for Speech-Language Pathologists & Audiologists
June 28, 2004 – Vol. 14 – Issue 26 – Page 11
By Stephen Sacks, MA, CCC-SLP
A multimodality approach for remediation of the /s/ sound works equally well with students who have frontal or lateral /s/ production. The goal for both is to stabilize the sides of the tongue on the top, back teeth and differentiate the front tip movement from the back of the tongue.
There may be other reasons why the student is not saying the /s/ correctly. Structural problems in dentition may be contributing factors to a lateralized /s/, while physical problems, such as large tonsils and adenoids that lead the student to breathe through the mouth and have incorrect tongue placement, may cause a frontal lisp.
At the beginning of therapy, get the tongue pulled back and wide. Using a mirror and flashlight, have students do “tongue push-ups,” opening their mouth wide, pulling the tongue back as far as they can into a ball, and then closing halfway and saying “EE,” pushing up on the top teeth with the sides of the tongue.
If students have difficulty pulling the tongue back, touching the side of the tongue near the back with an applicator stick usually works. If they are still unsuccessful, oral-motor techniques such as sipping pudding through a straw or blowing horns, as described by Sara Rosenfeld-Johnson, MS, CCC-SLP, will do the trick.1,2 The sides of the tongue should be pushed up against the back molars. These steps are all visible to the student.
A frequent problem is the inability to grade the jaw appropriately and stop halfway open. These students should practice jaw grading, using a scale of one to four:
- Teeth are closed in a normal bite.
- Teeth are open slightly.
- Mouth is open halfway.
- Mouth is open all the way.3
We practice different sequences until the student can easily stop at each number. At that point the mirror and flashlight are taken away and the exercise is repeated using only proprioceptive feedback.
With the tongue anchored to the back molars in the EE position, using a mirror and a flashlight for visual feedback, students say “EE” then point the tongue tip to the lingua-alveolar ridge. Typically, they will drop the tongue from the sides of the teeth and move their whole tongue forward. They may not be able to adequately point the tip of the tongue. Using a visual model, demonstrate to them the difference between keeping the sides of the tongue still and pointing the tip versus what they do moving the whole tongue.
When they are in the EE position, hold an applicator stick on one side of the tongue near the back, talk about how the tongue is wide, and ask them to keep that part of the tongue still against the stick. Using a mirror and flashlight, they can see and feel if the tongue remains in the proper position when they point the tip.
If students cannot do this after a couple of attempts, make sure they have the ability to point the tip adequately. Using a lollipop, which is moved around the outside periphery of the mouth, have them touch it with the tip of their tongue receiving tactile feedback. They need to extend their tongue far enough so the tip points. If they move their head instead of their tongue, hold the top of their head with your hand. Usually, they can point their tongue tip adequately in a short time. This can be supplemented with rapid diadochokinetic exercises, like moving the tongue outside the mouth side to side or up and down.
If students continue to struggle with this step, have them say “EE” then click their tongue. With visual feedback from a mirror, they can see that they are placing the tongue tip correctly in the lingua-alveolar area and are keeping the sides of the tongue wide against the back molars. Have them practice this step for a week in homework of 50 to 100 repetitions a day.
When they are doing this exercise easily and consistently, have them say “EE” and pretend they are going to click. At that point reinforce them and show them how they are keeping the sides of the tongue wide and still against the back molars and moving the tip independently. Using a mirror and flashlight and going EE-point, they can pay attention to just moving the tip of the tongue.
While they are now typically able to differentiate back tongue movement from front, there may be some jaw closing and lip movement. Using a small craft stick-sized tongue depressor to stabilize the jaw while having them hold their mouth in a big smile, have them practice EE-point. Typically, the jaw/lip movements are extinguished. The stick eventually is removed and the mirror taken away. Students close their eyes and make the same movement, receiving only tactile-kinesthetic feedback. You can say things like, “Feel how the sides of your tongue stay still against your teeth and only your tongue tip moves.”
Continuing in this vein, the student now says EE-T, saying the /t/ very gently. Visual feedback using a mirror may be helpful but probably isn’t necessary. The student should have complete differentiation of the tongue tip with no associated lip or jaw movements.
Demonstrate lengthening the duration of the /t/ sound and ask the student to say “EETS.” This is the perfect facilitating context for the /s/ sound based on the positioning of the articulators for the EE and T sounds.
Because many students have an incorrect notion of what the /s/ sound feels like and sounds like, Richard Shine recommends use of the “French /t/.” He says, “We are learning a new sound that kind of sounds like the /s/ sound but it’s not /s/. It is actually the French /t/.” With no preconceived notion of the French /t/, the student will make the correct /s/ sound.4
The next step is EETS-EE, with a slight pause before the final EE. If students think they are saying “SEE,” they are back to their habitually incorrect /s/ sound. The secret of getting this correct prevocalic /s/ is to have the student say “EETS-EE” faster and faster until there is no space between EETS and EE. Saying this VCCV combination quickly transitions to a CVCCVC nonsense word, such as BEETSEEK, which has a facilitating context, or BEETSEET, if the issue of tongue front/back differentiation is difficult for some students.
This CVCCVC facilitating context takes the student into the Systematic Articulation Training Program Accessing Computers (SATPAC) for remediation. The SATPAC program establishes a CVCCVC nonsense word through seven progressively more difficult steps, then uses nine lists of CVCCVC nonsense words and contrasting sentences to generalize correct /s/ production in every phonetic context. Finally, the sound is transferred into phrases, sentences and real activities.
1. Rosenfeld-Johnson, S., Manning, D. (1999). Using simple tools in oral-motor therapy. Part I: Straws. ADVANCE, 9 (16): 20-21
2. Rosenfeld-Johnson, S., Manning, D. (1999). Using simple tools in oral-motor therapy. Part II: Horns. ADVANCE, 9 (22): 20-21
3. Sacks, S. (2003). Multimodality approach to articulation. ADVANCE, . Oct. 27.
4. Sacks, S., Shine, R. (2004, 2000) Systematic Articulation Training Program Accessing Computers, SATPAC Speech LLC, Fresno, CA.
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