GOAL SETTING

Ever the twain shall meet...

H
Trish Morrison Susanne King

Concerned that their speech and language therapy expectations for children with severe cerebral palsy seemed very far apart from those of the parents, Trish Morrison and Susanne King looked for a way to meet in the middle. Their small pilot project using a controversial oral motor approach has implications for goal setting with parents and future research.
READ THIS IF YOU ARE INTERESTED IN DEVELOPING YOUR NEGOTIATION SKILLS WITH CARERS EXPLORING THERAPY WITH CLIENTS AND FAMILIES PERSPECTIVES, PRIORITIES AND OUTCOMES

ave you ever found yourself in a situation where a childs parents wanted the primary focus of intervention to be one area and your professional opinion would prioritise another aspect of communication? Parents and speech and language therapists may be approaching the therapy process from very different perspectives. Parents may have the expectation that the speech and language therapist will be helping their child develop speech and they may have the hope that their child will eventually talk. The speech and language therapist however may be looking at a child whose medical diagnosis, clinical presentation and progress in therapy may indicate that the primary focus of therapy should be augmenting the childs communication. Therapy services are now more client and family centred and espouse that both should be central to the goal setting process. This presents challenges when families and speech and language therapists have different views regarding what these goals should be. In our Early Intervention Service, in a centre for people with physical disabilities, this was particularly evident. Parents were actively looking for a main focus on speech while therapists were offering a total communication approach. Attendance at an oral motor therapy seminar triggered therapists into thinking that perhaps this approach had something to offer this client group. It would address parents wishes and goals to work on speech, and we hypothesised that providing this opportunity to work on parental goals may lead to greater buy in to augmentative communication at a later stage. Furthermore, this approach may have a positive impact on speech and feeding skills.

Effective?
There is a lot written about the controversy of whether oral motor therapy is effective in improving speech or not. Project CHANCE (Child Development and Oral Motor Skills) (internet source unavailable) cited delayed babbling or producing a limited variety of consonants among the reasons to select children for oral motor therapy. Underlying this is the assumption that oral motor work will help develop speech production. Conversely Bowen (2005), although agreeing that oral motor therapies are widely used in North America, quoted research which reviewed six studies and concluded that these overwhelmingly demonstrated that oral motor exercises do not improve speech sound production. It was stated that if clinicians wished to target improved speech production they must work on speech and

not on tasks that only superficially appear to be speech like movements (Lof, 2003 cited by Bowen, 2005, p.3). Clarke (2003, p.400) states there is limited empirical evidence to support what she calls neuromuscular treatments and goes on to suggest that many clinicians do not have the foundational information needed to judge the theoretical soundness of unstudied treatment strategies. These unstudied treatment strategies abound, and there is a plethora of commercially available programmes and manuals that are actively promoted by lecture tours, internet promotions and conference presentations (Bowen, 2005). Parents are very aware of these treatments, both through word of mouth and the internet. The empirical research articles we read did not support the claim that oral motor tasks affect the development of vocalisation or speech, although some supporters of oral motor treatment would argue that not enough research has been done in the area. This left us wondering - if we worked on oral motor activities, would we be giving false hope to parents that their child may develop functional speech? Conversely, if we did not offer the children oral motor therapy, would these parents feel like they had failed or let down their child by not exploring every avenue for speech? Given all of these factors, we undertook a small pilot project to evaluate the impact of this intervention approach with a group of children with severe cerebral palsy. We decided to run an intensive oral motor group along with parental education and training in the area to see what benefits if any - this population would gain. After the group, we gave the parents a programme to follow for a month and then followed up with a two day intensive to review progress, programmes and to get parental feedback. We were keen to see whether a regular, structured oral motor programme would improve the quality of early vocalisations in non-verbal or partially verbal pre-school children with cerebral palsy.

Structure
As identified by Bahr (2001), an oral motor treatment session typically includes four segments and we used this format as a template for our session structure: 1. A gross motor activity To help develop postural tone and stability. We have noted (as did Bahr, 2001, p.139) that vocalisation of ten occurs during movement activities, hence including a gross motor activity at the beginning of the session may enhance vocalisation.

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GOAL SETTING

Figure 1 Session objectives Session 1 Informal baseline assessment of oral motor skills and the quality of the childrens vocalisations was compiled (see figure 2). Assessment focused on the childrens skill level in tasks to be used during intervention and included information provided by the mother. Information given to parents. The speech and language therapists devised an oral motor programme for each child based on the information obtained during their initial assessment. Occupational therapy gross motor activities and hand massage. Speech and language therapists modelled the oral motor programme. Occupational therapy gross motor activities and hand massage. Parents trialled the oral motor programme with supervision from the speech and language therapists followed by problem-solving any difficulties. Parents were asked to do the occupational therapy and oral motor programme 3 times per day prior to an oral task such as brushing teeth / eating. The session began with feedback from parents regarding any difficulties they experienced in following the programme and changes they observed, if any. This was followed by an occupational therapy led gross motor activity and massage. The session ended with a speech and language therapist reviewing the childs programme, making any changes and modelling the new activities. Occupational therapy gross motor activities and hand massage. Parents trialled new programme and problem solved any difficulties. Re-assessment and results compared with baseline.

Figure 2 Baseline assessment ORAL MOTOR PROGRAMME PRE-COURSE SCREENING Date: _______________________ NAME: _______________________

Between Sessions 1 and 2 Session 2

1. Tolerates firm touch on hands (H = hands/fingers T = toothette) -----cheeks------forehead------around lips------lips-----Front teeth------side teeth------inner cheeks------tongue 2. Current level of vocalisation (check list):

Session 3

(A) (B)

Identified by parent Observed by therapist

Between Sessions 3 and 4 Session 4 (4 weeks later)

3. Respiration: Bubble blowing programme: (level achieved). 4. Phonation level achieved with echo horn. 5. Jaw stability number of bites on arc grabber, red or yellow chewy. Any other comments:

Session 5

SIGNED: _____________________________

2. Oral massage Which prepares the infants mouth for the remainder of the therapy activities in the session (Bahr, 2001, p.121). 3. Specific oral motor activities In this section we focused on developing breath support through the use of Rosenfeld-Johnsons Bubble Blowing Hierarchy and jaw stability which, in this programme (2001), is identified as the necessary foundation for later dissociated movements of the lips, tongue and cheeks. 4. Specific speech and language activities In our programme, we wished to focus on promoting speech, hence we used Rosenfeld-Johnsons Echo Horn programme (2001) to help the children develop voluntary vocalisation, increase their range of vocalisations and practise speech sound imitation. Five children aged between 2 years 4 months and 4 years 6 months with a diagnosis of cerebral palsy attended, accompanied by their mothers. Four of the children had cerebral palsy with Gross Motor Function Classification System (GMFCS) of level IV or V, with one child having a level II (Palisano et al., 1997). The group contained three girls and two boys; four of the children were identified as non-verbal with one child being partially verbal. This group attended for sessions on three consecutive days, followed by two consecutive days four weeks later (figure 1). In the final session we looked at therapy outcomes and compared them to baseline measurements and asked parents for feedback about any changes they had noted in their child.

Number of children tolerating

Controversy continues regarding the efficacy of oral motor therapy and its role in speech development; consequently, we should continue to elaborate our knowledge base through research. We were interested to note that most of the improvements noted on re-assessment and parental feedback were not related to speech. Increased tolerance to touch on the body was noted in two children and increased tolerance to touch intraorally in another two children (figure 3). Bahr (2001) reports that oral massage increases blood supply to the oral facial muscles which can help normalise sensation, increase muscle tone and promote awareness of the oral motor structures. Although not related to speech, this outcome could have implications for oral hygiene (for example, increased tolerance to tooth brushing), feeding (ability to tolerate food textures in the mouth) and social factors (reduced mouth open postures at rest).

Figure 3 Results for tolerance of firm touch

Tolerance of firm touch

4

Impact on saliva
Increased muscle tone, normalisation of sensation, and an increased awareness of oral motor structures could also have an impact on saliva loss - and decreased saliva loss was reported on parental feedback by four of the five parents (figure 4). While we didnt formally assess this at baseline it merits further investigation and would be an interesting follow-on study. The parents of one child reported that, prior to the therapy programme, she had severe saliva loss to the level of the chest. Bibs were always wet and had to be changed up to 20 times daily. After the therapy programme, this had reduced to mostly moderate saliva loss to the level of the chin, with

Body / face

Intraorally

Pre-therapy Post-therapy

SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 2007

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GOAL SETTING

Figure 4 Parental feedback

Parental feedback
4

Decrease in Saliva Loss

Improvement In Feeding/ Chewing

Increase in Vocalisations

Programme Difficult to follow

Number of parents

Figure 5 Results for jaw stability, respiration, vocalisation, phonation

Post Therapy Outcomes

Number of children
4 3

Jaw Stability

Respiration

Vocalisation

Phonation

Improvement No Change

REFLECTIONS DO I USE PILOT PROJECTS TO UNCOVER ISSUES I WILL NEED TO ADDRESS IN FUTURE VENTURES? DO I TREAT THERAPY AS A JOURNEY, WITH THE OPTION TO TEST OUT ALTERNATIVE ROUTES? DO I EVALUATE OUTCOMES IN A NARROW OR HOLISTIC WAY?

bibs remaining dry for a couple of hours at a time. There was a mixed picture when looking at the results of specific oral motor activities (figure 5). Sara Rosenfeld-Johnson advocates a hierarchical approach to oral motor therapy starting at the childs level of ability and progressing slowly at the childs pace. Our programme only ran for five weeks and the children had severe oral motor difficulties so improvements were slight but there was progress in the hierarchy for four of the children in two of the motor areas. Only one child did not improve in any of the assessed oral motor components. Improvement in jaw stability, assessed by the number of bites achieved on an arc grabber, was only seen in one child, who was the oldest and partially verbal. Three children showed improvements in respiratory function, and three children showed progress in phonation. The research articles mentioned earlier were mostly looking at the efficacy of oral motor therapy on speech development. Our small project was inconclusive as to the benefit to speech. Two of the children improved quantity and quality of vocalisation on reassessment (figure 5) and three of the five parents reported increased vocalisation on feedback (figure 4). However, it is unclear whether this was directly related to the oral motor component of the programme. The gross motor component could have encouraged the increased vocalisation (as reported by Bahr, 2001) or the increased time spent face to face with the child, or indeed the parents may have been more focused on vocalisation than prior to the programme. Improvement in feeding (chewing and keeping food in the mouth) was noted in the parental report of two children (figure 4). This was another element that was not specifically assessed or targeted in the therapy programme. Sara Rosenfeld-Johnson suggests that her oral motor programme targets speech and improving feeding skills and should be used in conjunction with speech and eating, drinking and swallowing therapy. Four of the five parents indicated (figure 4) that trying to do the programme three times per day every day (as recommended by Gangale, 2001) was very difficult to achieve. The child with physical disability requires a lot of time for basic care needs such as washing, dressing and feeding. Add to this physiotherapy programmes (essential for health, movement and handling) and the numerous appointments they have to attend and there is not much time left for oral motor programmes even for the parents who are highly motivated. Some parents adapted the programme so that it fitted in with their daily lives, the consensus being that daily practice was a reasonable expectation when the child was well. This could have skewed the results; for example, only doing the programme once daily or doing different parts of the programme at different times in the day rather than altogether.

look at how oral motor therapy benefits the children in this population. We learned a lot in the process and feel that it is essential that, as clinicians, we record therapeutic outcomes however imperfectly to add to the evidence base. The things we have learned in our small project would lead us to further more empirical research where we would consider: Increasing our sample size and refining our selection criteria Increasing the time frame and including regular followup appointments Using more formalised oral motor assessments Refining and structuring the parental questionnaire Including assessments on feeding and saliva loss at the baseline of therapy outcome stage Exploring programmes that fit with the activities of daily living so that parents can incorporate it into their daily life and do not have to find extra time. Apart from research, the project gave parents the opportunity and skills to work on oral motor work with their children in a way that allowed them to see realistically what the results were and the effort needed to go down this road. Although most of the parents still want to work on speech, they are more willing to allow us to work on speech as part of a total communication approach. Giving the parents a chance to be part of goal making, and to be honest about feedback, gave us a better working relationship with them and their children. Trish Morrison is a Senior Speech and Language Therapist at the Central Remedial Clinic, Dublin, Ireland. Susanne King has now returned to Australia and is working as a Senior Speech and Language Therapist for the Cerebral Palsy League of Queensland.

Acknowledgements
Our thanks to Rachel Glennane, Occupational Therapy Manager and to Senior Occupational Therapists Jean Oswell and Frances Corazza at the Central Remedial Clinic.

References
Bahr, D.C. (2001) Oral Motor Assessment & Treatment (Ages and Stages). Boston:Allyn & Bacon. Bowen, C. (2005) Non-speech Oral Motor Exercises. Updated version available at: http://members.tripod.com/ caroline_bowen/oralmotortherapy.htm (Accessed 25 July 2007). Clarke, M. (2003) Neuromuscular Treatments for Speech and Swallowing: A Tutorial, American Journal of SpeechLanguage Pathology 12, pp. 400-415. Gangale, D.C. (2001) The Source for Oro-Facial Exercise Updated and Expanded. East Moline: LinguiSystems. Palisano, R., Rosenbaum, P., Walter, S., Russell, D., Wood, E. & Galuppi, B. (1997) Gross Motor Function Classification System for Cerebral Palsy, Dev. Med. Child Neurology 39, pp. 214223. Office of Children and Special Health Care Needs (date unknown) Project CHANCE, Child Development and Oral Motor Skills. [Print out from internet page, source unavailable.] Rosenfeld-Johnson, S. and Smith Money, S. (2001) The HOMEWORK Book. Tucson: Innovative Therapists International. Rosenfeld-Johnson, S. (2001) Oral Motor Exercises for SLTP Speech Clarity. Tucson: Ravenhawk.

Limitations
Looking at this study objectively there are many limitations. Our subject size is small, specialised and diverse in age and ability; our assessments were informal; our results were not statistically analysed; there was a short time frame and there was a huge reliance on parental compliance. We also tailored a few different oral motor approaches to our needs and acknowledge that the authors of each approach would advocate following their full programme to achieve the best results. Despite these limitations, there was enough progress made by individual children to warrant a more in-depth

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SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 2007