Q: I was very excited to get your test, the MOST. Can you explain the scoring system to me?

We had to design the Marshalla Oral Sensorimotor Test (MOST) so that therapists who had no prior information about oral-motor assessment could administer and score it.

Original Design

I originally designed a 7-point scoring system, with one score for Pass, and six different scores for Fail. The seven-point scoring system was designed to reveal subtle differences in oral motor skill between one client and another. However, pretests revealed that this made the test too cumbersome. Therapists could not make quick judgments when given seven different options, and some therapists did not understand what made one scoring option different from another.

Problem

Oral-motor skills are not easy to quantify. The assessment of oral movement is much different than a test of vocabulary, which requires a client to simply point to a picture. This is a visual analysis of movement, and there are only subtle differences in movement between the child who has poor oral motor skill and the one who has exemplary skills.

To be very frank, most SLP’s are not taught these things in the universities. The universities train SLP’s to analyze articulation performance with the ears and not the eyes. In other words, we learn to assess phoneme productions by listening, not by looking. Therefore we had to design the MOST to be useful to therapists of all ability levels. It had to work for therapists who had no introduction to oral motor, as well as therapists actively involved in feeding training, and so forth.

Solution

Our solution was to design the MOST with a basic Pass/Fail scoring system. Clients receive a 1 for a Pass, and a 0 for a Fail. The client either can achieve the required task or he cannot.

Example

For example, a client is required to lower the jaw (open the mouth) for the first test item. He has to lower the jaw and hold it for three seconds (a three-count). The client scores 1 if he can accomplish this task, and 0 if he cannot. This is a simple task with a very simply way to score it.

More Than Pass/Fail

However, much information can be gained by simply asking a client to open his mouth. Jaw lowering can be used to determine if the client can move the jaw at all. But it also can be used:

• To assess the client’s range of jaw movement
• To make an assessment of oral tone
• To assess symmetry of jaw movement
• To note the pitch, roll, and yaw of jaw movement
• To record overflow of jaw movement to other body parts
• To note the retention of primitive reflexes
• To notice signs of oral-tactile hypersensitivity
• To judge the client’s ability to sustain oral position
• To assess rate of muscle contraction and relaxation
• To watch the face for signs of oral pain
• To determine a client’s willingness to move the mouth
• To evaluate the smooth grading of oral movements.
• To appraise how well the child differentiates jaw movement from face, lip, and tongue movements
• To levy how well the child differentiates jaw movement from head, shoulder, trunk, and hip movements
• To observe how well the child differentiates jaw movement from hand movements
• To determine the client’s awareness of his own oral movements
• To take note of structural deviations that may be interfering with jaw mobility

Underlying Information

We did not want to lose the more detailed information with the simple Pass/Fail system. Therefore we decided to place these types of details within the Fail option. Clients score 0 if they fail the item, but then therapists can provide more information with the second scoring option. This gave the MOST a two-tiered scoring system. The quantitative numeric system (Pass/Fail or 1/0) allows therapists to make quick judgments about skill. The qualitative alphabetic system (A, B, C…) allows therapists to make finer discriminations about oral movement.

Example

Returning to our example of the first item, lowering the jaw: The child scores 1 if he passes, or he scores 0 if he fails. But then he can be scored A, B, C, D or E as follows:

• A: The child scores A if he can attain the position but cannot maintain it. This may indicate that the child has poor oral strength or endurance, limited awareness of his movements, limitations in his ability to imitate oral position, etc.
• B: The child scores B if his movements are jerky. This may indicate low strength, poor control, asymmetrical tone, poor oral awareness, etc.
• C: The child scores C if he moves another facial part while lowering the jaw. This may indicate poor differentiation of movement.
• D: The child scores D if a structural problem interferes with jaw lowering. This may indicate that the child actually has good oral control, but that the structural problem is the cause of his difficulty with oral movement.
• E: The child scores E if he simply refuses the task. This could be an indication of oral pain, apraxia, simple stubbornness, boredom, etc.

The Pass/Fail score allows a bedside quantitative measure of oral-motor skill. The deeper qualitative measure affords therapists who know how to read such things to use the MOST in order to substantiate what they otherwise would simply be record as anecdotal information.