(Editor's note: In response to readers' requests, ADVANCE introduces a new column for clinicians by clinicians. The new "Therapy Tips" column will appear in the first issue of each month.)

It is universally accepted that the rhotacism, a defective utterance of the /r/ sounds, is usually the last and most difficult American English consonant to correct functionally. In my practice this is not the case in the absence of a pathology. Maturity of the patient must be taken into consideration, physiologically and neurologically.

I use two methods to help correct the rhotacism.

The first is a six-step exercise that begins with having the youngster put the tip of the tongue on the upper gum behind the central incisors to produce the /l/ sound. The child should take a deep breath and use voice to make the /l/ sound. With the voice going, gently push the underside of the tongue into palatal arch with the tip of a tongue depressor. With the lateral segments of the tongue contacting the upper molars and tongue blade in the palatal arch, you will hear a perfect /r/ sound.

Do this several times and have the patient kinesthetically feel the tongue position in relation to the intra-oral position. Finally, have the patient open the mouth wide, comfortably, and say "ah." Slowly move the tongue back from the /l/ position and try to replicate the feel of the tongue formerly formed by the use of the tongue depressor.

Note: As the tongue blade turns back, it innervates the superior longitudinal muscles (intrinsic), making a slight trough.

A prerequisite for the second exercise is to make the patient aware of the tongue's ability to not only change in size but also to move laterally, upward/forward and backward, all with precision. All of these abilities are usually normal developments of the intrinsic and extrinsic musculature of the tongue.

The following are preliminary exercises for the tongue:

• With the mouth comfortably opened wide, cup the tongue to hold approximately half a teaspoon of water, without spilling, for 10 seconds. Try to feel the corner of the mouth with the sides of the tongue.
• Hold the tongue out steadily for 10 seconds. The tongue must be a) narrow, like an arrow; b) pointed at the tip, like an arrow; c) straight, like an arrow; and d) rounded on top so no water can pool on its dorsum.
• Make the tongue narrow and wide 10 consecutive times. Do not move the mouth, lips or jaw.

The /r/ exercise begins by having the patient open the mouth wide and say "ah." The patient should keep the voice going as the tongue is cupped (inside the mouth).

As the lateral segments of the tongue contact the upper molars and the apex of the tongue is positioned in the palatal arch, you should hear the /r/ sound. It is important, kinesthetically, to feel the contact of the sides of the tongue pressing against the upper molars. The stronger the contact, the sharper the /r/ sound.

The patient then should say "ah" and slowly cup the tongue to get the /r/ sound. This should be done often, and the patient should attempt to do it faster.

Note: Be certain the patients does not move the lips. Involving the lips will produce a /w/ sound.

Beyond this point, clinicians should go on to the normal routine of /r/ exercises containing nonsense syllables, etc.

Dr. Fogel has a private practice in Florida. He can be reached at (239) 261-8828.