We are pleased to welcome Sara Rosenfeld-Johnson, MS, CCC-SLP
as the guest host for our first chat of 2004.  She will be addressing
the topic of Oral Motor Therapy.

Sara Rosenfeld-Johnson has more than 30 years of experience as a
speech and language pathologist. She has spent the last 20 years
perfecting her unique brand of oral-motor speech therapy with a high
degree of success, even where traditional speech therapy has failed.
Now she is devoted to teaching others the methods so they can help
their clients with difficult-to-remedy articulation problems.

She is the author of "Oral-Motor Exercises for Speech Clarity" and
"The HOMEWORK Book". Sara founded Innovative Therapists International
in 1995 as a speakers bureau and source for oral-motor therapy tools.
She has held seminars throughout the United States as well as in Europe.
She is the international spokesperson for Moebius Syndrome and CHARGE
Syndrome, and a nationally recognized presenter for Down syndrome and
Cerebral Palsy associations for both professional and parent
organizations. She also has been a featured speaker for ASHA, state
and national conventions.

<Robin> Welcome!  Tonight we are chatting about oral motor therapy with Sara Rosenfeld-Johnson,
          MS, CCC-SLP.
<SaraRosenfeld-Johnson> Hi everybody!
<Robin> Glad you could all be here!
<Robin> Sara, please start with an overview of Oral Motor Therapy.
<SaraRosenfeld-Johnson> Oral motor therapy is a specialty within our field of speech therapy
          that deals with muscle based speech communication disorders.  It has been used
          successfully with clients of all ages and ability levels with the following diagnoses:
          speech clarity disorders, voice disorders and fluency disorders.  This type of therapy
          which is now being validated through research has demonstrated the ability to work on
          non-speech movements and feeding movements to improve speech clarity. Oral-motor therapy
          is an adjunct to traditional speech therapy and is only used for clients with muscle-based
          disorders.  The type of oral-motor therapy that I use is different from other therapies
          in that it follows the teachings of neuro-developmental technique (the Bobaths) and each
          exercise follows a hierarchy of muscle skill development.  The final step of each exercise
          is to transition the movement into speech production.  Because this type of therapy is
          not yet taught on the graduate level it is going to be difficult for me to answer
          specific client questions unless the therapist is familiar with the association of the
          jaw-lip-tongue but I will try my best to help in any way I can.
<Robin> Can you give us some basic info about that association?
<SaraRosenfeld-Johnson> When physical therapists and occupational therapists work with our
          clients they follow the same priciples.  Stability in one muscle group will allow for
          mobility in other muscle groups.  For example, jaw stability is necessary for the lips
          and the tongue to move independently for speech.  If the jaw is weak or unstable, the
          tongue and the lips will move as one unit.  This lack of dissociation results in poor
          speech clarity.  You can experience this for yourselves if you sit on a chair with your
          feet touching the floor.  If I ask you to pick up both feet simultaneously you can do it
          with no effort because your pelvis is giving you stability.  Now stand up and try to lift
          up both feet simultaneously.  You cannot.  Now transition this idea to speech.  Your
          pelvis is your jaw and your legs are your tongue.  Without stability in the jaw the
          tongue cannot move independently.
<SaraRosenfeld-Johnson> As you improve muscle strength and stability in the muscles of the
          abdomen, velum, jaw, lips and tongue through a HIERARCHY of skills in each exercise,
          those movements can then be transitioned into speech movements.  This does not happen
          spontaneously but through direct work on a variety of exercises.  I think that is an
          overview where we can begin.
<Robin> Sara, could you talk about how you evaluate oral motor function?
<SaraRosenfeld-Johnson> Sure.  Each client is evaluated through a series of exercises that
          address the muscles of speech.  My approach to oral motor therapy uses therapy tools
          disguised as toys in a hierarchy of difficulty to test airflow, laryngeal muscle grading,
          velopharyngeal functioning, jaw strength/stability, lip closure/rounding, tongue
          retraction/lateralization/tip elevation.  I use a horn hierarchy, straw hierarchy, bubble
          blowing hierarchy and graduated bite blocks to name a few.  Each exercise has been          
          validated using typical developing children. 
<Brooke> Is there a good resource to read up that would explain it well what to look for since
          you can't cover it all?
<Robin> Sara has a book/therapy program that is listed on this website's product page.
<SaraRosenfeld-Johnson> The title of my book is "Oral-Motor Exercises for Speech Clarity". 
          In it every exercise is described in step by step detail with IEP goals.
<Brooke> Thanks
<sp4kid> When do you suggest we use oral motor therapy?
<SaraRosenfeld-Johnson> sp4kid, I use oral motor therapy as an adjunct to my traditional therapy
          techniques when my client demonstrates instability in any of the muscle movements
          necessary for speech production.  Frequently I use this therapy for children and adults
          who are not making progress when I use traditional speech therapy.  Upon testing I find
          that they have weakness in one or more muscle movements.  Once I complete teh oral motor
          intervention, I return to the traditional techniques and find that they are now effective.
          (this therapy is only used as an adjunct to traditional therapy for children and adults
          who have muscle based problems). 
<sp4kid> Would you suggest using OMT with a child who has adequate strength and mobility but
          has numerous articulation errors?
<SaraRosenfeld-Johnson> sp4kid, No, I would not use oral-motor therapy for children who do not
          have muscle weakness or motor planning problems.  It sounds like this kid has a
          phonological processing disorder.
<sp4kid> thank you
<SaraRosenfeld-Johnson> Oral motor therapy is a piece of the pie and should be used only for
          muscle based speech deficits.
<Kathy> Is your work with this oral motor therapy very much the same as treating neuromotor
          speech disorders?
<SaraRosenfeld-Johnson> Kathy, my approach is based on neurodevelopmental technique...
<Kathy> So does it follow  stages of motor development?
<Kathy> I don't think I ever learned anything like that before relating to muscle development.
<Kathy> What population do you find the most success with using your oral motor program?
<SaraRosenfeld-Johnson> Kathy, you ask many good questions.  Let me see if I can summarize the
          answers for you.  I have used this program with infants of only one-day of age as well
          as with adults following a CVA.  Age does not seem to be a factor as muscles can change
          at any age through exercise.  Think of the typically developing adult who has never
          exercised a day in his life, who has a heart attack and is put on an exercise program.
          In a few years, we hear he is running a marathon.  Because my oral-motor exercises are
          based on stimulation-response, using therapy tools, the level of client cognition is also
          not important in many of the exercises.  So I have used these techniques with clients who
          only have "cause and effect".  As I mentioned before, the exercises are based upon neuro-
          developmental technique which follows a pattern of normal development.  Since we know
          that speech clarity is superimposed on normal muscle movements, it is logical to assume
          that when the muscles are not developing normally the speech clarity will be impacted.
          Again, think of the physical therapist.  If their client does not have adequate strength
          to support body weight, they will not work on walking.  The same goes for oral-motor
          therapy.   If our client's jaw cannot support the dissociated movements of the lips and
          tongue we will need to improve jaw stability before we can work on specific speech sounds.
<SaraRosenfeld-Johnson>  I began my work with children with Down Syndrome.  The results were so
          positive that I started to introduce them to clients with CP (Cerebral Palsy).  Over the
          years, the successes have been so remarkable that now I have taught over 20,000 therapists
          to use these techniques with special needs children who evidence any muscle-based
          disorders, with children and adults with voice or fluency disorders and with typically
          developing children and adults who do not improve with traditional therapy.  The average
          length of therapy using oral-motor therapy for children or adults with persistent /s/ or
          /r/ problems is 7 months, not 3-4 years.
<Kathy> How specific is this program? Does it identify specific muscles and the age at which they
          are normally developed?
<SaraRosenfeld-Johnson>  Yes, it describes the hierarchies of muscle development and how to
          address deficits at any developmental stage.
<natalieisme> Does oral motor therapy work for developmental apraxia of speech? or oral apraxia?
          This school-aged kid is unintelligible with apraxia..any help?
<SaraRosenfeld-Johnson> Natalie, most kids with apraxia have a combination of motor planning
          problems AND muscle weakness.  Oral motor therapy, my program at least, certainly works
          for these kids.  You should check our website, www.talktoolstm.com for endorsements from
          families and therapists.
<natalieisme> Sara, this boy is completely unintelligible...with oral motor therapy do you
          think he will talk?
<SaraRosenfeld-Johnson> Natalie, it is impossible to tell through e-mail if one approach is
          better than any other but in my 33 years of experience I have found that oral-motor
          therapy is the key to working with kids with apraxia.  So many of these kids cannot
          coordinate volitional airflow with vocal productions.  Without volitional airflow you
          cannot make or even imitate a speech sound.  When you teach a child to blow a horn you
          are using an oral-motor approach to teach volitional airflow.  I always tease the OTs
          that I work with.  I say, "when you want a kid with apraxia to pick up a fork you pick
          up his hand and assist him in picking up the fork".  You are teaching that child the
          motor planning for self-feeding.  When I want a child with apraxia to initiate a sound
          I cannot use that same teaching technique.  I can, however, use a non-speech activity,
          such as horn blowing, to creat the motor plan for volitional airflow.  Then by using a
          kazoo I can transition that non-speech activity into speech production.  This type of
          therapy uses a "tool" to teach the motor plan for speech sound production.
<SaraRosenfeld-Johnson> I am giving a 3 hour talk at the Virginia Speech and Hearing Association
          on using oral motor therapy with apraxia.
<natalieisme> Thank you, Sara....how often should tx be done?
<SaraRosenfeld-Johnson> Good question.  OM therapy is based on exercise physiology so the
          exercises must be done a minimum of 3X per week but that does not mean that a therapist
          has to do it.  Parents love this therapy as it is fun and they can see progress. 
          Get them involved!
<braeswick> Is the purpose of performing the exercises 3X per week to strengthen the speech
<SaraRosenfeld-Johnson> Braeswick, for children with muscle weakness as in Down Syndrome, the
          exercises do normalize muscle weakness.  But please remember you do not need a tremendous
          amount of strength for speech but you do need adequate mobility.  The horns improve
          strength for those who need it but also work on motor planning for speech movements.
<braeswick> Thank you. Is three times a week enough to alter muscle strength?
<SaraRosenfeld-Johnson> Braeswick, my therapy program is based upon exercise physiology.  We are
          told as adults that working out in a gym 3X a week will improve muscle strength. 
          Obviously if you work out more, the progress will be faster but we need a minimum of 3X.
          This practice does not need to be done an an SLP.  We see children 1 time per week to
          reassess changes and the families or school personnel do the homework 2 or more times
          per week.
<braeswick> Adults in gyms (who gain strength) perform exercises many times AGAINST RESISTANCE.
          Do you include "resistance" in the therapy "mix" ?
<SaraRosenfeld-Johnson> Yes, resistance must be a part of the program to improve strength. 
          Resistance is not necessary to teach a motor plan so I use a combination of exercises
          that require resistance and some that do not.  My Jaw Grading Bite Blocks use resistance
          to develop grading in six jaw levels or heights (have exercises.)  You must have adequate
          strength in each jaw height to improve jaw stability for improved feeding and speaking.
          (All use resistance to improve stability in the jaw).  The horns and the straws also use
          resistance because they are in a hierarchy of difficulty.
<speechy> Is it too late to start therapy with a child who is almost 4 who has very low tone?
<SaraRosenfeld-Johnson> Speechy, I live in Tucson, AZ.  When you live here you learn that
          muscles can improve at any age.  We have people who move here at 65 who have never
          exercised a day and are now running marathons.  Muscles can improve at any age. 
          Four is young!
<Miriam>_ I work with a 2-year-old who is very low tone and has limited lip rounding and lip
          potrusion.  He can drink with a straw and blow bubbles with assistance.  What else can
          I do?
<SaraRosenfeld-Johnson> There is straw drinking and there is therapeutic straw drinking.  In my
          straw drinking hierarchy the client learns to use lip rounding and tongue retraction to
          draw liquid through increasingly difficult straws.  Many children and adults continue to
          suckle on a straw.  This is not therapeutic straw drinking.  The same goes for bubble
          blowing.  Each exercise I use is described in step-by-step sequence to maximize movement.
<Miriam> Do you any suggestions for decreasing drooling and increasing oral awareness for a
<SaraRosenfeld-Johnson> I have a drooling program which enables the therapist to diagnose the
          factors that are contributing to the saliva control issues and then a therapy program of
          exercises which address each of the problems.  I have used this with clients as young as
          12-16 months of age.
<lopa> Yes, how do you handle saliva control?
<SaraRosenfeld-Johnson> Miriam, a few years ago I was asked to write a drooling program for
          children with Downs Syndrome as I am their national spokesperson.  That program is now
          being used with typically developing children with low tone and with adults. It uses a
          combination of exercises to address the causes of drooling: body posture, inability or
          reduced ability to close the lips/jaw, oral hyposensitivity, and inability/reduced
          ability to retract the tongue for standard swallowing.
<natalieisme> How can I find out more about that drooling program for Downs Syndrome?
<SaraRosenfeld-Johnson> You can find information on our website.
<Miriam> How do I work on closing the lips/jaw aside from verbal cues?
<SaraRosenfeld-Johnson> My book gives you step-by-step instructions to improve these skills using
          therapy tools such as bite blocks, horns, and flavored tongue depressors.  You would have
          many to choose from.
<Kathy> Does your program include a diagnostic test?
<SaraRosenfeld-Johnson> Kathy, yes the drooling program includes a diagnostic tool.
<Kathy> OK
<Mary> What would Ms. Sara R.J. suggest for a 3 year old cerebral palsy child who is not speaking?
<SaraRosenfeld-Johnson> Mary,  today I evaluated a 7 year old child with CP who had intact
          language.  He could use 10 word phrases but was 90% unintelligible because his jaw could
          not support lip and tongue movements.  That is the biggest problem I find in CP.
<Mary> What would you do to help the CP child?
<SaraRosenfeld-Johnson> I would begin by doing a complete oral-evaluation to determine which
          areas of deficit exist.  As I mentioned before, the jaw seems to be the biggest problem.
          Jaw exercises include: bite block exercises, gum chewing hierarchy, slow feed technique,
          chewing on the back molars, and chewing on non-food items.  The diagnostic techniques and
          the exercises are all covered in the videos of my classes.
<speechy> Sara,  can anything be done for those CP children? Unfortunately, there difficulties
          are due to neurological deficits.
<SaraRosenfeld-Johnson> I think we can do much more using oral-motor therapy than we can with
          auditory-visual cues.  Ask a PT if it is work working with a child with CP.  The answer
          would be, of course.  When I describe to laypeople what I do with these clients I say
          that I do "physical therapy for the mouth".
<Amy> Can you explain on the whistles program WHEN to proceed?  I have the horn program but am
          not clear when to go to the next whistle.
<crystal> What is a horn?
<SaraRosenfeld-Johnson> Crystal, my horn hierarchy uses 14 horns which address all of the muscle
          movements of speech.  They are used as diagnostic tools and treatment.
<SaraRosenfeld-Johnson> Amy, each horn must be blown 25X of a designated duration, with no
          compensatory postures before you can go to the next horn.  At no time do you work on 
          2 horns in the hierarchy at once.  Also, remember that each of my exercises/horn kits,
          etc., come with a complete set of step-by-step directions and if you are still unsure,
          you can e-mail us with any questions.  We have a staff of therapists who answer e-mail
          questions everyday.
<Amy> If I have to hold him in position- then stay at that horn even if he can do 25?
<SaraRosenfeld-Johnson> Amy, explain hold him in position.
<Amy> Andrew has apraxia and OM issues.  He specificially has bilabial issues.  Do I work only
          on those horns (bilabial) and skip the others or do them in succession with all the horns? 
          He has problems with other consonants as well.
<SaraRosenfeld-Johnson> Amy, the beginning horns work on lip closure so you would start with
          Horn #1.  If a child has trouble with lip closure they will generally have to work
          through the whole hierarchy because the higher horns work on lip rounding which is a
          more advanced movement.
<Amy> Thanks Sara
<Anna-logoped> I'd like to see these horns... What web site can I log in for that?
<SaraRosenfeld-Johnson> www.talktoolstm.com has pictures of all the tools we use.
<Robin> the horn kit is listed on the product page of this website also.
<lidiahuerta> At what age can we initiate horn therapy?
<SaraRosenfeld-Johnson> With most kids, we start at 12 months.
<Amy>   If you are going to start with a program - is horns the place to start?  or straws? 
          We have cut all Andrew's straws short but I haven't looked at that program.  He does
          bite on straws.  He has other issues as well, SI, attn, apraxia, deaf/language at 2 year
<natalieisme> Great question Amy.
<SaraRosenfeld-Johnson> Amy, I use both horns and straws together.  Think of the concept of
          cross training.  We can work on tongue retraction, lip rounding, and jaw stability with
          these tools.  Please make sure to read all the directions before you use any of my tools. 
          If you do not follow the directions the tools become toys and will not improve speech
<Amy>  Is it OK to let him play with other horns not in the kit for "reward?"
<SaraRosenfeld-Johnson> Amy, no I would not do this because the kids are not allowed to hold
          their therapy horns as they could bite on them and that would negate the effectiveness
          of the program.  It would confuse these kids if they could play with other horns and
          hold them.
<Amy>   Thanks Sara
<speechy> Can you use the straw hierarchy without using the horn heirarchy? I am thinking of
          an 11 year old child that I have who is cognitively delayed.
<SaraRosenfeld-Johnson> You can do them separately but generally do them together, cross
          training, as described above.
<Melyssa> Is it possible for a child to progress successfully throught the straw and horn
          hierarchies and still not achieve good tongue retraction and minimize drooling?
<SaraRosenfeld-Johnson> Yes, that is possible because when you use only these two exercises and
          omit the jaw exercises, the tongue cannot work independently.  The assessment should
          include diagnostic information about jaw stability.  If the jaw is unstable you would
          use all three exercises as a basis: jaw grading bite blocks, horn hierarchy and straw
          hierarchy to facilitate tongue retraction.
<Kate> I'm working with a 9 mo. baby s/p anoxic event at birth - very low cognitive level.
          Low tone throughout trunk, cheeks, etc. but TIGHT jaw.  She seems to be fixing, and it's
          clenched with only about a 1/2 inch opening at most.  She's NPO - Ideas on jaw work?
<SaraRosenfeld-Johnson> Kate,  It would be dangerous to use any food source, obviously, so have
          you tried ARK   Probe, Grabbers, or the Chewy Tubes?  We use them for children of that
          age and the directions come with the tools.  Remember if you use any of my exercises you
          can alway always ask us at TalkTools any questions you have about your clients.
<Kate> Well, we'll do an MBS when she's ready, but I can barely get the chewy tube/NUK in her
          mouth it's so tight.
<Kate> Any follow up for my tight jaw child?  I've tried all the tools.
<SaraRosenfeld-Johnson> Kate, what have you used?
<Kate> Nuk brush, toothbrush, chewy tube, the little blue ridge one (?) that vibrates, and
          pacifiers, which work best for her so far but doesn't address the jaw.
<SaraRosenfeld-Johnson> Kate,  you should be placing all the tools on the back molar extending
          out the side of her mouth.  Use the palm of your non-dominant hand to support her jaw
          as you press down and feel her jaw close, release the pressure.  Repeat movement 5X each
<SaraRosenfeld-Johnson> This should improve strength
<Kate> Yeah, that helps some, but doesn't get her jaw open any wider.
<Linda> Is there a "range" of jaw opening that we should aim for?
<SaraRosenfeld-Johnson> Linda, yes, there are 6 jaw heights that have to be strengthened to
          enable the individual to grade for feeding and speech.
<Kate> Sara, she doesn't have any molars yet - she's only 9 months old.  But I do exactly as you
          are describing.  She fusses - if I hang in there she can maintain an opening the width of
          a standard NUK for 1 min.  I don't think this case is about tools.
<SaraRosenfeld-Johnson> Kate, my goal is not to maintain opening, it is to achieve grading
          which can only be taught through biting/mobility.
<natalieisme> Any suggestions for eliciting /k/ and /g/?
<Christine> Natalie, my co-worker uses a marshmallow to be held down under the tongue.
<speechy> Natalie, I found laying kids down on the floor helps produce velars.
<tam_bl> Sara has great ideas in her book to elicit /k/ and /g/.
<SaraRosenfeld-Johnson> Thanks for the endorsement of the suggestion in my book, but until you
          have that, there is one way to test if a child has the physiological ability to produce
          k/g, which is to have him/her blow Horn #12.  This horn requires the back of the tongue
          and the velum to approximate if the child cannot blow the horn he/she does not have the
<sp4kid> Re: k/g -- what if the child is able to cough?
SaraRosenfeld-Johnson> The best techniques that I have for tongue retraction are the straw
          hierarchy and the horn hierarchy.  They really work.
<SaraRosenfeld-Johnson> You can also use an exercise called cheerio for tongue tip depression.
<Christine> I needed some suggestions about how to get some children to self-correct after they
          can produce/say final consonants following a model.
<Christine> The child can produce final sounds following a model but not without it(poor
          attending to self generated utterances).
<SaraRosenfeld-Johnson> Christine, have you ever used the PROMPT system?  That is a terriffic
          technique for transitioning movement into speech for children with apraxia.  We also
          use another program called Sensory Stix.  It teaches you how to transition movements
          learned in exercises into movements for the targeted speech sound.
<wannatalktoo> My 3 year old apraxic son will not eat fresh fruits unless they are pureed or
          juiced.  Any suggestions?
<SaraRosenfeld-Johnson> Kids with apraxia frequently have sensory deficits.  Fresh fruit is a
          mixed texture when you bite into it, it has a solid and a liquid.  Try cutting the fruit
          into small cubes. Freeze the cubes and see if he can deal with them then.
<Kathy> Do you find your motor exercises to benefit school-aged children who are not
          making progress with the /r/?
<SaraRosenfeld-Johnson> Kathy, YES, the typical length of time for an /r/ therapy should
          be 7 months, not 7 years.  The technique I use is in my book.
<Kathy> Wow! That can help so many SLP's working on correction of the r/ sound, especially
          in the public schools.
<SaraRosenfeld-Johnson> I feel really bad about this.  It is obvious that oral motor is very
          confusing for so many of you.  It is because you don't have enough knowledge.  I wish
          this stuff was taught in schools.  My best suggestion is for you to learn these
          techniques and then you will be able to apply them professionally.  I am so afraid that
          I am going to give you suggestions that are not professionally responsible unless you
          know how to use them.
<BethAnn> I agree with Sara. I feel like there is this whole area of SLP that is not taught-
          but really seems to work for many therapists.
<braeswick> Why is it, do you think, that Oral Motor Therapy is not taught in SLP graduate
          programs? Is it because of the lack of an evidence-base?
<Linda> Braeswick, that is exactly what I am wondering.............
<SaraRosenfeld-Johnson> Braeswick,  there is research. but ASHA will not accept it.  Please go
          to our website to read the research that proves oral-motor therpay is effective.
<Kate> I feel I'm well versed in oral motor therapy and have seen it used inappropriately,
          so that is a concern.
<SaraRosenfeld-Johnson> Kate, I agree with you.  That is why ASHA has to look at my work
          and agree to have it taught in the Universities.
<BethAnn> I don't want to be one of those SLPs who use it inappropriately- I want to learn
          more before I put it into action.
<SaraRosenfeld-Johnson> BethAnn,  You are right.  You can take my classes on video or live and
          in April we are starting a certification program.  Perhaps you'll join us.
<Robin> Sara, thank you for being here tonight, and sharing your expertise with such a large
          chat group!
<manymax> Thanks Sara, your work is appreciated!
<Kate> Thank you
<braeswick> Thank you!
<wannatalktoo> Thanks Sara.  This chat room has been very helpful to me.
<Linda> Thank you for your time and information!
<Ann> thank you
<Miriam>_ thank you
<BethAnn> Thank you!
<Kathy> Thanks
<lidiahuerta> Thank you for your time and suggestions Sara.
<Robin> and thanks to ALL of you for comimg
<SaraRosenfeld-Johnson> Good night to all!