up with oral sensory-motor work followed by a rapid drill with the “r” sound in the beginning of words. Then, we focused on a vocalic “r” sound (i.e., the “r” sound following a vowel) in words and phrases using more traditional therapy techniques.

At the four month mark, we took a 3-week break. At this point, the “r” sound was at least 90% accurate at the conversational level. When he had errors, it was due to his rapid rate of speech. When cued to slow his rate, he self-corrected. We had two more sessions focusing on conversation and making a chart of all he had learned and why the various exercises and techniques were helpful. Then, he was discharged.  And reluctantly, he admitted that he was going to miss seeing my face on his computer screen each week.

About the Author

Lisa Wright is a speech-language pathologist with a private practice in Glen Allen, VA. She works with the pediatric population with a special interest in treating children with autism, social communication disorders, apraxia, and children with motor related speech disorders. She is also passionate about helping parents advocate for their children with special needs. She is a sometimes blogger at 0newordatatime.wordpress.com and maintains a Facebook page devoted to developmental milestones and tips for parents to encourage speech and motor skills. She can be reached at In2speech@aol.com