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Ask A Therapist: Challenging Patient

Hi TalkTools!

 

I have taken your Three-Part Treatment Plan for Oral Placement Therapy class and have 3 of your books. I am using OPT within my practice and see positive results in my patients. I do have one patient who is very challenging. She is 16 years old, globally delayed and has a diagnosis of cerebral palsy, sensory processing disorder, low cognition and is nonverbal. She loves to eat and does eat a fairly typical diet despite all of this, but of course, can't chew very tough meats. She drools. She has had very little oral motor therapy integrated into her speech therapy treatment plan over the years.

 

I will call my patient, M. We have been working on the bite tube hierarchy following the OPT evaluation, and she is able to compress the bite tubes (red bite tube- 10, bilaterally which is an improvement from where she started;  yellow bite tube- 7 on left and 5 on right- both sides of jaw are weak, but right is weaker). We are about to add purple bite tube when parent is ready. It has also resulted in less mouthing of objects, oral seeking and general calming.

 

M. is hypersensitive to facial touch and having her hair touched. She is also over responsive to some kinds of touch within the mouth despite use of sensory techniques from OPT (sensory program with toothette) and Beckman techniques used for several months. She has shown an improvement to tolerate tooth brushing at home since intervention.

 

1 - M. is using straw #1 on the straw hierarchy, but since it has been systematically cut to 1/4 inch, she is showing an increased jaw movement, which I'm thinking means she is still suckling the straw rather than using a true suck. She is getting better at not placing her lips over built in lip block. She only uses the straw for part of the evening at home with parent supervision, it is not used during the school day, but I might be able to arrange this with school staff. Do you think the reason she is not progressing on straws is that I have cut the straw too short, too soon, or is she just not getting enough practice with it? She likely has been suckling for many years now.

 

2 - I have not had any success using the bubble blowing hierarchy or horn hierarchy or pre-hierarchy horn, even with having a PT present to assist with positioning. She does not appear to understand how to grade her abdominal movements to exhale at all.

 

3 - I would appreciate any guidance you can give me regarding M., as I do want to help her with saliva control. We have had some success increasing her ability to request preferred snacks and activities with the PECS program, since she came to me with no communication system at all. I am about to visit her school to collaborate on her treatment program. Her parents are willing to work on PECS with her at home. They would like for her drooling to decrease, but they are only able to work on straws and bite tubes to a limited degree at home.

 

Thank you for your time.

 

Holly

 

Hi Holly,

Thanks for your question! Allow me to address each of your questions individually to make things easy to follow.

1 - Go back to the 1/2" length to see if she is moving her jaw.  If not, then go to 3/8" as she is 16 years old and may need that amount of the straw to give her enough room to protrude her lips.  The length is not as important as her ability to use only her lips with her tongue retracted and not biting on the straw.  If she can do that without jaw movement, progress to Straw #2 cut to 3/8".

2 - Try working with an OT who can bounce her on a ball to generate airflow.  Once she can do that, you can put the horn in her mouth as she is bouncing down to teach the relationship.  I have also described another technique below that I use with some kids.

Whispered “Huh”

Place the open palm of M's hand 1” in front of your mouth as you say a whispered “huh” sound.  Immediately place M's​ open palm in front of M's​ mouth as you model the whispered “huh” sound.  Continue to alternate between your mouth and M's​ mouth until M tires, refuses the intervention or produces a volitional exhalation.  Reward any attempt at imitation. (Goal:  Associate the feel of airflow on M's​ hand with volitionally controlled oral airflow for speech sound production)

3 - ​It sounds as though you are on the right track with this young girl.  Keep at it as the techniques you are suggesting are the correct ones and you are making progress.  Let the parents know that the horn blowing will be the best treatment for the drooling but that you need them to do the homework at least 3 times a week or it will not work. I hope this answers your question but if not, please let me know how else I can help.

Sara Rosenfeld-Johnson, MS, CCC-SLP

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