When an Orofacial Myofunctional Disorder Lingers in the Shadow of Oral Apraxia

“He had no clue as to how his articulators worked or moved” - Rebecca, an SLP, recalls about her client, Xavier*, before he began myo treatment with her. Xavier’s story is being shared to exhibit a case where orofacial myofunctional disorders (OMDs) emerged from the shadows of comorbid apraxia and articulation disorder diagnoses. Imagine a 5-year-old boy that loves nature - frogs, critters, spending time outdoors. He’s handy with scissors and paper and even makes his own little puzzles. Yet his speech can not be understood by most people. His own family can’t understand only about 60% of what he says. He has been labeled simply as “apraxic”. 

The Initial Diagnoses and Background 

Xavier had had a complex smorgasbord of conditions and challenges in his first years of life: difficulty breast and bottle feeding, oral phase dysphagia, failure to thrive, lingual and labial restrictions, expressive language issues, and poor lingual mobility. He had been in speech-language therapy since he was 2-years old due to delayed and unintelligible speech. He also received feeding therapy in his early years. Additionally, no improvement was observed in his lingual mobility and function following the release of his lingual and labial restrictions at 2 years, 8 months (which occurred during the height of COVID and there were no prescribed post-op aftercare/exercises). 

Two years later in May, 2022, another SLP diagnosed him with Oral Motor Apraxia using the Kaufman Speech Praxis Test. He could not imitate many of the oral commands asked of him - protrusion, lateralization, or elevation of his tongue; however, he could do some of the lip movements. Interestingly, he was diagnosed only with Oral Motor Apraxia and did not meet the criteria for a Verbal Apraxia diagnosis “since his articulation errors were consistent”. 

Xavier’s speech was a mechanical and auditory tangle. He was formally diagnosed with “severe articulation disorder”, which his SLP suspected was related to his Oral Motor Apraxia. The mechanics of his speech were characterized by oral groping and “constant movement” of the tongue. As he tried to navigate sounds, long pauses between speech sounds appeared as though he was “figuring out” how to articulate, and he demonstrated an inability to accurately move his oral musculature on command. Auditorily, his speech had a fast rate and was “clutter-like”, characterized by poor clarity and hypernasality of most speech sounds. As a result of the latter, he was assessed for velopharyngeal insufficiency but the exam was unremarkable. The most aberrant and curious speech errors were his vocalizing upon inhalation, the production of /n/ for /l/, and his production of /t/ with a “tongue-smacking” sound (imagine using the dorsum of your tongue to break lingual-palatal seal in the middle of your palate). Any clever person will use oral compensations to get as close as to a speech sound as they perceptually can, and considering his history of lingual restriction and oral motor apraxia, this sounds like one such compensation that he had acquired. 

By 2023, speech intelligibility was significantly below age expectations and was estimated to be, shockingly, 30% intelligible to strangers, meaning only 30% of what he said could be understood by people unfamiliar to him. He was only 60% intelligible to his family - he should have been 100% intelligible to everyone. It is no surprise that a knock-on effect of his poor speech intelligibility was that he did not talk to strangers, not even to the ice cream scooper to request his favorite ice cream flavor and toppings. 

Xavier received intervention from both his school SLP and a private SLP to target his articulation disorder with the goal of improving overall speech intelligibility. Childhood Apraxia of Speech interventions were not used since he did not fit this diagnosis. His progress in speech-language therapy over the years was slow and minimal. 

What led to the idea of using Myo on an apraxic client like Xavier? 

The purpose was to reveal and treat underlying OMDs that were buried, easily missed, or masked under his Apraxia and Articulation diagnoses. 

The Myo Diagnosis

Myo crossed paths with Xavier just at the right time. Rebecca had previously worked with him in a preschool program for a year while he was 3 years old. She couldn’t shake the feeling there was a “missing link” in his case. “Why hadn’t he gained progress in prior therapies?” and “Was there something else co-occuring with the Oral-Motor Apraxia and Articulation Disorder Diagnoses”? After years of wanting to learn more about myo and no longer working in the schools, she trained with Neo-Health, and then reached out to Xavier’s family to offer him a therapy that had not yet been explored. His mother, an OT, had already been researching Myo and had wondered if it could help her son. He was also at the perfect age to begin Myo - the stars had aligned! There were no promises that it would help, but desperate times called for innovative measures…

In April 2023, Xavier began a journey that unearthed and treated a previously undiagnosed orofacial myofunctional disorder (OMD) that subsequently improved his speech, confidence, and orofacial function forever. Rebecca conducted an Orofacial Myology evaluation on Xavier, revealing that he presented with an Orofacial Myofunctional Disorder characterized by the following: open mouth posture and mouth breathing, dry lips, low tongue rest posture, inability to elevate or shape the tongue as requested, disordered movements of the tongue, lingual-mandibular differentiation difficulties, inability to suction tongue to the palate, hyperactive gag, munch-chewing pattern, pocketing of food in the buccal cavity, inability to create and propel a bolus correctly, and excessive liquid intake with food swallows. He did not appear to have any neuromuscular deficits such as paralysis or weakness. He had no history of noxious oral habits. 

Feeding and swallowing issues remained significant. The case history intake and examination revealed that he overstuffed his mouth with food and had difficulty coordinating his oral structures when eating. He dropped food on its way to his mouth. He open-mouth chewed and was observed to facial grimace when eating. He experienced previous coughing and choking episodes and had previously required the Heimlich maneuver during one such choking episode. This meant his mother had to cut up his food into small pieces for safety and keep a “close watch” on him during meals. 

The Journey 

In April 2023, one year of Myo treatment began with his mother as an active participant in his weekly sessions. Rebecca used the Orofacial Myology: From Basics to Habituation Program, tailoring and pacing treatment to Xavier’s individual needs. Within the first session, Xavier experienced a monumental breakthrough. With his mandible stabilized, Xavier was able for the first time to briefly isolate his tongue from his mandible to elevate it! Rebecca believes it was this oral motor skill that paved his path to progress. He and his mother worked hard every day as he sat on the bathroom counter, practicing in the mirror. Over the course of the next few months, Xavier made impressive gains in his lingual coordination and accuracy, especially with lingual-mandibular differentiation and tongue elevation. Though oral fatigue remained a challenge, within 3 months working on myo with some articulation work carefully integrated, his tongue clicking on /t/ in isolation and in single words was resolved! 

By mid-December, 2023, Xavier had achieved amazing progress considering his oral-motor apraxia diagnosis. He had mastered numerous lingual-basic training skills, lingual-mandibular differentiation across all planes, lingual-palatal suction, shaping of his tongue… the skills and criteria usually expected of his peers who only have OMDs and not apraxia. It was an impressive feat after years of essentially being at a therapeutic plateau. In myo he completed the lingual skills with accuracy and consistency. He eased nicely into more sophisticated motor tasks for Chewing and Swallowing Mechanics. Like a duck to water, he learned to suction, trap and swallow liquid. 

Throughout treatment his apraxic tendencies remained. In February 2024, he demonstrated difficulty coordinating the steps for suctioning water on command and instead was blowing the water. When prompted to “suck like from a straw”, it was still a challenge for him and for the therapist. Like many children with complex cases, Xavier was sometimes behaviorally challenging. He became frustrated when some tasks were too hard. Rebecca managed to creatively navigate his behaviour to set him up for success. 

The Light at the End of the Tunnel 

One year into myo therapy, Xavier’s progress was astounding. He was surprised at the leaps and bounds he had accomplished during the past year. Whereas he previously could not coordinate even one oral skill on command, he was now able to perform multi-step oral skills . 

In spite of some lingering articulation errors, he was now remarkably 100% intelligible to strangers and family with spontaneous speech in conversation. He was passing the proficiency exams in therapy and breezing through all the therapy stop points. As he worked towards incorporating and habituating his skills into his daily life, his mother found that Xavier no longer was at risk of choking, and he did not need monitoring at school during mealtimes by the school nurse. His mother no longer had to cut up his food into small pieces and no longer had to supervise him. He no longer pocketed food and he swallowed without using water to assist bolus propulsion. His oral kinesthesia improved and he now had awareness of where his tongue was in his mouth. 

Xavier’s speech, confidence, and orofacial function were almost unrecognizable from one year prior. His toothbrushing and hyperactive gag during dental examination had normalized. Family members whom he hadn’t seen often were remarking that they could understand him, much to the relief of his mother who had been acting as his “translator”. He was able to attend school and no long had the fear of not being understood. He was pleased that he could eat alongside his peers in the cafeteria. When he was asked “Who do you like to talk to?” he responded “everyone”. When his mother reminded him that in the past he did not talk to everyone, he agreed and said “but now I like to!” His confidence blossomed over the past year, and he gained control and agency over his oral-motor coordination. His mother admitted that she had been prepared for him to be in therapy until he was 20 just to be understood by others. Recently, Xavier’s mother and Rebecca spoke on the phone, and it was reported that Xavier is now a confident child that talks to new people and is independently ordering his own favorite toppings for his ice cream at the ice cream parlor. What a sweet resolution for a boy who seemed entangled in a web of comorbid diagnoses. 

*Not the client’s real name.