Tagged "Assessment and Treatment of the Jaw"


Ask A Therapist: Child with a small mouth

Posted by Deborah Grauzam on

Hi TalkTools,

I am working with a child with a very small mouth, and the Yellow Chewy Tube is still too big and too hard for him. What would you recommend I use with him instead until he can use that? Thanks.

Jennifer

 

Hi Jennifer,

I received your question regarding your patient with the very small mouth. There are two things that I would try. You could do the gum chewing exercise that is explained in detail in Sara Rosenfeld-Johnson's book Assessment and Treatment of the Jaw, page 115.  I would just use a small enough piece of gum to fit in your client's mouth.  I would also try to work on the Sensory Friendly Bite Blocks (Purple) and gradually work up from the smallest and see if this would eventually increase the oral range of motion for your client. I would then revisit the chewy tube and see if he is able after working on the other exercises.  I hope these ideas help.  Please let us know if you have any other questions.

Thanks,

Liz

 

Elizabeth Smithson, MSP, CCC-SLP is a Speech-Language Pathologist who has over 10 years of professional experience working with infants, children, adolescents and adults. She earned her Master of Speech Pathology at the University of South Carolina. Liz is also a Level 5 TalkTools® Trained Therapist. She has received specialized training in Oral Placement Therapy, Speech, Feeding, Apraxia, Sensory Processing Disorders, and PROMPT©. Liz works with clients with a wide range of disabilities including Cerebral Palsy, Down Syndrome, and Spinal Muscular Atrophy.  She works through her own private practice Elizabeth Smithson Therapy, LLC in the home setting and in the TalkTools® office in Charleston, SC.

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Ask A Therapist: Jaw Stability

Posted by Deborah Grauzam on

Hello. I am working with a 6 year old boy who shifts his bottom jaw when producing most fricative and sibilant phonemes. According to his dentist he does not have any structural abnormalities. When working with him he is able to keep jaw stable but it is not without effort and he has yet to generalize. I was wondering what tool(s) you would recommend for me to use with him.

 

Thank you.

 

Pamela

 

Hi Pamela,

It sounds to me like you may be dealing with some underlying jaw weakness and instability. If you have not seen the 3 Part Treatment Plan video or read the "Assessment and Treatment of the Jaw" book these would be great references. I would work on using the z-vibe with blue tip, and the Bite Tube Set (red bite tube, yellow bite tube, purple grabber, and green grabber).  Jaw stability is the foundation for speech and feeding.  If there is any weakness on one side or both sides these tools will help to correct that. Please let us know if you have any other questions or if anything else comes up.

Thanks,

Elizabeth Smithson, MSP, CCC-SLP

 

Elizabeth Smithson, MSP, CCC-SLP is a Speech-Language Pathologist who has over 10 years of professional experience working with infants, children, adolescents and adults. She earned her Master of Speech Pathology at the University of South Carolina. Liz is also a Level 5 TalkTools® Trained Therapist. She has received specialized training in Oral Placement Therapy, Speech, Feeding, Apraxia, Sensory Processing Disorders, and PROMPT©. Liz works with clients with a wide range of disabilities including Cerebral Palsy, Down Syndrome, and Spinal Muscular Atrophy.  She works through her own private practice Elizabeth Smithson Therapy, LLC in the home setting and in the TalkTools® office in Charleston, SC.

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Ask A Therapist: Tips for Implementing the Horn Hierarchy

Posted by Deborah Grauzam on

Hello Talktools,

 

I'm a pediatric SLP with a clinical question for your experts. I attended the Three-Part Treatment Plan for Oral Placement Therapy (OPT) workshop last year. I have a little guy (3;4) who presents with low tone, has a breathy voice and speaks in short bursts.

 

I recently introduced the Horn Program, hoping that we could use it to improve his abdominal grading and breath support. However, we are having some problems with compensatory movements, and I'm having trouble remembering from the workshop what we are supposed to do about that!

 

When I hold up the horn, he leans, opens his mouth wide and reaches for it with his arms. If I can get him to sit back in the chair as I bring the horn to him, he inevitably opens his mouth wide. He also bites the horn for stability, and if I can get him to close his mouth as I present the horn, he grabs my shoulder for support.

 

I feel we need to back up, but I'm not sure where to go! Would one of the TalkTools® Instructors be able to help me with this? Do these sound like things his OT should work on? Are there some other activities you might recommend as a prerequisite for success with Horn #1?

 

Thank you in advance for any guidance on this issue.

 

Sincerely,

 

Kim

 

Hi Kim,

This is a common problem when starting with a client, especially if he is just beginning an OPT program, has overall low tone and also has jaw instability and difficulty with lip-jaw dissociation. The aforementioned are all good reasons to use the TalkTools Horn Hierarchy. Following are some things to remember about using the Horn Program that may be helpful.

1. Consider your seating - Is he well supported with his head, pelvis, knees and ankles at 90 degrees? Does he have a place to rest his hands, head and feet? These are important to think about initially, remembering that what happens in the body often is seen in the mouth. If you do not have access to good support from a chair, try lying him down on the floor (I like a wedge if possible, but if you are working in a home you may only have access to a pillow). Gravity can help him with stabilizing the body, and if he’s not working against his own lack of support through his core muscles, you may get a better start.

2. It is absolutely OK to provide jaw support when starting out. If you remember, you can also progress forward through Horn #1 and #2, even if you are still needing to give him support. Jaw support can help and is crucial in eliminating a few of the problems you are reporting: Moving forward (you are providing stability at the lowest level of oral function and often need good support to start. Think about getting his body and jaw positioned first with your support and THEN present the horn. Doing both at once often leads to habitual compensatory movements), controlling the opening of the jaw (increase your support as needed until he opens just wide enough - if he still has difficulty, think about where you are in his Jaw Program. If you are just beginning and he has poor jaw control, this may not be something you can completely control just yet, working on a jaw program simultaneously- the TalkTools® Bite Tube Set and/or the TalkTools® Jaw Grading Bite Blocks will help! You may also want to consider supporting him from behind if his chair seems to be supporting him OK at the hips, knees and feet but he has nowhere for his hands or head to stabilize. In this case, you would use your body as the support from behind while wrapping your hand around the head to support the jaw. This can also eliminate some of the leaning forward you may see, especially if he is seeking stability/sensory input.

3. If you continue to struggle, consider backing up and working with Step B of the Bubble Blowing Program to teach him to control airflow; this is where you blow the bubble and catch it on the wand, having him use a voiceless “ha” to teach him to isolate the abdominals. This would take out the focus of lip closure and jaw stability for now, while teaching him to access volitional air with control. I’d also really consider your jaw program, and see if several sessions of jaw input might help you gain a little more control over his oral function.

All great questions and I hope these suggestions help you find a starting point. Of course if it leads to more questions, please don’t hesitate to contact us again!

Sincerely,

Renee Roy Hill, MS, CCC-SLP

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Ask a Therapist: A Therapeutic Alternative to Mouthing Habits

Posted by Deborah Grauzam on

Hi Sara,

 

It has been awhile since we have seen you in Richmond! James is doing well. His speech seems pretty normal to us at this point (maybe some subtle things remaining). I was emailing with a related question, and hoping that you can point us in the right direction.

 

James has had some issues in the past with "mouthing" things (for lack of a better word). This seems to wax and wane, but in the last few months, it seems to be significantly worse. He will either have his hands/fingers/thumb in his mouth, or water bottle, pencil, swim cap and goggles, etc depending on the situation. It seems to be something that he does unconsciously, despite our attempts to call his attention to it, even trying "penalties" for having his hands in his mouth. Lately, I have noticed him doing even while talking to his friends, while playing soccer (when there isn't any action near him), etc. He is 11, so it is an increasingly odd behavior than it might have been at age 2. (We haven't noticed any other odd behaviors or habits, just this one...and otherwise he does well in school, socially and in sports).

 

We aren't sure what the next right step is to help him be able to stop this habit. Deterrents don't seem to work, other than to stop it while it is happening, and I wonder what the root cause of it actually is. I am not sure that a regular speech therapist would be there right person. Do you have any thoughts on how to help him?

The situation you describe is often seen with individuals who have innate muscle weakness. The habits seem to come and go and can take many forms as you mentioned above. Last time I saw him (May 27, 2012) I recommended a gum chewing program. I use gum chewing as outlined in the book Assessment and Treatment of the Jaw for both improving muscle skills in the muscles of the jaw and as an alternative to the "habits" you describe. There are more nerves going through the Temporo-mandibular joint (TMJ) than any other place in the human body. It is where we go for calming. Babies suck their thumbs, bite on their fingers, rely on a pacifier, etc, to give stimulation to that joint.

James may also need to give stimulation to that joint for calming and that is where gum chewing comes into play. If he does not know how to chew gum without swallowing the gum you will have to teach him this motor plan by going to that activity in the book Oral Placement Therapy for Speech Clarity and Feeding. In it you will be given a step-by-step program which I have used with children as young as 2 years of age.

Once​ ​ he can chew independently​ use the gum chewing as an alternative to the "mouthing." I hope this answers your question. Please tell him I said "hello."

Sara Rosenfeld-Johnson, MS, CCC-SLP

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Ask a Therapist: When to start Tongue Retraction Exercises?

Posted by Deborah Grauzam on

I have attended two of Sara's workshops. I have a 7-11 year old student with a frontal lisp who still sucks his thumb at night and sometimes during the day. His tongue is forward with an open mouth position when he is at rest. I haven't yet checked to see if his swallow is affected. Should I wait until he has stopped sucking his thumb before I start tongue retraction exercises and using the straw, horn and blowing procedures? (I intend to give the parents suggestions to encourage him to stop sucking his thumb. I have Marshalla's, How to Stop Thumbsucking and Mayer & Browns', My Thumb & I.)

Thanks,

Marge

You obviously understand the relationship between thumb sucking and the frontal lisp, but...remember kids sometimes have prolonged tongue sucking because they are seeking stimulation to the temporo-mandibular joint (TMJ). This child sucks his thumb at night, so he may be using it to calm down and relax his body to go to sleep. The sucking during the day may be related to frustration or to calming when he is relaxing or tired. I would certainly look at when he is sucking to see if it is pure habit or if it is based upon jaw weakness, asymmetry or stress. If any of these issues are present, then a behavioral approach to eliminate the thumb sucking would not be indicated. Taking his thumb away could result in the formation of other habits to address the need (sucking on his tongue, biting his nails, grinding his teeth).

I delve into this extensively in my book Assessment and Treatment of the Jaw: Putting it all together - Sensory, Feeding and Speech. If there is a muscle-based component to his frontal lisp, then using a behavioral approach alone will not be effective. With that said, I use Pam's book myself and think it is a great asset to eliminating the tongue sucking WHILE doing the OPT interventions.

Your first step is to do an assessment of his jaw, lips and tongue using the Bite Blocks, Straws and Horns to see if there is a muscle- based component. If so, you may be interested in looking at my most recent book OPT for /s/ and /z/I use a combination of OPT and traditional speech therapy techniques, including auditory discrimination and training, in addition to production activities, to normalize the muscle skills needed for standard production of the /s/ and /z/ up to the conversational level.

I hope this helps, but if not please feel free to email me again.

Sara Rosenfeld-Johnson

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