Written by Michele Cole Clark MEd CCC/SLP
Last October, I had the pleasure of meeting Krisi Brackett. I served as a moderator for her continuing education course, “Pediatric Feeding & Swallowing: A Medical, Behavioral, Oral Motor Model.” I, of course, had an instant interest in her work as I fancied myself one of the few SLPs with an oral motor behavioral approach to feeding. She and I quickly found we were kindred spirits linked by our approach to feeding intervention i.e., use of basic behavioral strategies to advance oral intake by mouth, a rarity amongst SLPs. As we talked across the weekend, we compared notes about our views of intervention, mine being heavily influenced by an oral motor model. I introduced Krisi to the idea of using a structured oral motor program, sharing how its use informs my practice. Krisi was immediately interested, and so with that, I invited Krisi to attend the Beckman Oral Motor Assessment and Intervention Protocol course by Debra Beckman MS CCC/SLP; this being the oral motor assessment and intervention protocol that influences all my therapeutic decisions concerning functional feeding skill.
Krisi asked if I would share how I use Beckman’s protocol in my daily practice.
To preface, my journey to competent feeding intervention was a bumpy one until I found Dr. Suzanne Evans Morris CCC/SLP, my first pediatric feeding course instructor, who molded my current core beliefs about the basics of feeding intervention. Together with her colleague and co-author, Marsha Dunn Klein OTR/L, she published a manual, Pre-feeding skills: A comprehensive resource for mealtime development (2nd Edition), which I have fondly referred to as my “feeding bible” across the years. Dr. Joan Arvedson CCC/SLP also influenced my practice with her work in pediatric dysphagia and feeding with medically fragile infants and babies. But, the largest contribution to my current treatment focus was the Beckman Oral Motor Assessment and Intervention Protocol. Many years ago, a colleague introduced me to Beckman’s Oral Motor course (as a source for motor speech intervention techniques); I was thrilled to have a fresh view point and a hands-on tool to add to my tool box for motor speech concerns and feeding skill development. These SLPs laid a sound foundation in my belief that touching the mouth (oral motor intervention) would influence nutrition going in the mouth. As my pediatric feeding caseload grew, my reliance on Beckman’s work grew planting the seeds that have grown into my current diet texture advancement work.
In our collective drive as feeding interventionists to find, create, and use evidence-based methods of intervention, the Beckman protocol was the most logical tool I found for oral motor assessment. I found over time that without a common assessment tool, I felt as though fellow SLPs/ OTs were talking apples and oranges when describing a child’s oral motor skill; the reported skill didn’t match the child’s presentation -ultimately setting the child up for failure with volume of food by mouth and/or diet texture advances. Beckman’s signature work is a criterion referenced, evidenced -based oral motor assessment tool and intervention protocol. It allows the clinician to identify oral motor deficits, quantify skill, progress and maintain motor skill, and track oral motor changes over time i.e., the strength and range of movement of the lips, cheeks and jaw, jaw resting range and alignment, soft palate competence, hard palate contour, and lingual variety of movement for bolus control (lingual tip elevation, mid-blade elevation, and lateralization), elicited through a therapeutic peri and intra-oral touch protocol yielding a baseline summary of functional oral motor skill. I find that Beckman’s work allows my colleagues and I to have a conversation about oral motor competence and proficiency using quantifiable, common language without subjective guesses and opinions about oral skill.
About 8 years ago, I joined a multidisciplinary pediatric feeding disorders program. As a part of this team, I function as one of the four professional arms- gastroenterology, psychology, nutrition, and oral motor. As the SLP, my role is to make accurate determinations and predictions regarding the client’s readiness for texture advances commensurate with developmental skill, to habilitate/ rehabilitate/accelerate skill acquisition, and to predict the advances that could be expected in an 8-week to 6-month time period, dependent on the model of care. To fill that tall order, my assessment begins with completion of the Beckman Oral Motor Assessment to identify the child’s baseline (current) oral motor deficits and/or delays (non-nutritive skill) possibly affecting nutritive intake i.e., weak jaw strength, poor lingual variety of movement, etc. I consider general oral motor function to be the prerequisite to nutritive function; treatment is a systematic plan to bridge the gap between the two. The Beckman intervention protocol provides the base plan to progress isolated areas of weakness, range of movement, lingual contour and variety of movement, and builds the foundational skill through therapeutic touch (compression and stretch of the muscle) and functional tasks influencing oral skill development to provide the control needed for safe effective oral intake or best feeding potential.
A great ‘ah-ha moment’ in my years of pediatric feeding (second to focusing on oral motor skills for improved oral intake) was to incorporate the behavioral principle of antecedent manipulation: *persistence (non-removal) and *reasonable request of the child into every oral motor non-nutritive and nutritive therapeutic task, including Beckman protocol tasks. With these two behavioral components intertwined in treatment, combined with the Beckman protocol, treatment progress i.e., nutritive oral motor skill and diet texture advances occur quite timely. Timely treatment is imperative when dealing with a child’s nutritional status.
*Reasonable request of the child is a request (task) that is introduced at the least challenging level for the child, and is advanced by incrementally fading (or advancing) the challenge of the task to a more challenging task(s) over time (within the session or over several sessions); the challenge, for the therapist, is to increase the challenge without the child feeling anxious and refusing the task.
*Persistence implies that the therapist takes the lead, offering the task within 2 inches of the mouth, remaining within a 2- inch vicinity of the mouth until the child accepts the task or tool (chewing tool, spoon, gloved finger) and completes the task; a task that was predetermined by the therapist to be a reasonable request of the child (incremental fading of the task challenge).
My more recent work, based on the Beckman Oral Motor Assessment, along with my colleague, Paige Roberts OTR/L, was to develop a therapeutic progression we call the Chew Development Protocol. It combines the structure of evidence-based behavioral treatment model and achievement of minimal oral motor competence to accomplish developmentally appropriate oral skill for diet texture advancement. We define minimal oral motor competence as those skills the client must demonstrate prior to advancing diet texture; as the nutritive demand increases, the minimal competency of the skill(s) increases i.e., the skill demand required for oral transit of a puree consistency vs. advanced skill required to masticate a chewable bolus. The Chew Development protocol guides our diet texture choices in meals and diet texture targets in therapy.
As with any feeding intervention, the approach taken does determine the success of the child and the family in maintaining feeding skills. We (SLPs and OTs) are obligated to progress the client’s skills in a timely manner; changes should occur within weeks, not months or years. To make these strides, the families must be engaged and invested in their child’s feeding advances. I ask/urge the families to engage in oral motor tasks and/or exercises multiple times per day (frequency across the day with short duration), and sustain the oral motor home program across time. The home program usually consists of hands-on Beckman oral motor exercises (Beckman teaches caregivers to use therapeutic touch to advance and/ or maintain oral motor changes). The magic ingredient to change is the family’s consistency with engagement of their child in oral motor experiences daily i.e., Beckman therapeutic exercises and non-nutritive and nutritive tasks. Every caregiver receives ample coaching during each and/or all oral motor sessions, sometimes session after session, with each home program task, as needed, to help him/her work with their child daily with ease.
My broad goal for intervention is to present the child with the “just right” oral motor challenge at each session, establish a simple yet impactful daily home program with the parent, and progress oral motor skills for timely diet texture advancements. By using the Beckman Assessment and Intervention Protocol to inform oral motor skill level, I am able to scaffold skill, progressing from non-nutritive tasks to nutritive accomplishment. The Beckman assessment protocol encourages re-assessment of oral motor gains as often as necessary to glean the child’s readiness for the texture advancement, and to document progress as often as needed.
With the knowledge of Arvedson, Morris, and Klein etched in my head as my on-demand developmental feeding knowledge, Beckman’s assessment and protocol is my starting point. Oral motor progress becomes somewhat predictable, guided along a predictable path, with timely goal achievement toward food by mouth and diet texture advancement.
Michele Cole Clark MEd CCC/SLP
Children’s Feeding Program at the Marcus Autism Center, Children’s Healthcare of Atlanta
http://www.beckmanoralmotor.com Note: Once you take The Beckman course, Debra allows clinicians to attend again for free as lab assistants. This allows for extra help practicing stretches and continued learning!
Beckman, DA, (1986, rev. 2013). Beckman Oral Motor Assessment and Intervention. Published by Beckman & Associates, Inc., 620 N Wymore Rd, Suite 230, Maitland, FL 32750.
Morris, S.E., & Klein, M.D. (2000); Pre-Feeding Skills: A comprehensive resource for mealtime development. San Antonio Tx: Therapy Skill Builders