#017: How to Tackle Oral-Facial Exams

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In this episode I got to sit down and talk to Amy Graham, an SLP who has been practicing for 20 years (!!) and owns Graham Speech Therapy, a private practice in Colorado Springs that specializes in speech sound disorders. She’s listed on the Apraxia Kids Directory of SLPs as having expertise in apraxia, and I can see why — with her years of experience, she has tons of practical strategies and tips related to speech sound disorders that she generously shared with us today.

If you’ve been following Amy, you know that she does an amazing job supporting and equipping SLPs with the tools we need to really have an impact with our work. She does these awesome video demonstrations that you will definitely want to check out. 🙌

Okay let’s be honest here for a minute. We often work on articulation, but don’t always do an oral-facial exam. Or if we do it, it’s not always done super effectively. The biggest culprit is usually confidence — if we don’t feel like we’ve had enough training on an assessment, we’re less likely to do it.

Amy came on the show to help us develop some practical knowledge and tips for assessment so that we can walk away feeling more confident administering oral-motor and oral-mech exams. 💪

So grab your beverage of choice (I’ll have a chai latte!), put your feet up, and listen in.

Key Takeaways

– How Amy landed in private practice and speech sound disorders
– Why it’s important to do oral-facial exams
– Examples of cases from Amy’s practice
– A general overview of what we’re looking for in the oral mech exam → The components + process of the assessment
– What to do with the information you get from the evaluation
– Tips + strategies for administering the assessment
– How to make it feel like a game when you’re treating younger kids
– What the research has to say about tongue ties + their impact on speech
– Factors that determine difficulty with “R”
– Distinguishing between a proprioceptive issue vs a motor planning issue
– The difference in how these issues present during an oral-facial exam
– If you have a child with proprioceptive issues, and really that can often come across in those oral-facial exams

Links Mentioned in the Podcast

The Goldman-Fristoe
Cari Ebert— an apraxia expert
Edythe Strand + Free CEUs!
The Apraxia Kids Conference
Jennie Bjorem’s assessment
The Dynamic Evaluation of Motor Speech Skill (DEMSS) by Dr. Strand and Dr. McCauley
Amy’s Instagram account: @GrahamSpeechTherapy
The Oral-Facial Exam — A checklist-style evaluation from GrahamSpeechTherapy.com

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Transcript

Marisha: Hey there. Welcome to the SLP Now Podcast. It's Marisha, and today we have a very awesome guest, Amy Graham. She has been a speech language pathologist for 20 years, and she's the owner of Graham Speech Therapy, which is a private practice in Colorado Springs that specializes in speech sound disorders.

Marisha: She's listed on the Apraxia Kids Directory of SLPs with expertise in apraxia. And, she's also prompt trained and brings a wide range of expertise to the conversation that we're going to have today. And, she's also worked in a variety of settings. She's worked in public and charter schools, acute care, rehab, hospitals, audiology clinics, and now she's in her private practice. So, she's been in the trenches, she's seen all the things, and she has so many practical strategies and tips to share with us.

Marisha: And then, just before we dive in, if you don't follow Amy Graham on Instagram or any social media platform really, Facebook I guess would be the other one, you definitely should. She does an amazing job supporting and equipping SLPs with really practical strategies. I just love her video demonstrations on there. So, if you love this podcast episode and you want to learn more from her, that's definitely one place I would highly recommend, and I'm sure we'll talk about others throughout the podcast.

Marisha: So, without further ado, let's bring on Amy Graham.

Amy: Hi, Marisha. Thanks for having me today.

Marisha: Yeah, I am so excited to have this conversation with you because we have a lot of students on our caseloads. Like, we often work on articulation, and the oral-motor exam is something that we might not always do, if we're being real. It's something that I didn't always do a great job with. And, then I think it'll be really exciting just to dive into all of the pieces that we can look at in an oral-facial exam, and then also how we can use that to kind of work through our therapy. And, I've been getting several questions about it, and you are the perfect person to break that down.

Amy: Oh, good! Well, I'm happy to. I know, I've heard from quite a few SLPs myself just even through social media or who have reached out to me just saying that they're not confident giving and oral mech because they don't really feel like they had enough training on it, and so you're right. I think it's something that tends to be left out of our evaluations.

Marisha: Yes. And, then before we dive into all of those amazing tips and tricks, can you tell us a little bit more just about how you came to the field of speech language pathology and how you came to specialize in speech sound disorders?

Amy: Sure. Well, many, many years ago when I was a child, my sister actually had to have speech therapy. And, now looking back, I know exactly what she was working on. She had multiple phonological processes going on, so she had a phonological delay. And, she also had some residual articulation errors going on back then too. But, I was probably, gosh, 9 or 10, I guess. She was a little younger than I was. And, I had to go to all her speech sessions because we were homeschooled, and so I got to do all my homework in the waiting room while she was back with the speech therapist, the SLP. And, so I just remember as a kid, thinking, "Wow. This is kind of a cool office." They had a big fish tank. It looked pretty. It was a nice place to go, and so it was... That kind of planted the seed for what would later become my chosen profession.

Marisha: Yeah, I love that story. And, it's funny to hear how we all kind of end up in this space. And, you ended up working in a lot of different settings. How did you land on private practice and speech sound disorders given all the things it could've been?

Amy: Right, yeah. Yeah, I know, I changed my major a couple of times in college like we are all prone to do. And, then I eventually landed on comm disorders, communicative disorders, and then basically halfway through my... the undergrad found out you had to have a master's degree. And, man, that was a shock. I didn't realize that, but I'd already put some time in, so I just went with it.

Amy: And, I really think when I was taking those undergrad and graduate courses, the classes that just always jumped out at me were the motor speech classes, the child speech disorders classes. They've just always appealed to me. And, honestly, when I was a child, that's all I thought speech therapists did. I think that's all most people think speech pathologists do is just work on Rs and Ss. And, honestly, that's all I thought we did too. Which, surprisingly that is what appealed to me initially. So, that's after even going through all our training and all of our different... all of the places that I worked, I ended up landing on it.

Amy: I think I had so much experience in the schools as well because I did my CFY in the schools, and just working on all the different language, autism. I worked in special day classes. But, I just always came back to those speech sound disorders. I think, for one thing for me, when you do an assessment, I think it's so straightforward. I think you can hear immediately like, "Oof, yep. There's gliding going on there. Yep, there's a lateral lisp." And, for me, the assessment is super straightforward, so that appealed to me as well.

Amy: And, then I just have always loved that kind of mechanical nature of [inaudible 00:06:03]. If you know... If your tongue is hitting your alveolar ridge in the right spot, you know exactly what sound it's going to make if you've got the right breath support. And, so I just feel like it just came naturally to me. It just was curing underlying etiologies as well. Like, if you hear the hyponasality, the hypernasality, "Like, okay, there's something going on with the velopharyngeal mechanism." And, it just... just appealed to me, I suppose.

Marisha: Yeah, that makes so much sense, and it's funny because I feel like I was drawn to the field for a similar reason. And, it as kind of different. I was studying abroad, and I got to work with a speech language pathologist on accent reduction. But, at the time I was feeling, because I was a psych major and I was into all of the research and all of that, and it was just so... just so... It felt like such fluffy, big concepts. Whereas, she could tell me exactly where to put the articulator, and that systemic kind of nature to things was really interesting. And, I think as Type A... a generally Type A profession, I think that appeals to us.

Amy: Oh, I completely agree. I think just as I was working on kids and they have these language goals and vocabulary, I thought, "Okay, great. We're working on all these vocabulary words, but..." How do you truly measure somebody's vocabulary when they're 11 or 14? And, it's just... I just feel like you have to take a small, little sample, which with assessment and speech-sound disorders, it's like, "Yep, they're 90% on phrase level, and we're good, and let's keep going."

Amy: And, then also too, I think the treatment approaches. If you know what type of speech-sound disorder you're dealing with and you know evidence based practice, you're going to pick the most appropriate treatment approach and you just go with it. And, I feel like... Like, if you've got a phonological kid, I'm going to look at maybe cycles approach, minimal pairs, maximal oppositions.

Amy: If I have a child with obvious motor-speech issues that has childhood apraxia, I'm going to use principles of motor learning, and dynamic temporal and tactile cueing. And, I just feel like it's so much more clear-cut because there seems to be a decent amount of research at least right now. There can always be more. But, as far as what is the most... has the most evidence behind it as far as treatment too. So, that's also what I love about speech-sound disorders.

Marisha: Yeah. And, it's really amazing because I know a lot of us aren't feeling as confident about the oral-motor exams, but I feel like you have ... you're going to give us a way to make that more clear-cut and easy too.

Amy: I hope so! That's the whole plan.

Marisha: So, before we dive into all of those logistics around that, why is it important to do an oral mech Exam in the first place?

Amy: And, that is a great question. I think because we have to understand... In order to choose an appropriate intervention, you have to understand the nature of the disorder to begin with. And, I think part of doing that is either identifying or ruling out those structural and/or functional contributors.

Amy: So, like for example, I hear... I'll have SLPs contact me 'cause I have a decent following on Instagram, and so I get direct messages all the time, and I'll get questions like, "Gosh, I've got this kid who, he's just... he doesn't seem to have a speech problem, you know, when I give him an artic test, but man his intelligibility is just terrible in connected speech."

Amy: So, oftentimes, I'll ask them, "Well, what did the oral mech exam or the oral-facial exam show you?" And, so many times they're like, "You know, I'm not sure it was a really thorough one, so maybe I should do it again." And, so I'll ask questions like, "Well, was there any overall weakness of the articulators? That could maybe... You might want to think about dysarthria." And, so I think it can reveal a lot about the underlying issue.

Amy: Like, for example, maybe the oral mech exam is... Everything's within normal limits, and there are not issues, and the child has an obvious phonological issue, inaudible going to work on strength, strengthening or over articulation, basically, of those articulators. You're going to work on more of a linguistic approach.

Amy: So, excuse me, in other words, I just think it helps us rule in or rule out those structural and functional issues that we may have to address, that we would miss otherwise, and an articulation test is not going to show that.

Marisha: Yeah. Can you give us a couple concrete examples of maybe like a couple kid... maybe one or two kids that you've worked with?

Amy: Sure.

Marisha: Where you did the articulation test, but the oral-motor... or, oral mech exam revealed something that really helped you kind of change course or helped you clarify where you wanted to go.

Amy: Absolutely. I can think of one just a few months ago actually. This was a child who came to me, already had an IEP, and they were working on language, which there were obviously expressive language issues going on. But, the parents were just thinking that there's something else, she's just... it's not just that she's having a hard time putting sentences together, she's just really tricky to understand.

Amy: And, so basically all that was done previously was the Goldman-Fristoe, and you know there are not many multi-syllabic words on the Goldman-Fristoe. And, so really nothing much showed up. There was maybe... I think there were issues with a "T-H," but at her age it was like, "Okay. We should work on that, but that's probably not what's contributing so much to her un-intelligibility."

Amy: And, so as I did the oral mech exam, come to find out, she had incredible difficulty with volitional movements, just with non-speech volitional movements. So, you know, to me that's always a clue of, "Ooh. Are there some motor planning issues?" And, so that's all included in the oral mech exam, and so that's... Basically, that's not going to give me any diagnostic information, but it certainly is going to raise some red flags if children have issues with volitional non-speech and speech movements as well. And, so then my little question mark goes off in my head about, "Okay. Well, I'm going to consider childhood apraxia if speech is a contributor."

Amy: And, so then we did... went on to do the diadochokinetic rates, and boy were they jumbled up and just she had so much difficulty with the [putika putika putika 00:12:55] and the discoordination of those movements were kind of all over the place. And, she even told me, she's like, "Man, that's really hard to do!" And, then what that did is made me think, "Okay. We're not going to just look at a regular old articulation or phonology test. I need to do a motor-speech assessment with this child because that's what I suspect might be the underlying issue or at least a contributing factor."

Amy: And, we did that and there were obvious, obvious motor-speech issues. The longer and more complex utterances I gave her to produce, she had much, much more difficult time producing them. And, so things like that where you give the kid a straight artic test, "Oh, they're fine. You know, they're maybe borderline. We'll just work on "T-H." But, if you dig a little bit deeper, you might something else that is really contributing to their intelligibility.

Marisha: Yeah, that was such a great example. And, I feel like I've heard you talk about this before, but there's also structural components that might not be-

Amy: Absolutely.

Marisha: ... totally obvious. Can you give one example of something like that that came up in your practice?

Amy: Yes, absolutely. So, sometimes we'll get kids who sound a little hypernasal, and so that's really one of the parts of the oral mech exam too that we have to look at is you've got to look inside the kid's mouth, and not just how they're moving their tongue. We need to be looking at their palate and their velum, and seeing if there's any structural issues happening because oftentimes also I've gotten DMs from other SLPs and they're thinking, "Man, we've done therapy with this child. They're hypernasal and they just..." Or, sometimes I'll even hear, "You know, they have a substitution of they keep saying "M" for "B" or "N" for "D." And, of course that in my mind, my red flag is, "Well, that's hypernasality." So, how is that velopharyngeal mechanism working? Or, is there anything structural?

Amy: And, you would be surprised how many times I have found a bifid uvula, which can be an indicator of a submucosal cleft, which can really impact velopharyngeal insufficiency. Or, any kind of velopharyngeal dysfunction could be there. So, that's a child that really needs to be referred to a specialist and not just an ENT, but a team of specialists so that you have a craniofacial team or a cleft palate team. Here, in Colorado Springs, we have a VPI team that I refer to when I see that.

Amy: So, sometimes those things, they don't come up. You just might think, "Well, that's just an articulation substitution. It's no big deal." But, if a stop is changing to a nasal, that should be a little red flag that you need to consider that nasality might be an issue, and it could be structural, and we're not the ones that can rule that out. We need to send those kids to a team for that.

Marisha: Yeah, so helpful. And, I hope that we're all convinced that this is... that these are important things to look into when we're evaluating a student with speech sound disorders. And, so I'm curious, can you give us... 'Cause you touched on a lot of these things already, but can you give us a general overview of what you're looking for in the oral mech exam? Kind of like which components you go through. Like, do you have a process that like you always go through it in the same way or-

Amy: I do [crosstalk 00:16:23]. That's pretty much the reason I developed this particular checklist style format is because... And, what's the saying, "necessity is the mother of invention." Because I was looking for an easy-to-use, kind of a quick and simple, checklist style form that I could just take with me wherever I'm doing an assessment to go through. And, so I had to really think through, "Okay. Well, what all am I going to be looking for?"

Amy: And, really, it's everything that I was taught in grad school, and have learned through taking other Continued Ed courses just through the years about what we really need to be observing. So, for example, the first thing I go through is I'm just going to observe the child's face at rest. I'm looking for symmetry. Is there any drooping? Because sometimes, you might be surprised that some of the kids that we get might have some underlying neurological issues happening that parents aren't even aware of. And, we might be the first people to notice these things. Pediatricians miss this kind of stuff all the time. So, sometimes because we're looking so in-depth at their oral-facial structures, we might see things that nobody else will.

Amy: And, so I'm always looking, just observing symmetry, their tone of their face at rest. I'm looking if the child is mouth breathing. If you have a child that's come into... If I have one that's coming to me and they've got a pretty significant frontal lisp, there's a lot of distortions, and they're mouth breathing, and their mouth is open all time, that might be a child that we need to look at also how their feeding is, how their swallow function is because that could be a big issue as well.

Amy: I'm looking for how their jaw is moving. Do they have a good range of motion? Sometimes, I have kids who either their jaws are not opening sufficiently for speech. That's something we have to teach, about how to make those vowels better with good jaw grading. Is their jaw moving symmetrically when they're speaking?

Amy: I look at dentition. Sometimes, if children have crossbites, underbites, overbites, sometimes that can impact speech. However, I will say, as I go through this list, just because you notice something doesn't mean that, "Okay. Well, we can't work on anything until they get their braces on," or... Because I am always surprised at how kids can compensate for structural differences with their oral structures. But, it is always something good to note because if a child doesn't have good progress in therapy, you might want to go back and think, "Well, okay, well it could be because of these structural differences."

Amy: I'm looking at the pharynx. I'm looking to see how big their tonsils are, if they have tonsils, which is also why we need to do a case history because maybe they had their tonsils removed and that's why you don't see tonsils. And, if they had their tonsils removed and there is nasality in the child's speech, then that might be something you need to make a referral for as well. I've had that happen several times.

Amy: I'm going to look at the hard and their soft palate. There could be fistulas that have never been noticed. There could be submucosal clefts. So, I'm looking for all of these... I'm even looking at their soft palate to see what kind of movement I'm seeing with that soft palate when they're phonating. Is there lateral movement? Is it moving towards the center? Or, does it look it's moving up a little bit? We need to... And, sometimes if there are soft neurological signs, you might see some asymmetries in even the velar movements.

Amy: I look at their lips, how... Are they able to pucker their lips? This is another way to kind of check for oral, non-speech oral apraxia. Do they have a hard time doing what you're asking them to do? Like, can you pretend to blow bubbles for me? Can you pucker your lips like you're going to give mom a kiss? Do they have any issues with that? And, then do they have any strength issues? I use a tongue depressor, a lot of times, to have them push against my tongue depressor with their lips just to kind of gage how strong their muscles are. Not that you need a lot of strength for speech because we all know non-speech oral-motor exercises are not effective for improving speech if it is... if weakness is an issue.

Amy: But, it's just something that is good to note because if you ever have to refer inaudible to another specialist, it's something to have in your notes that we should all know about. So, there lots of things with the lips. I'm looking for rapid movements, for are they able to puff their cheeks out and hold their lips closed? Can they maintain that air in their oral cavity, or does it escape through the nasal cavity? Do you hear any air escaping, and is that maybe the velopharyngeal mechanism and are there issues there?

Amy: I'm looking at their tongue... Excuse me. I'm looking for range of motion. I'm looking for weakness. And, there are... We have ways, and I list them all out in my oral-facial exam on how to do that. But, I'm looking also for... As far as range of movement goes, I know it's kind of controversial right now in our profession about tongue-ties or shortened lingual frenums. But, I mean, if it's really restricted and that poor kid can't lift the tip of their tongue very far at all, then even though, okay, maybe you could get them to say a certain speech sound, it's going to be so effortful that in connected speech maybe that's going to be an issue. So, it's just something to note.

Amy: And, then I'm always looking at rapid side-to-side movements as well with the lingual movements. And, then at the very end after we kind of go through all of those oral-facial structures and their functions, I have the diadochokinetic syllable rates at the very end of the assessment sheet.

Amy: And, then 'cause I know I've heard from a lot of SLPs that, "Okay, great. I know how to assess strength, I know how to assess all this stuff, but what do I do with this information?" And, so I have a little section at the end too to kind of walk you through, "Okay. Well, if you're seeing these four things, then you might want to consider a referral here." Or, "If you see these three things, you might want to consider looking at feeding issues or tongue thrust assessment." Or, "You might want to consider a motor-speech assessment based on these findings."

Amy: So, I try to help walk through any SLP with whatever experience and SLP has. If you've taken your anatomy and physiology classes, you might have to go and review a little bit... and even neurology. But, I tried to make it as easy to use as possible.

Marisha: Yeah, and I personally love the checklist format, and it's been so helpful in just feeling confident. I know I looked at all of these different components, and then that gives me enough to go off of. Especially with those jumping-off points, that's such a helpful resource.

Amy: Right.

Marisha: And, then... 'Cause I think especially for a newer clinician, they might be like, "What is normal strength? What is it supposed to look like?" What would you suggest for someone who's still trying to figure that out?

Amy: Well, probably the best tip I can give is go assess about five or six typical developing kids that don't have a speech sound disorder. Because in order for us to be comfortable saying, "Yeah, that doesn't look right. That's kind of outside of the realm of typical development," we need to know what typical looks like. So, that would be my best advice is find a cousin, a niece, a daughter, a son, a nephew, a child of a friend where... that would... that you can just go and say, "Hey. I just have this little quick assessment. It won't take long. It's about 10, maybe 15 minutes at the very most. It'll be fun. Can I assess your child really quickly?" And, just have a good idea of what typical looks like, and the only way to do that is to assess typical kids.

Marisha: Yes, I love that, and I think it's a good way... Because it'll probably be easier to run through the assessment with a friend's kid versus a kid-

Amy: Right.

Marisha: ... in the therapy room.

Amy: [Inaudible 00:24:55].

Marisha: So, it could be a good way to get that flow down and kind of get the process.

Marisha: So, speaking of actually administering the assessment, what are your tips for make... like getting through... 'Cause there's a lot of different things that we're asking students to do. We work with a wide range of students who might have difficulty in several aspects of like following the directions and attending. Like, what are your go-to tips and strategies in terms of actually administering that?

Amy: Right. Yeah, the oral mech exam can be tricky, especially if a child maybe has bad experiences with medical professionals, and you're coming at them with a tongue depressor and a flashlight and he's like, "Whoa! I know what this is all about. I'm going to get a shot in a minute," or it just kind of... It can freak him out a little bit. So, I think we have to be really careful to understand a child's medical history so that we can be prepared for that.

Amy: So, what I recommend, one of my absolute best tips is I have a throat scope and I got it several years ago, I think, when it kind of first came out. And, it just changed the dynamic of doing an oral-facial exam because the minute you show that child that, "Oh, no, no, no. We're not going to stick this icky wooden thing in your mouth. Look at this, this is my light saber and that's..." I've talked to so many SLPs, and that's what they call it too because it is. It looks like a little light saber. It's a light-up flashlight, basically, that sticks on a plastic tongue depressor that basically lights up the whole tongue depressor.

Amy: So, when you stick it in the child's mouth, it just lights up the oral cavity. And, for one thing, it's better for us because I can see so much better. I don't have to have a tongue depressor in one hand and a flashlight in the other. It's now I'm only using one hand to hold, and then I can kind of help maybe hold the child's hand or kind of show them what I'm doing with my other hand. And, so it kind of frees me up to either write with one and do the assessment with the other. But, the kids love it.

Amy: I mean, sometimes I'll even have them practice with a little hand puppet themselves and say, "Here, why don't you do it first?" Especially if they're a little timid about initiating the oral mech exam. And, so I'll have them do it. That's another tip is have a little hand puppet on hand where they can practice doing it, and you give them the instructions like, "Okay. Tell them to open their mouth wide. Okay, now it's your turn."

Amy: And, so you can kind of have a little turn taking game that you're... You can kind of make it into a game, "Okay, now it's your turn. Oh, we're going to do something really silly now! I want you to move your tongue back and forth like this." And, so I think trying to make it as fun as possible. And, I even tell my kids, "I'm going to ask you to do some weird stuff right now. Are you ready? It's going to be so silly." And, so just to kind of make it a game.

Amy: Sometimes, though, if that's just not working, I will often just save it for the last thing that I do in my assessments. I will... We'll do the easy stuff like, "You're just going to name all these pictures I show you." And, then once we're kind of comfortable, we've maybe... I've gotten a good language sample because we're talking a little bit back and forth and they're comfortable with me now, then that's when I'll bring out my throat scope or my tongue depressor and say, "Hey, let's try something crazy now. Let's do something a little silly." And, then they're a little more comfortable sometimes if I hold it off to the very last thing.

Amy: But, then sometimes I think you have to be okay with doing it across multiple sessions. I've even told parents that that, "You know what? He is just not wanting to open his mouth for me today. So, I'll tell you what. Let's hold off on writing this report. Or, I'll write my report and say we're going to get this information later once more rapport is built between the client and myself."

Amy: And, so sometimes I will just either put it off down the road or I'll just say, "You know, we were only able to maybe get this first part of it where I just kind of observed their facial structures, but they weren't willing to stick their tongue out for me or have me kind of tip-toe that tongue depressor along their tongue. So, we're just... We're going to get the rest of it at a next session." So, I think sometimes we have to be okay with that. And, I think if we explain that to parents, they completely understand.

Marisha: Yeah, those are great tips. I also love the throat scope, like what an amazing invention that was.

Amy: Crosstalk fabulous.

Marisha: 'Cause it help us and it's super cool.

Amy: Oh, yeah.

Marisha: And, then yeah, I love the idea of using the puppet and making it a game, being silly around it, and just... I mean, we model it first just naturally when we're going through, but I think that it's nice because it is such a visual activity.

Amy: Mm-hmm (affirmative).

Marisha: Like, that we have built-in supports there even for a variety of students, so that's-

Amy: And, I even think explaining to the child what we're doing too. Because I think sometimes, we get so used to doing these assessments, we're just, "Okay, now do this, now do this." And, they're kind of thinking, "Well, what? Why?" But, so I will explain to them inaudible like, "Ugh, you know what? I need to look at your tongue because sometimes your tongue might move a different way than mine, so that's what I'm... I'm just looking to see how it's moving, that's all." And, so I think if we kind of give them a good explanation sometimes, especially if they're a little older, they're much more apt to go along and be cooperative during the assessment.

Amy: I thought of one more thing though. I had... I was speaking with Cari Ebert, a new friend of mine who's a fabulous apraxia expert, about how she can kind of get her really little ones 'cause she works with early intervention. And, so she will have the kids lay backwards on an exercise ball and have mom or dad there. And, as they roll them back, she says, "They always open their mouth really wide." So, you can get a good look inside their mouth when you do that, as you kind of roll them back just in a playful way on the exercise ball. So, that's another great tip that she gave me that I had to pass on.

Marisha: Ooh, that is genius! Crosstalk I love that one.

Amy: [Inaudible 00:31:05].

Marisha: That's like a little hack there. Oh, good. Okay, and so that's super helpful. I feel like we know why we want to administer these exams in the first place. We have a really good idea of what we're looking for and what we might do if we see certain components. And, then we also have a nice tool belt of different tricks that we can use if the student doesn't want to open his or her mouth or if we're just having some challenges there.

Marisha: So, then let's talk a little bit more about what we do once the exam is done and we have that data. Because I know sometimes, there can be some more controversial findings and it's not always super clear what the correct path is. So, can we talk... Like, one of the ones that came up, I think, is tongue-tie.

Amy: Right.

Marisha: So, what would you do if you find tongue-tie?

Amy: Well, I think we have to understand to what degree that tongue-tie might be impacting speech, and sometimes we don't really know. I think there's a tendency to go... to throw the baby out with the bathwater, so to speak, when there are SLPs out there and researchers who just automatically, "No, tongue-tie has nothing to do with speech. Don't worry about it. Maybe feeding, but not speech. The research doesn't show that it has an impact at all."

Amy: However, when you... When I read the research, and I'm sure I need to speak with an expert who has really read the research more than I have, but it's not that the... What I have found, anyway, is not that the... A tongue-tie, in general, doesn't impact speech. It's that when the tongue-tie is clipped or released, whatever you call it, that they haven't found that it has made an impact in speech improvement.

Amy: But, to me, there are so many variables of "haven't been looked at." I mean, have you looked to see if... What kind of therapy did they have beforehand or post? And, I feel like I, at least in my looking into that, the literature, I haven't... It hasn't answered that question for me. So, however though, there are other SLPs out there too who'd be like, "Oh, it's a t-... They have a tongue-tie? That's their problem. Let's clip it. That's it." I'm not there either because I don't think the research shows that, obviously.

Amy: So, what I do is I note the... to what degree that tongue is restricted. I think we should know it. I don't think we need to completely disregard it because I've seen kids who, oh my gosh, their tongue is so restricted that they can't even lick an icecream cone. They can't stick it past... stick their tongue out past their lips. And, if you don't think that's going to impact speech, then I wonder how many kids you've worked with with speech sound disorders because I've had kids who just... I mean, honest to goodness, they back everything because their tongue tip will not raise to that alveolar ridge in quick, connected speech. Now, you might be able to get them to do it at the single word level. But, as far as generalization goes, those kids are going to have probably a much harder time doing those movements quickly, and rapidly, and coordinated in connected speech.

Amy: So, for me, it's something I always note. However, I've had some kids that I've seen are not that... They are restricted, but not to the degree to maybe where they're... They can maybe stick their tongue out a little bit if they open their mouth wide and their tongue can reach... Or, it can at least get pretty close or halfway up to the palate. But, they don't have any issues with S's, or T's, or D's, or those alveolar sounds. Then, that's something I note for later.

Amy: However, I will say, I've had a few kids who I've noticed a, I would say, mild to moderate lingual restrictions. We've done therapy, and the issues have been an "R", actually, for the two that I'm thinking of. And, boy, we just couldn't get this "R" sound. I tried every tool in my tool box. We did it for a few months. Three or four months, I think, we did therapy for. But, I had back in my oral-facial exam that you know what? This restriction was noted. This lingual restriction was noted.

Amy: And, so I've gone back to the parent and I've said, "Okay, look. The research doesn't say "yes, if we get this tongue-tie taken care of, that her speech is going to improve and it's going to work." However, we've tried therapy for this long. I feel like she just is not able to elevate the back part of her tongue high enough to get it in the right spot to make that really good "R" sound. Because if you think of "R," I mean, you have to elevate the back of your tongue, you have to tense it. There's all these things you have to do. And, so in my opinion, I think you should consider it."

Amy: I never tell a parent, "You have to have this done." Because it's a medical procedure. I'm not a doctor. I'm not a pediatric dentist, which is who I refer out to for those kinds of referrals, those issues. And, so I'm not the one who's going to say, "Yes, this has to be done." But, I will share with a parent what I know. And, what I know is that we've done therapy, it's not work, there's a restriction. Research doesn't necessarily say it'll help, but you might want to consider it because I'm all out of my bag of tricks here." And, I've had two that I can think of that have had their tongue-tie clipped or whatever, their tongue-tie revised, whatever you want to call it, and we've made progress.

Amy: So, not that that's worth publishing, but I will say that I've had a couple times where that was the key to what helped them finally produce a particular sound accurately, consistently, and then they were able to actually generalize it much, much quicker. So, I guess I'm kind of, I don't know, agnostic as far as tongue-ties go because I think it's not something like I said before, we shouldn't be throwing the baby out with the bathwater just because the research doesn't show yet that it could be impacting speech. Or, maybe that research just hasn't looked at some specifics that we can see in clinical practice and maybe not in the research yet.

Marisha: Yeah, that's such a helpful case study, and it's really cool that you got to see that in action.

Amy: Yeah.

Marisha: That's so interesting.

Amy: Yeah.

Marisha: Have you seen any other factors? 'Cause that just peaked my interest. Have you seen anything else? 'Cause "R," I feel like, is one of the sounds that we... a lot of us struggle with.

Amy: Mm-hmm (affirmative).

Marisha: Have you seen any other factors that determine difficulty with "R" and kind of-

Amy: Yeah, absolutely. I think one thing that has, I think a lot of our kids with R's have trouble with proprioception, honestly. Because if you think about, when you tell them to make a "T" or a "D," what are you going to tell them? You put your tongue tip up, and you put it right here behind your teeth, and you just pop your tongue, "T-t-t-t," just like that. It's easy. It's visual. You can see exactly what to do.

Amy: Okay. Well, how do you explain what to do with your tongue for an "R?" Well, you kind of bunch it up in the back. Maybe you're going to tell them to curl their tongue if you're doing bunched or retroflexed versus bunched. And, so there's all these very kind of nebulous descriptors that we're trying to explain to this child to do. And, it's not like for bilabials, we can touch their lips and you can give them that tactile feedback. Well, that's a little harder with an "R" sound.

Amy: And, so I've found when I've given this oral-facial exam to kids who have those residual "R" errors, they are having a hard time telling where their tongue is in space. So, I feel like... I wonder if sometimes these kids with "R" problems who just can't ever quite get it, it almost always sounds even a little bit vowelized, they're just having trouble telling where their tongue is.

Amy: And, so if you have a child with proprioceptive issues, and really that can often come across in that oral-facial exam. You know, you tell them, "Okay. Don't look in this mirror. Just look at me. Copy what I do." And, you could see that they are not doing what you're doing. That might be a proprioceptive issue. It might be a motor planning issue. But, it also might be proprioception. And, so for me when I have... when I see a child with that deficit, I use a lot of tactile feedback.

Amy: And, so sometimes I will back up with those kids, and we will just get our little... my little swizzle sticks, and we will kind of touch the sides of the tongue and the tongue blade so that they can feel... As they're looking in a mirror, they can feel where their tongue is in space, and we practice moving your tongue in the context of speech a lot of times, but sometimes we just need to figure out where their t-... They need to figure out where their tongue is when they're moving it in a particular way. So, I think, yeah, that's another issue that that wouldn't... The only place that would come across is is really in an oral-facial exam, in an oral mech exam.

Marisha: That is so interesting. And, if you identify like the proprioception as a potential challenge, how... Like, I love the ideas and examples that you gave of what you could do in therapy. But, how would that fit into the general context? Would you... And, I know it varies for each student, but do you have kind of a general... Like, if you notice that, is there something that you generally do in terms of, "We just do it like a couple minutes at the beginning?" Or, do you spend a lot of time?

Amy: You know, like you said, it does... It's totally dependent on the child. Sometimes, they can get it pretty quickly if you give them a mirror and they get the visual feedback. Sometimes like, "Oh, okay. I see that my tongue is not going where I thought it was going." So, giving them a mirror helps almost initially. I've had some that we are working for weeks and weeks on trying to use tactile feedback along with visual feedback.

Amy: So, we've got a mirror and maybe a tongue depressor just to kind of say, "Okay. Do you see how we're curling our tongue? You're not curling your tongue, so let me help you with this tongue depressor," or this little Toothette or whatever you use for that tactile feedback with your kids. And, sometimes it takes a while with some kids. It just depends on the degree to which they have a deficit in that area.

Amy: And, sometimes you'll have a child who it's motor planning, plus proprioceptive, plus a few other things. So, I think if you have other... if there are other contributing factors going on, you might expect therapy just to take even a little bit longer.

Marisha: Yeah, that's so helpful. And, I think this is a good reminder too that we're not just looking in the mirror moving our tongue, we're looking in the mirror and doing all those different activities in the context of shaping those different speech sounds. So, it's always working towards that main goal. But, are there times when you would stray a little bit more away from that?

Amy: Stray from-

Marisha: Just like always having... 'Cause I guess we would break it down, and take a step back as we're shaping a new sound, and just practice some of those movement components.

Amy: Well, I try always, as quickly as possible, to put it into the... into speech. So, I mean, sometimes if we're inaudible what I might do is not even work on "R" for a little bit, but we'll work on another similar phoning like "L." And, we'll give a lot of tactile and visual feedback pairing "L" with vowels because they're very similar to the "R" sound. So, if we can put it in the context of speech, I think that... I mean, that's always the goal, right? We don't want to sit there and just, "Okay, we're just going to tap on your tongue. You feel that? Yep, that's right." Well, we've got to put that into the context of speech as soon as possible. And, for me, often it's on our first session.

Amy: And, so we might... Like you said, we might begin a session with, "Okay. Let's do a little feedback here. Touch this on your tongue." And, I know there are programs that actually focus a lot on that. I'm not a big program person. If it has a fancy name to it, granted I have some certifications and some trainings, I'm all for gaining knowledge in whatever area might help you working with your children, but I'm not a program person because I don't think there's one program that's going to... that's a one-size-fits-all.

Amy: But, I think we can definitely glean some helpful information or some therapeutic techniques from those, quote unquote, programs. But, we also have to balance that with what we do know about evidence based practice, and that is speech improves when you practice speech. And, so my goal is to always, even though I'm backing up and might be doing a few non-speech tasks to kind of build proprioception and sensory awareness, that kind of thing, my goal is to put that within the context of speech ASAP.

Marisha: Yes. Yeah, and I feel like I talk about that all of the time with... 'Cause I'm all about literacy based therapy, and it's always about putting it in context, putting it in context. And, I heard a really cool metaphor analogy from Dr. Ukrainetz who was talking about... Like, she compared... And, she was talking about language, but I think it applies really nicely to this too.

Marisha: So, we can teach... If we're a basketball coach and we're teaching students how to play basketball, we could have them just drop the ball on the floor 'cause that's a component of dribbling and that's a component of playing the game. But, if we... If that's all that we work on, if it's game time on Saturday and all they know is how to drop the ball, they're not going to be able to participate and be successful during that game. So, I think... I just really like that comparison.

Amy: That's a great [crosstalk 00:45:27]. I love that.

Marisha: So, awesome, and that was a super helpful breakdown of that.

Marisha: And, so I'm also curious in terms of... I feel like a lot of us are overwhelmed when it comes to motor-speech disorders, and if we... Can you just highlight again what we might see if a student does have difficulty with motor-speech, motor planning? Like, what would we see in the exam? And, what are some things that you would do based on that?

Amy: Right. So, initially if I see... Now, granted, this is not a speech, necessarily a speech test because you're looking at non-speech movements. But, if you see some groping with volitional movements during this oral-motor task... If you're asking them to stick out their tongue and move it side-to-side and you've already done a bunch of oral mech exams with typical developing kids, you're going to know what groping looks like.

Amy: And, typically, three-year-olds, four-year-olds, if we can stick our tongue out and move it side to side rapidly, there's no... Inaudible rhythmic movements, they're able to do pretty rhythmically. And, so if you see a child who has difficulty with that and they're groping, and they're kind of moving their whole head or they're moving their jaw along with it because they're having the hardest time getting their tongue to move quickly, rapidly, and you're just noticing a lot of difficulty with that, that's a red flag for apraxia.

Amy: And, then if they're only able to complete it upon imitation... It's better with imitation. Okay, well that's... That means that they need that extra support in order to do that movement. And, then also with the diadochokinetic syllable rates. If you're noticing all these issues like poor rhythmicity, coordinating, groping during those oral mech exam tasks and they're maybe more than 1.5 standard deviations outside the mean for those diadochokinetic rates, then to me those are really big red flags that I need to do a motor-speech assessment.

Marisha: And, I know we're not going into the full motor-speech assessment here, but what are some things that you would look at when you're doing that?

Amy: When I'm doing the motor-speech assessment?

Marisha: Yes.

Amy: So, you're going to look at... And, there are some really great guidelines. I know Edythe Strand, and I believe [inaudible 00:48:03], I don't have it right in front of me, have developed the DEMSS. And, gosh, don't ask me to say what it... Dynamic, Motor, Speech. I can't even tell you what it is, but that has come out recently and it has some... I just recently was at a talk, at the Apraxia Kids Conference, about how to conduct that assessment. And, basically, you're kind of walking the child through increasingly more difficult speech syllables, words, phrases, and you're assessing how accurate they are with different levels of prompting, the consistency of those productions.

Amy: And, there's a whole way to assess that basically, and there are some other... Even Jennie Bjorem has a really great assessment, an informal assessment, to help you kind of walk through what to look for for a motor-speech assessment. But, you're looking for accuracy, consistency specifically upon multiple repetitions of words that these child... that the children are given to repeat and how well they do as those words get increasingly more difficult.

Amy: Vowel production too, vowel distortions are another key component of apraxia, and as well as coordinating movements between sounds because these kids have difficulty with the motor aspect of speech and from going maybe from one syllable to the next. So, there might be some pauses, unusual pauses, poor rhythmic... What's the word I'm trying to come up with? I can't think of it off the top of my head. But, so there's many different aspects of speech that you're going to look at and too much for me to probably go into too much right here, but that's kind of a general idea.

Marisha: Yeah, that's super helpful, and I think it's... Maybe that'll have to be a whole other episode.

Amy: There you go.

Marisha: But, yeah, I love the... I got to learn about the DEMSS, and I just looked it up. It's the Dynamic Evaluation of Motor Speech Skill.

Amy: There it is.

Marisha: And, it's by Dr. Strand and Dr. McCauley?

Amy: Yes.

Marisha: I believe is how you say it.

Amy: Yep.

Marisha: But, I got to... Actually, a couple years ago I went to an intensive with Dr. Strand, and it was so incredibly helpful, and it's just I love... Like, this is all so systematic. They have like a nice framework around it, and it's a lot like the inaudible oral... oral exam that we've been talking about today. So, there are some really nice things that we could explore-

Amy: [Inaudible 00:50:47].

Marisha: ... and talk about more maybe in a future episode. But, that was a really helpful breakdown just to get us started and to know where to look for some resources. So, it was the DEMSS and Jennie Bjorem's resources-

Amy: Yes.

Marisha: ... to get started there.

Amy: Absolutely.

Marisha: Awesome. Well, I fee like I've walked away with a lot of good, practical tips and strategies and things to look for. I just love all of the practical suggestions and ideas that you shared. Is there anything else that you think is really important to share or something that you just wanted to end on?

Amy: I think that if you... Any SLP, if we don't do an oral mech exam, and I probably have said this before, with any child who has a suspected speech sound disorder, I think you're going to miss some things. So, I just think make sure... I'll reiterate. Make sure you always do one even if it's just, "Ah, this kid just has an "R" sound," or, "We just have a lisp, no big deal," always do an oral mech exam.

Amy: And, then if you're... Like I said, if you're unsure about how to interpret those findings and what to do with them or even just don't have confidence in your ability to understand what you're seeing, reach out to more experienced SLPs. I'm a sole practitioner, so I'm all by myself, so I have discovered that the social media outlet of finding other experts within the field has been so great with connecting me with other SLPs who have more experience and knowledge base than I do. So, I would say to anybody who's even new to giving oral mechs, reach out to an experienced SLP.

Marisha: Yeah, that is such a great strategy to use regardless of the area that we're working with.

Amy: [Inaudible 00:52:37].

Marisha: And, yeah, so valuable. And, where can... 'Cause I feel like everyone is going to want to learn even more from you, and check out your videos, and just learn all that you have to offer, so where can they find you if they want to find [crosstalk 00:52:54]?

Amy: So, yeah, my Instagram account is @grahamspeechtherapy, and Graham is G-R-A-H-A-M. And, I post... Like, I think you said earlier, I post real life therapy videos of me doing therapy with all my kids, whose parents have given me permission to do so. But, I record myself doing different therapy techniques. I have more information on how I administer my oral-facial exam on there in my highlights on my Instagram account.

Amy: I'm also on Facebook at Graham Speech Therapy. And, if you want to purchase the oral mech exam, the oral-facial exam is actually what I call it, that's on my website at www.grahamspeechtherapy.com.

Marisha: Awesome. And, we will share the link to the exam and all of the different resources that we mentioned throughout the podcast in the show notes, and that will be at slpnow.com/17. So, you can go there to find the link to, like I said, the exam, the DEMSS, the throat scope, all of the good things. Oh, and also Amy's social media platforms. So, let us know if you have any other questions about the oral-facial exams. But, I feel like... I think you did a pretty amazing job today, Amy.

Amy: Thank you.

Marisha: And, thank you so much for sharing your time and knowledge and expertise, and we'll talk to you soon.

Amy: Thanks. It was my pleasure.

 

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marisha-mets-about-mobile

Hi there! I'm Marisha. I am a school-based SLP who is all about working smarter, not harder. I created the SLP Now Membership and love sharing tips and tricks to help you save time so you can focus on what matters most--your students AND yourself.

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