Protocol - Oral Mechanism/Cranial Nerve Examination for Young Children

This protocol is based on the following publication: Robbins, J., & Klee, T. (1987). Clinical assessment of oropharyngeal motor development in young children. Journal of Speech and Hearing Disorders, 52, 271–277. Administering it and interpreting the results may require training in the area of speech-language pathology or similar.

The protocol consists of three parts: Structures, Functions, and Rate and duration. The structures are scored as 1 (normal) or 0 (abnormal). The functions are scored as 2 (adult-like function), 1 (emerging skill but not with adult-like precision), or 0 (absent function). The rates of the child’s syllable repetitions and the duration of the vowel prolongation are compared to norms that are provided by the authors.

For the structural exam, the scores are based on visual inspections of the structures. Tongue carriage refers to the position of the tongue at rest; watch for things like tongue position that is too far forward. Fasciculations refer to muscle twitches in the tongue. Furrowing refers to abnormal grooves in the tongue. Atrophy and hypertrophy refer to tongue sizes that are too small or too large, respectively.

For the functional tasks, try to elicit the function with verbal instructions (e.g., “Stick your tongue out” (Item 34); “Lift your tongue tip up behind your teeth” (Item 35); “Move your tongue back and forth across the roof of your mouth” (Item 36), and “Stick your tongue between your upper and lower teeth.” Here are some suggestions for eliciting items 3 through 10:

3. Make your lips go round. 4. Push your lips out, like a pucker. 5. Give me a big smile. 6. Now go back and forth between a pucker and smile, as fast as you can. 7. Bite your lower lip. 8. Pinch your lips together. 9. Puff up your cheeks. 9. Open and close your lip, like a fish. Note that items 11–16 require exactly the same oral movement but are now overlaid with phonation to make speech sounds. The sounds to be produced are written in International Phonetic Alphabet, not English orthography, where /o/ corresponds to the vowel in “go,” /u/ is the vowel in “shoe,” and /i/ is the vowel in “see.” If you notice poorer performance during the alternating vowels /u/ and /i/ (Item 14) compared to just the alternating of the pucker and smile (Item 6), this is a red flag for apraxia of speech.

For Item 50, ask the child to open their mouth and say “ha, ha, ha.” You should see the soft palate moving up and down. If you do not see this movement, this may explain any hypernasal resonance in the child’s speech.

For the functional assessment, if the child is unable to follow the instructions, provide a model. After three unsuccessful trials, move on to the next item.

The syllable repetitions (Items 56– 60) measure how rapidly the child can produce strings of syllables. You can say, “We are going to say some sounds that are not real words. I’ll show you how to do it first, then we’ll do it together, and then you’ll do it on your own. The goal is to say these sounds as fast and accurately as possible. Watch this: papapapapa….” Count how many syllables the child produces in a 3-second interval and compare that number to the norms provided in the protocol. If you notice that the child’s productions of the multisyllabic trials (pataka, pattycake) are much slower than the monosyllabic trials, this is a red flag for apraxia of speech. If you notice slow productions in all types of syllable stimuli, this could indicate a neuromuscular deficit, for instance dysarthria.

Prolonging the vowel /a/ (as in “car”) requires adequate breath support and vocal fold functions. If you notice shorter durations than expected for age, this would warrant further evaluation in these areas.