AJ’s Journey: From Non-Verbal to Speech Production

I met AJ in April 2014, a mere 6 months ago. His story makes me realize why I do what I do, day in and day out. When I met AJ, he was 9 years old. He had a diagnosis of Autism. His family had relocated from India to Orange County a few months prior to our meeting. His mother later told me that they had made the move specifically because she wanted AJ to receive P.R.O.M.P.T therapy. His mother also revealed how AJ had been through no less than twelve speech therapists, several ABA therapists, and a few occupational therapists. They had also tried Neuro-Feedback therapy; several detox programs, and nutritional supplements, all in the hope that they would help with speech production. After all those setbacks and disappointments, it still amazes me that this family decided to move across the world to try another program. But I guess hope is a crazy thing.

During the initial evaluation, I realized that AJ was truly non-verbal. There were no vocalizations on demand. When asked to say “ah,” he would open his mouth, but there was no sound. He could imitate some lip movements with tactile prompts and cues, but again, without any vocalizations. He did spontaneously babble labial sounds like /baba/ and /mama/, but there was no intentional speech. I realized that at age 9, with little to no progress after years of speech therapy sessions, the odds were stacked against us. When I tried to explain this to his mother, she was quick to respond, “But it can’t hurt to try, right?” I knew then, I had to at least try. P.R.O.M.P.T therapy with tactile cues, in combination with Sara Johnson’s TalkTools® was definitely the way to go.

I saw AJ once a week for 45-minute sessions. His mother would sit through each session, carefully taking notes about the activities and target sounds and words. She would then practice all the activities each day during the week. This video is proof of AJ tremendous progress and his mother’s singular dedication. It was taken after merely 25 sessions of P.R.O.M.P.T. therapy. While there is clearly a long way to go, his incredible achievement so far, makes the future look bright and positive.

Oral Myofunctional Therapy to Eliminate Tongue Thrust

Oral Myofunctional Therapy to Eliminate Tongue Thrust using the SMILE Program by Robyn Merkel-Walsh and Sara R. Johnson (TalkTools)

According to ASHA, Oral Myofunctional Disorders (OMD) is when the tongue moves forward in an exaggerated way during speech and/or swallowing. The tongue may lie too far forward during rest or may protrude between the upper and lower teeth during speech and swallowing, and at rest. Although a “tongue thrust” swallow is normal in infancy, it usually decreases and disappears as a child grows. By age 3 years, a child will typically develop a mature swallow and the tongue thrust is usually resolved. However a tongue thrust may persist due factors such as thumb sucking, cranio-facial abnormalities, allergies, repeated ear infections and Down’s Syndrome. In terms of speech, the most obvious impact of a tongue thrust is during the production of /s/, /z/, /sh/, /ch/, and /j/. The sounds appear distorted and will often attract listener attention due to the atypical quality. In addition, the /t/, /d/, /n/ and /l/ may also appear impacted.

Robyn Merkel-Walsh’s SMILE (SysteMatic Intervention for Lingual Elevation) program is a fun therapy program for tongue thrust or Oral Myofunctional Disorder. I particularly like this program because it is based on Sara R. Johnson’s Oral Placement Therapy. The program utilizes the oral-motor prerequisites (horn hierarchy, straw hierarchy, bite block hierarchy) that forms an essential part of my treatment program for my children with speech production disorders. It combines oral-motor, swallowing and articulation therapy techniques to treat myofunctional disorders.

The program is designed for children 7 years and older. She uses child-friendly terms such as the “Smile Spot” (alveolar ridge), the “Smile Swallow,” (mature swallow), and sad swallow (reverse swallow). The program taps into the meta-cognitive abilities by building the child’s awareness of the “SMILE parts” (cheeks, tongue tip, palate, teeth, lips, etc.).

The lessons are hierarchical, systematic and the progress is measurable. The first lesson includes cheek exercises, while the second targets the lips. The second lesson includes exercises to work on lip seal, lip rounding, lip strength, tone and dissociation. At this point the program also includes articulation drills for lip sounds (/p/, /b/, /m/ and /w/). The third lesson works on building appropriate oral posture at rest. The program uses “cute” illustrations of Mr. SMILE to demonstrate the difference between good oral posture and poor oral posture at rest. The exercises in this lesson use a variety of tools such as a nose flute to establish volitional nasal airflow. This is followed by exercises to maintain lip and jaw closure. The final aspect to this lesson is appropriate tongue placement (at the SMILE Spot) at rest. Lesson four A.K.A. the “Lazy Tongue Buster” incorporates a group of exercises that targets tongue protrusion (as a precursor to tongue retraction), tongue retraction, tongue lateralization and tongue elevation. This lesson also includes the articulation drills for tongue sounds /t/, /d/, /l/, /n/, /k/, /g/. Lesson five targets the oral habits often associated with myofunctional disorders such as thumb sucking, biting fingernails, biting bottom lip, chewing on pencils, leaving the mouth open, and licking lips. The assumption here is that these habits will interfere with developing a new tongue position and a mature swallow. Lesson six is essentially a review of the previous lessons. Lesson seven through ten teaches the “New Swallow” – with liquids and solids. Lesson eleven focuses on making the new swallow a daily habit. This lesson also targets the appropriate placement of tongue for articulation of /s/, /l/, /sh/, and /ch/. Lesson twelve is also a review lesson of all previous lessons. Lesson thirteen and fourteen consist of maintenance exercises for the new swallow and tongue placement to ensure that it is generalized and essentially a part of the child’s daily behavior.

The systematic, simple and well laid out program make it easy and fun for the children and the families to follow. The homework practice charts make it easy to log the children’s performance at home and ensure progress. Overall, I think the SMILE program is complete, holistic approach to remediate oral myofunctional disorders or tongue thrusts.