by: David W Hammer, MA CCC-SLP, Children’s Hospital of Pittsburgh, PA UPMC

Please note: I will be using the term “client” to refer to the children and adolescents in this article.  I feel this is a happy-medium between “patient” in a hospital setting and “student” in a school setting.]
As a practicing therapist for over 30 years, one of the most intriguing speech sound production disorders to me has been persistent “r” distortions.  While we are inclined to think of single sound errors as “mild” when referencing severity levels, a persistent “r” distortion, especially for adolescents who have been through years of therapy without success, is anything but “mild”.  In the English language, unfortunately, this sound is so frequently occurring in consonantal and vocalic forms.  I have treated many older school-age children and adolescents with persistent “r” distortions over the years, and was asked to share some thoughts about how I approach this challenge and to provide therapy ideas that I have found successful.
One of the first things we have to remember is that the older school-age client may see himself/herself as being perceived as immature sounding, and the adolescent often sees himself/herself as a failure for not having modified their “r” despite years of therapy.  It is imperative to address the feelings and attitudes about their “r” problem just as it would be for children and adolescents who stutter.  Sometimes I find that just having them understand why they may have not been successful before is enough to provide a starting point of motivation for the challenging therapy that lies ahead.
First, I thoroughly investigate potential differences in tongue function that may create challenges for the client in trying to produce “er”, which to me is the building block for all “r” productions, whether consonantal or vocalic.  I look for overall tongue stability and lingual tension, when the tongue is inside and outside the oral cavity.  What I have found, in a percentage of my clients, is that they are unable to hold their tongue still at rest, or do so with great effort and/or wave-like movements in the tongue body.  My pediatric neurology associates say that true lingual “fasciculations” result in muscle atrophy over time in the purest definition, but this term is what I use to describe even the most subtle wave-like movements in the tongue.  By having the client observe in the mirror their inability to hold their tongue at rest without movement is the first step in the “Ah-hah!” process of trying to discover why this sound has been so difficult to change.
Whether or not the adolescent demonstrates a quiet tongue or the lingual wave-like features, I move on to the next step in the brainstorming process.  I ask them the 3 key features of producing a good “er” sound.  The “er” requires the most precise of fine motor speech movements and involves timed tension, lateral stability, and posterior lingual movement of some degree to generate the sound approximation.  (On a side note, I am often struck by the fact that a number of these clients tell me that they have been working most recently at the conversational speech level, despite the fact that the isolated “er” is not even close to an accurate production!)  I usually hear the typical “I put my tongue up, and then move it back.”  Even if they were taught about lateral stability and lingual tension, they generally don’t show evidence of knowing about these critical features.
Another answer I often get starts with “I hold my lips like…” which I quickly dispel with the following demonstration.  I say “er” out of the right side of my mouth, “er” out of the left side of my mouth, “er” with my lips moving down toward my chin, and “er” with my lips moving up toward my nose, all of which are beautifully-sounding “er’s”, albeit they look rather silly.  I immediately tell them that this is a “tongue sound” and we will be ignoring their lips for a long time (in very later stages, I may find certain lip positions that help color the “er” the best, but most of the time, I do not have to do this)
The problem with the front to back movement that many of my clients have learned is that we often observe the further back their tongue goes in the oral cavity, the less lateral stability is maintained.  We know that lateral stability is critical in “er” production.  Yes, a percentage of our clients do get better when we introduce the simple tongue up and back strategy, but I am talking about the persistent cases here when this did not work.  Obviously the successful clients who only focused on the up and back movements did so without losing lateral stability.  To counter this, I always start by having the client begin in what Pam Marshalla refers to as the “butterfly” position.  As suggested in Pam’s therapy materials I ask the client to gently bite down on the sides of their tongue (of course, not to the point of drawing blood!), and then “push up” at the touch points without any sound.   This forms the tongue in what looks like a butterfly in flight (Well, actually no tongue ever reminds me of a butterfly to be quite honest!).
The key is to have the client go straight up with their tongue and we don’t even talk about going back quite yet.  I tell them it is like getting mad at their sibling without saying anything but “rrrrrr”.  For some clients, I get a very close approximation of “er” far forward like this, but for most, I do have to have them move it back, although some just a slight distance, to achieve an “er”.  We experiment with this until we find the most forward position in which the “er” is achieved with accuracy.  This may take awhile for a percentage of them, but it is worth it later on.
My next phase of therapy involves computer visual feedback, although I realize a high percentage of therapists don’t have access to this technology.  This does not mean that you can’t go on from here with my therapy ideas, but we do have to realize that there are a percentage of our clients who may not achieve solid “r” productions without involving some form of computer visual feedback or biofeedback, as is recently being tested more in-depth.  The challenge is that computer visual feedback programs on the market tend to be either too limited or too costly.  The software programs I use are the IBM Speechviewer and the TheraVox program by WEVOSYS.  Unfortunately the IBM Speechviewer was taken off the market a few years ago.  My investigations have shown there is no plan to bring it back.  The TheraVox program is out of Germany and is very similar to the Speechviewer.  You can view a video of a child using the program on the www.wevosys.com website to observe the variety of modules available.  The video actually portrays a child that I treated but is not involving the “r” sound.
Once the “er” is established in isolation, I move to production in consonantal position with the “er” exaggerated starter in words ending in velar stops (e.g. “rock, Rick, rug, rag) which enables the client to say the word without any lip movement in a ventriloquist-type fashion.  From there, I build to “her-rock”, “her rug”, etc. while extending the sound in an exaggerated manner to “stay in the articulatory moment” for sensory feedback. I then move to consonantal “r” words that vary in ending sounds.  Once established, I work on “word pairs” where I use pictures or printed words in sequences such as “car-robot” and use a volume fading technique to move the sound from one position to the next (say both words at same volume, whisper the supportive word and maintain normal volume for the target word, then “think” the supportive word and say the target word at normal volume).
The key to successful later stages of “r” therapy involves choosing activities that maintain motivation and better assure home carryover practice.  For example, I use sports surveys which involve the client creating a list of “r” sentences in which something is wrong (e.g. “The quarterback threw the ball to the center and scored”) and the person who is surveyed has to figure out what is wrong.  The client is directed to survey 3 people at home and report back from the checklist beside each sentence a final score for each family member or friend surveyed. Sometimes they find out that grandma knows more about football, tennis, soccer, or baseball than they thought!
One of my frustrations over the years is that the pre-packaged practice materials for “r” often involve infantile-looking pictures or stories that are of no interest to clients in this age group.  I have the clients write stories for me so that I have a collection of “r” stories that are meaningful to this age of client.  They first look through the stories in my story album and choose X number for home practice.  Then they are ALL required to write me a story to add to my collection.
In a similar manner, I design my own board games with frequent “Pick a card” spaces.  When landing on a “Pick a card” space, they have to pick from a pile of cards that contain instructions for what they have to do.  I started out years ago with my own made-up cards, but now have a collection from my clients that are much more creative than mine (e.g. Pretend you are on a roller coaster and say “I really feel like throwing up” three times then move ahead four spaces.)  If they choose not to do what’s on the card, they must go back to start.  I send 3-5 blank index cards home with each client to have him or her contribute to my card pile.  This always results in solid follow-through with a home assignment as they try to out-do what others have written!
There are many other activities I have developed over the years that always keep in mind what motivates clients of this age.  Modifying card games like “War” by calling the cards “red hearts”, “dagger hearts” (spades), “three-leaf clovers” (clubs), and “girl’s best friend” (diamonds) allows for lots of practice opportunities.
Advances in technology have given us many more options as well.  One of the recently available “Speech Buddies” tools by Articulate Technologies is designed to facilitate “r” production. One very bright client, whom I challenged with the task of finding a motivating way to practice at home on the computer, discovered a free app called V-lingo.  You talk in to the iPhone or device and it tells you what it thought you said, which is mind-blowing to me!  Not only that, it frequently lists a column of words entitled “or did you say…” which then allowed us to figure out a graduated scoring system.  When the iPhone had his word totally correct, he gave himself 10 points.  When it was in the “or did you say…” list, he got 7 points.  If the iPhone showed a word with any variation of “er” in it, he at least got 3 points.  Nothing better than activities that the client can practice himself or herself without the therapist or parent having to be present!
 
This Month’s Featured Contributor: David Hammer, MA CCC-SLP, Children’s Hospital of Pittsburgh
Special Thanks to Dave Hammer for contributing this great article.
Dave Hammer is the Manager of Speech and Language Services at the outpatient north satellite of Children’s Hospital of Pittsburgh, Pennsylvania. He has over 30 years of pediatric clinical experience, with specialty interests in apraxia of speech in children, childhood and adolescent stuttering, and severe articulation/phonological disorders. Dave has been invited to present workshops on apraxia of speech throughout the United States, Canada, and Australia. He is a member of the CASANA (Childhood Apraxia of Speech Association of North America) Advisory Council. Dave was a member of the ASHA AdHoc committee on childhood apraxia of speech. He has been involved in the production of a number of apraxia-related DVD’s and an innovative children’s CD.
Dave is known for his practical and therapy-oriented approach to his presentations.