audit

A lot of hot air?

In spite of academic controversy and a lack of evidence of effectiveness, non-speech oral motor and respiratory exercises are commonly included in therapy programmes. Deirdre Cosgrave, with the support of Jill Titterington, conducts a preliminary audit in a language unit to see if sucking and blowing games can improve phonology in children with moderate phonological / articulation difficulties.
L-R Deirdre and Jill ll pupils attending the language unit where Deirdre works have a specific language disorder. Some of them also have a phonological disorder with a motor component, which we refer to here as phonological / articulation difficulties. We decided to conduct a preliminary audit of current practice to see if there was a significant association between improvement in sucking and blowing ability and phonological skills in these children. The results give indications for the direction of future research and we draw tentative conclusions for practice. A. RATIONALE Many speech and language therapists have been trained in and use non-speech oral motor and respiratory exercises in their treatment of a wide range of speech sound difficulties in children (Lof & Watson, 2008). However, there has been a great deal of vocal academic discussion around the value of such exercises for the treatment of speech sound difficulties (see for example Bowen, 2005; Clark, 2003) and the consensus is that there is little - if any - good quality research to support their use. Furthermore, the theoretical underpinnings of such an approach for treating speech sound difficulties are far from sound (Clark, 2003). Indeed, the collective opinion of authors contributing to a recent clinical forum into oral motor exercises for the treatment of speech sound difficulties in children suggests that this treatment should be viewed as experimental and, as such, should only be carried out on children with the informed consent of their parents / carers (Powell, 2008a; Ruscello, 2008; Lof & Watson, 2008; Lass & Pannbacker, 2008; Powell, 2008b). Despite this, oral motor therapy (with an emphasis on sucking and blowing) has become a popular supplement to treatment for many speech and language therapists in their approach to children with speech sound difficulties. This is not an unusual state of affairs; Joffe & Pring (2008) looked at current practice in the treatment of children with speech sound problems throughout the UK and READ THIS IF YOU WANT TO KNOW WHAT IS WORKING BACK UP PRACTICE WITH EVIDENCE PROMOTE CLINICAL / ACADEMIC COLLABORATION

found that clinicians tended not to be influenced by the current evidence-base in their choice of therapeutic intervention. Indeed Lof & Watson (2008) found that, out of 537 speech and language pathologists surveyed across America, 85 per cent used non-speech oral motor exercises as part of their treatment regimen for children with speech sound difficulties. As Bowen (2005) emphasises, the glossy advertising, fun toys and passionate self-report of trainers in the area of oral motor therapy for speech sound disorder easily convince the speech and language therapist to at least try this approach out. Research into the treatment of mild to moderate speech sound delay shows that a range of therapeutic approaches do work (Gierut, 2001; 1998; Joffe & Serry, 2004). However, it seems that as speech sound delay becomes more severe and disordered things are not quite so straightforward. Recent research suggests that the heterogeneous nature of more severe speech sound problems means that some therapy approaches may be more effective than others depending on the underlying levels of breakdown (Stackhouse & Wells, 1997; Dodd & Bradford, 2000; Dodd et al., 2004). As a consequence of this, busy speech and language therapists often adopt an eclectic approach to the treatment of these more complex speech sound difficulties. The toolbox of therapeutic interventions is often a mixture of approaches that are both evidence-based (such as minimal pairs therapy) and non-evidence-based (for example, oral motor therapy) (Joffe & Pring, 2008). Our audit therefore looks at current practice in a language unit for children with specific language disorder. We investigated the association or otherwise between suck / swallow / breathe ability and speech sound skills for a group of children presenting with moderate phonological / articulation disorder. B. METHOD 1) Participants There are four classes in the Language Unit, each consisting of 10 children and serviced

by 1.3 speech and language therapy wholetime equivalents. We selected children with phonological / articulation disorder from primary one and two (n = 12, age range = 57 years). They all had some degree of difficulty with sucking and blowing activities but only one had had previous therapy involving sucking and blowing exercises. 2) Procedure a) Assessment of phonology The class teachers assessed the degree of phonological impairment using six different levels from very severe (0) to age appropriate speech (5) adapted from the outcomes measurement drawn up by Enderby et al. (1998) (see table 1).
Table 1 Severity ratings for participants phonological impairments (0 = severe, 5 = age appropriate) Participant A B C D E F G H I J K L Severity Rating 1 1 3 2 2 4 2 3 4 4 2 3

Based on Fletchers (1972) criteria for diadokinetic rates, none of the children were able to sequence speech sounds within the age ranges expected. These results indicate that all participants had a degree of oral motor sequencing problems (although three of them had a relatively mild score on the severity rating scale). b) Assessment of sucking and blowing abilities Deirdre made informal pre-treatment measurements of each childs sucking and blowing abilities (table 2, p.16). They involved the following: i. Length of time (in seconds) taken to suck

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up and transfer 5 cardboard circles from one plate to another (2 cms in diameter and mm thick). ii. Length of time (in seconds) taken to suck up and transfer 5 Maltesers from one plate to another. iii. The amount of yoghurt (petit Filous) sucked up a straw 70 cms long and cm wide within 60 seconds. iv. The distance (in cms) a dart was blown from a blo-dart (3 cms in diameter and 50 cms in length). it is important to note that iiii all look at the strength and sustainability of sucking while iv looks at blowing / forced expiration. c) Treatment provided Treatment involved training and practice on all the skills assessed using a range of sucking and blowing activities and oral motor toys (whistle stop Therapy resources). Deirdre carried out these activities once a day, three days a week over a six month period in the school setting. The aim of this therapy was to increase the strength and sustainability of sucking and blowing. According to the rationale provided for this approach, this aims to increase the physiological / respiratory support and sensorimotor planning and programming necessary for speech resulting in improved intelligibility (van der walt, 2006). Additionally, Deirdre invited the parents of the children to attend a teaching / advice session on the use of sucking and blowing techniques for developing strength and range of movement in oral musculature. she demonstrated a range of activities using a variety of blowing toys (whistles, blo-darts, straws, kazoos) and sucking games. she gave a list of the types of toys and objects useful for developing these skills to each parent and actively encouraged them to practise these activities as often as they could during the week at home. This audit did not evaluate the extent to which the sucking and blowing activities were carried out at home, which would be useful to consider in future investigations. The children also all received a typical direct eclectic speech and language therapy approach towards phonological treatment which included minimal pairs work and auditory training (Joffe & pring, 2008). This was provided within 1:1 therapy sessions and class group sessions two to three
Figure 1 Length of time taken to suck up and transfer 5 cardboard circles
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pre-treatment post-treatment

Table 2 Informal pre-treatment sucking and blowing measures Participant Sucking cardboard Sucking Maltesers (secs) circles (secs) Pre Post Pre Post A 66 14 100 29 B 33 12 100 42 C 31 12 100 60 D 100 15 100 23 E 34 18 100 100 F 100 100 100 100 G 16 15 100 100 H 18 10 60 100 I 100 12 100 27 J 31 21 100 60 K 21 12 100 60 L 18 16 100 100 Sucking yoghurt (cms) Pre 35 15 18 21 64 17 85 79 51 43 30 19 Post 30 22 35 48 55 37 170 100 60 38 37 130 Blowing distance (cms) Pre Post 100 125 75 150 0 150 100 125 100 175 0 200 150 200 200 200 100 150 150 200 0 175 0 200

Note. For cardboard circle and Malteser sucking we allocated a value of 100 seconds to those children who were unable to attempt the task. Table 3 Comparison of means for pre and post-treatment measures p-values obtained from Wilcoxon Signed Ranks Test (2-tailed) Severity rating for phonological impairment .02 p < .05 Sucking cardboard circles .003 Sucking Maltesers .03 Sucking yoghurt .02 Blowing blo-dart .003

times a week. Deirdre repeated the same measures noted above (both phonological severity ratings and informal sucking and blowing tasks) at the end of the therapy period. C. RESULTS statistical comparison of means (wilcoxon signed ranks Test) of pre and post-treatment measures showed that there was a significant improvement in all measures after therapy, including the severity rating of the phonological impairment (table 3). Figures 1 to 4 show the pre and post-treatment scores for each sucking and blowing measure. The length of time taken to suck the target for cardboard circles and Maltesers got less as children got better at the skill, while the distance of yoghurt sucked and the length the dart could be blown increased. These results suggest that therapy for the sucking and blowing tasks improves performance on these skills. They also show that severity of phonological impairment decreased signifiFigure 2 Length of time taken to suck up and transfer 5 Maltesers
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pre-treatment post-treatment

cantly within the pre to post-treatment periods. it is important to keep in mind that these children all received a more direct eclectic approach to the treatment of their phonological difficulties alongside the sucking / blowing exercises. To see if there was an association between any of the sucking and blowing activities and improved phonology, we ran spearmans correlations between the five variables outlined in table 3. A significant association was found between the severity rating for phonological impairment and the distance of blowing the blo-dart [p = .04], but not for any of the other variables (which all involved sucking activities). There was a degree of variability in improvement made on the blo-dart blowing task which ranged from no improvement (by one child who had received therapy for sucking and blowing previously and who produced a blowing performance of 200 cms for both pre- and post-tests) to an improvement of 200 cms by two children who were unable to blow the blo-dart for the baseline measure at all. when we re-ran spearmans correlations excluding the outlier who scored 200 cms pre and post
Figure 3 The amount of yoghurt sucked up a straw within 60 seconds
200 180 160 140 120 100 80 60 40 20

Amount of yogurt in cms

Time taken in seconds

80 60 40 20 0

80 60 40 20 0

Note. A value of 100 seconds was allocated to those children who were unable to attempt the task.

A B C D e F g H i J K L participants

A B C D e F g H i J K L participants

Note. A value of 100 seconds was allocated to those children who were unable to attempt the task.

A B C D e F g H i J K L participants pre-treatment post-treatment

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treatment, a decrease in significance to [p = .08] was found. This is still a trend in the same direction, but indicates that this association needs further investigation with larger numbers and a more homogeneous group. D. ANALYSIS As a small scale, preliminary audit there are many limitations which must be noted. This was an audit of current practice rather than a research study so there was no control group. All the children receiving therapy for phonological impairment were included and therefore heterogeneity of the condition was not controlled by inclusion / exclusion criteria. The additional direct phonological therapy provided will have influenced improvement in phonological impairment. Limitations not directly associated with this study being an audit rather than research are that there were very small numbers which reduced the power of the findings, and also there was notable variability in performance on the informal measures used to assess sucking and blowing ability. This variability may have been related to the nature of the informal assessments used and it would be important to evaluate how to measure these skills more accurately in future studies. Variability may also have been due to the heterogeneous nature of the group and this would also need to be controlled for in future studies. Despite this, the audit has provided some interesting preliminary findings. notably there was a significant improvement in all the measures post-treatment. while we know that conventional direct therapy for phonological impairment works, and this may explain the decrease in phonological severity noted, the finding showing a significant association (or at the least a trend in that direction) between improvement in blowing ability and phonological skills is interesting. This clearly warrants further investigation through a research study using larger numbers, a more homogeneous group, more accurate blowing measures, and control group/s. This link between blowing and phonological severity may indicate that some children with phonological impairment have problems with control of expiration associated with their difficulties. while keeping the limitations in mind, it is possible to draw some tentative conclusions for clinical practice. The use of sucking and blowing exercises
Figure 4 The distance a dart was blown from a blo-dart
250 200

to support the direct treatment of phonological difficulties should be treated with caution. sucking exercises in particular should be considered very carefully in relation to each childs specific needs before incorporating them into therapy plans. On the other hand, developing blowing skills, in particular focusing on improving the force of exhalation and the ability to grade airflow, may be helpful for some children. Activities such as blow football, blo-darts and those that encourage prolonged production of sounds such as /s/, /z/ or /a/ could improve respiratory support for speech and possibly help children with phonological impairment improve their ability to grade airflow for speech production although, of course, the value of blowing exercises for improving phonological difficulties will need to be corroborated by conclusive, well-developed research.

Deirdre Cosgrave is a speech and language therapist with Western Health and Social Services Trust in Derry, e-mail deirdre.cosgrave@gmail.com. Dr. Jill Titterington is an associate lecturer in speech and language therapy at the University of Ulster, Jordanstown, e-mail j.titterington@ulster.ac.uk. Acknowledgements Thanks to the children, their parents and their teachers from woodlands Language Unit in Derry who participated in this audit. Thanks also for the support of Una isdell, the speech and Language Therapy Team Leader in western Health and social Care Trust for facilitating this project. SLTP reFLeCTiOns DO i see THe VALUe OF OBTAining sUperVisiOn AnD sUppOrT FOr CArrYing OUT AUDiT? DO i Use AUDiT TO eXAMine MY prACTiCe AnD iDenTiFY CLiniCAL reseArCH QUesTiOns? DO i eXpLAin TO CLienTs wHen AnD wHY i AM Using THerApY THAT is eXperiMenTAL?

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References Bowen, C. (2005)what is the evidence for.? Oral motor therapy, Acquiring knowledge in speech, language and hearing 7(3), pp.144-147. Clark, H.M. (2003) neuromuscular treatments for speech and swallowing: A tutorial, American Journal of Speech-Language Pathology 12(4), pp.400-415. what have you learnt about your practice Dodd, B. & Bradford, A. (2000) A comparison from audit? Let us know via the spring of three therapy methods for children with 09 forum at http://members.speechmag. different types of developmental phonological com/forum/. disorder, International Journal of Communication Disorders 35(2), pp.189-209. Dodd, B., Crosbie, s. & Holm, A. (2004) Core Vocabulary: Intervention for children with inconsistent speech disorder. Australia: perinatal research Centre. enderby, p., John, A., sloane, M. & petherhem, B. (1998) Therapy Outcomes: Speech Language Pathology. London: singular publishing group. Fletcher, s.g. (1972) Time-by-count Measurement of Diadokinetic rate, Journal of Speech and Hearing Research 15, pp.763-770. gierut, J.A. (2001) Complexity in phonological Treatment: Clinical Factors, Language, Speech & Hearing Services in Schools 32(4), pp.229-241. gierut, J.A. (1998) Treatment efficacy: Functional phonological disorders in children, Journal of Speech, Language, and Hearing Research 41(1), pp.s85-s100. Joffe, V. & pring, T. (2008)Children with phonological problems: a survey of clinical practice, International Journal of Language & Communication Disorders 43(2), pp.154-164. Joffe, B. & serry, T. (2004)The evidence base for the treatment of articulation and phonological disorders in children, in reilly, s., Douglas, J. & Oates, J. (eds.) Evidence based practice in speech pathology. London: whurr publishers, pp.258-285. Lass, n.J. & pannbacker, M. (2008) The application of evidence-based practice to nonspeech oral motor treatments, Language, Speech & Hearing Services in Schools 39(2), pp.408-421. Lof, g.L. & watson, M.M. (2008) A nationwide survey of nonspeech oral motor exercise use: implications for evidence-based practice, Language, Speech & Hearing Services in Schools 39(2), pp.392-407. powell, T.w. (2008a) The use of non-speech oral motor treatments for developmental speech sound production disorders: interventions and interactions, Language, Speech & Hearing Services in Schools 39(2), pp.374-379. powell, T.w. (2008b) An integrated evaluation of nonspeech oral motor treatments, Language, Speech & Hearing Services in Schools 39(2), pp.422-427. ruscello, D.M. (2008) nonspeech oral motor treatment issues related to children with developmental speech sound disorders, Language, Speech & Hearing Services in Schools 39(2), pp.380-391. stackhouse, J. & wells, B. (1997) Childrens Speech and Literacy Difficulties 1: A Pyscholinguistic Framework. London: whurr. van der walt, C. (2006) Oral-Sensory-Motor & Respiratory Experiences. 2 Day workshop. Centre for CpD for Allied Health professsions, Clady Villa, Knockbracken Healthcare park, Belfast, n.ireland, 19-20 June. Resources / Maltesers, www.maltesers.com petit Filous, www.petitfilous.co.uk Toys used for the sucking and blowing activities were obtained from the whistle stop Therapy resources starter kit (15 per pack), 7 Almshouse, st Monmouth, Monmouthshire np25 3De, e-mail joanna.collins3@btinernet.com.
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A B C D e F g H i J K L participants pre-treatment post-treatment

Distance blown in cms

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