TeamHope Mild Motor Speech Disorders A Note from the Director of TeamHope: At last! Those of you who know me, have had consults with me or have heard me speak on a variety of issues related to speech & language disorders in young children, are already aware that I’ve been beating the drum about the importance of recognizing the impact of motor disturbances in young children. A delay is not just a delay! It can have far reaching impact on the functional skills of the children it effects. ESPECIALLY FOR SPEECH, FEEDING AND LANGUAGE DEVELOPMENT. These delays do not occur in a vacuum, instead delays in speech, feeding and language production should not be dismissed as “just a delay”. They are indicators that additional assessments, particularly in the sensory motor domains, need to be considered. I’ll get off my soapbox now. Kudos to the good folks at Kennedy Krieger for compiling the “evidence” on what I’ve been observing clinically for years. The effects of severe motor disorders on children’s functional skills are well recognized. The same cannot be said for mild motor disorders, which may not be detected or diagnosed. Their effects on children’s function may not be understood by parents or professionals. Children with mild motor disorders often present with late mastery of motor milestones and slow or awkward movements compared to typical peers or siblings. Diagnostic terms used to describe mild motor deficits include minor neuromotor abnormality, central hypotonia and developmental coordination disorder. Development of the oral motor skills required for feeding and speech production depends on earlier mastery of essential gross motor skills. Good trunk control provides a stable foundation onto which control of head movement and finely graded oral motor movements are built. Feeding and, to a greater degree, speech production require the ability to produce rapid and accurate alternating movements. Speech production skills are complex, such that motor movements needed for speaking are not fully refined until adolescence and adulthood. Given this complexity, even mild motor difficulties are enough to disrupt feeding, speech development or both. While it’s hard to say exactly how many children have mild motor deficits, due to differences in terminology and the trend toward underdiagnosis, this often unrecognized disorder occurs fairly frequently. Estimates range from 5% to 15% of children. Rates of occurrence are even higher in children with other diagnoses. In one study approximately 30% of toddlers with speech language disorders also had mild motor disorders. Therefore, speech language pathologists have the opportunity to document children’s co-existing neuromotor needs. Co-existing conditions can compromise function to a greater degree than diagnoses that occur alone. When they go unrecognized, co-existing problems impede progress in treatment. Oral motor treatment for feeding disorders is somewhat more accepted, but use of such treatment to improve speech clarity remains controversial. Rigorous research studies are needed to substantiate clinical findings. However, our clinical experiences at Kennedy Krieger Institute, in Baltimore, MD, suggest that even children with subtle low tone have benefited from inclusion of oral motor strengthening activities as part of their treatment program. Measureable changes in oral motor strength and stability seem to yield functional changes in feeding and swallowing and speech production. The prenatal and birth history of Ryan Norris was uncomplicated. Before he was a month old, Ryan was diagnosed with severe reflux. He gained little weight. When he was 8 months old, he and his mother met with a speech language pathologist on an interdisciplinary feeding and swallowing outpatient team at Kennedy Krieger Institute. The team noted Ryan’s negative sensory experiences from persistent reflux. Aspiration occurred only after reflux. Also present were mild oral motor difficulties that affected his management of food and contributed to late talking. Ryan began outpatient treatment when his reflux was under better control. Goals included decreasing oral sensitivity so he could accept food and increasing oral motor control and jaw strength. Before he turned 2, Ryan showed signs of frustration in expressing himself. His limited speech sound repertoire did not offer many options beyond whining and negative vocalizations he sometimes used. Functional communication goals were added to his treatment program. Throughout this time, Ryan learned to accept different textures on his tongue. He built up jaw strength needed for chewing and drinking from an open cup. He frequently practiced feeding and communication skills. New feeding skills at discharge included biting through a cracker on his molars, beginning to chew, and drinking sips from an open cup. This progress was paired with an improved ability to express basic wants and needs verbally, using word and phrase approximations like “more”, “all done”, “help”, “give me”, “play” and “let’s go”. He had learned more words but had to supplement them with other sounds and gestures to be understood. His speech sound inventory included many vowels and early developing consonants: “m”, “n”, “p”, “b”, “t”, “d”, “k”, “g” and “h”. Ryan formed syllables by combining one consonant with one vowel (e.g., “ba” for “ball”, and “boo” for “spoon”) and by repeating the consonant vowel sequence (e.g., “ma-ma”). These expanded verbal skills allowed Ryan to accomplish more of his goals by talking. Several months later, Ryan had enough vocabulary and grammatical skills to combine words into phrases, yet his phrases-length speech was harder to understand. He could say speech sounds in single words much more clearly than he could say the same sounds in phrases due to the increased motor demands needed for connected speech. Ryan hardly moved his mouth when he talked. His inability to execute the rapid, precise, movements, needed for speech production is dysarthria, the neuromotor equivalent to problems he experienced earlier with feeding. His treatment program incorporated resistance activities. These activities helped him build jaw strength and endurance and, in turn, improved oral motor control. When Ryan was almost 3 years old, he “really took off in treatment,” his mother said. By then, she understood about 80% of his speech, and adults who didn’t know him well understood about half. Ryan’s frustration with communication subsided with these gains. Ryan completed his outpatient speech language treatment about six months later, with remarkably improved feeding and speech language skills. His discrete oral motor achievements were paired with functional skill improvements. Ryan could now eat “kid friendly,” regular-textured foods like chicken nuggets, fruit chews, and a hamburger on a bun. His speech and language skills blossomed to the point where the repertoire of his language and speech sounds was age-appropriate. He could pronounce several consecutive syllables in single words and whole sentences. Despite subtle signs of oral motor difficulty, Ryan’s parents understood nearly everything he said, while unfamiliar listeners understood about three quarters of his speech. His mother described Ryan’s improved feeding and communication as “huge” changes that assured he will do well in his new PreK program this fall. For many reasons accurate diagnosis remains challenging in pediatric populations with neurodevelopmental disorders. Development itself is dynamic, and the individual skills of children vary widely even with ranges expected for age. Deficits often cross disciplinary boundaries. Systemic “roadblocks” exist in educational and health care settings that can affect referrals and clinical services. Adopting an interdisciplinary perspective goes a long way toward determining appropriate diagnoses that lead to treatment programs designed to help children build essential skills. |