Tagged "bubble hierarchy"


Ask a Therapist: Significant Tongue Thrust Swallow Pattern and Tongue Protrusion

Posted by Deborah Grauzam on

Hello!

 

I have a 13 month old with Down syndrome who has a significant tongue thrust swallow pattern and tongue protrusion. Her tongue is ALWAYS out of her mouth, far. Almost as if she is intentionally pushing it all the way out. She retracts her tongue when I place a straw in the corner of her mouth, place a puff on her molar ridge (and will maintain tongue lateralization for a short period), and when I place the elephant jiggler in her mouth. As soon as she attempts to control the puff with her tongue or swallow, her tongue pushes forward again. I can prompt her to retract her tongue at rest but it comes right back out. What else can I do? I only get to see her one time per month at this point. Mom sits in on sessions and carries over at home. Pediatrician and ENT have no concerns about size of tonsils; I have not observed them myself yet.

 

Aubrie

 

Hi Aubrie,

It sounds like you have been working really hard with this patient to address the tongue retraction.  Everything you are already doing sounds great.  I would add bubble blowing, horn blowing and chewing on the back molars (with cubes of food if able, z-vibe and the bite tubes). All of this will encourage tongue retraction in the mouth. The more you can work on the retraction the better.  

I hope this helps.

Please let me know if you have any other questions.

Thanks,

Elizabeth J. Smithson, M.S.P., 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: Client with Autism and Apraxia of Speech

Posted by Deborah Grauzam on

Hello TalkTools,

 

I am an SLP working with a four year old boy with autism and apraxia of speech. He has some significant drooling and is non-verbal. I completed the "Three-Part Treatment Plan for Oral Placement Therapy" on-demand course, but was hoping for some guidance from your Instructors.

 

He is the first child I've used Oral Placement Therapy (OPT) with, and we're working on the Drooling Remediation Program. He's progressing really well with the Chewy Tubes and the Straw Hierarchy but is not able to volitionally blow on Step 3 of the Bubble Blowing Hierarchy, nor is he able to blow for Horn #1 or hold a tongue depressor between his lips for any length of time.

 

He is able to produce the /m/ and /b/ sounds, but often not on command. He just recently began to show some lip rounding while producing a /w/ sound.

 

I did purchase the Pre-Hierarchy Horn and have been working on the ball/exhalation activities. Is there anything else I can/should be doing to help him with blowing?

 

Also, when he eats, he sometimes will chew the food, remove the bolus from his mouth, rest for a few seconds and then place the food back in his mouth and finish chewing/swallowing. Do you have suggestions on how to address this?

 

Thank you in advance,

 

Amber

 

Hi Amber,

I'm Robyn, a TalkTools® Instructor, and I will answer your questions the best I can without knowing the child.

I will start with the feeding issue first. This sounds like a self-stimulatory associated with the autism or an issue of bolus mobility. He certainly could have chewing fatigue, or perhaps cannot lateralize the bolus to where it needs to go to swallow it. You will need to assess this, and if needed, implement a pre-feeding program such as, Feeding Therapy: A Sensory-Motor Approach. If all is assessed and nothing is wrong from an oral motor perspective, I would work with the child's behaviorist on a regimented plan to keep his hands down and away from the mouth during feedings.

On to your OPT questions... Phonatory control and volitional blowing can be a very big problem with apraxia. The sounds the child is making can be reflexive in nature but not achievable on command. This is also a defining trait of apraxia. I would consult with OT/PT to start working on rib cage expansion, trunk stability, and core strength as prerequisites for blowing. For now, expose him to the Bubble Program staying on step 2 of the Bubble Hierarchy and practice placing Horn #1 in the mouth and taking it out for the lip closure motor plan. You may also model it for him with your own horn. I often sing, "If you are happy and you know it blow a horn toot toot" and place the horn in the lips when I say 'toot'. I also place children in a prone position on an OT wedge during this task. Immediately after drilling the horn, use the Apraxia Bilabial Shapes to practice the bilabials.

Good luck!

Sincerely,

Robyn Merkel Walsh, MA, CCC-SLP

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Ask a Therapist: Frontal Lisp

Posted by Deborah Grauzam on

Hi,

I am an SLP in an elementary school in Virginia. I have been recently viewing your course A Three-Part Treatment Plan for Oral Placement Therapy. I have found your information to be extremely fascinating and, although I have 2 more hours, I have learned so much through your training. I do have a question. I have a 3rd grade student that is considered having a frontal lisp. He fronts many sounds. He is able to accurately produce the /s/ in conversation, when structured and prompted. However, in the course a child was mentioned that was able to accurately produce the /s/ in the structured setting, but once the setting was relaxed, she reverted back to her resting/comfortable position  of frontal sounds. Being that he is a typically developing child (9 years), would the bubble blowing and/or horn hierarchy be appropriate?

My thoughts would be that I need to work on establishing tongue retraction. I am just wondering what your professional judgement would be, considering he sounds a lot like  the girl that played "golf-ball air hockey" against Sara's daughter. I appreciate any thoughts you may be able to share! Thank you so much for your time and expertise!

 

Hi,

Thank you so much for your interest in TalkTools.

I am so glad you are enjoying the course and learning so much.  You are definitely on track with the client you are referring to.  It takes a while to establish the correct resting position for the tongue.  Keep in mind that this child has had his tongue in the wrong position for many years now so you are correcting a bad habit as well.  It is difficult to give detailed suggestions without seeing the child but have you assessed his jaw?  I would look at his jaw placement when he is producing the sound in a variety of contexts.  An excellent tongue retraction exercise is also the straw hierarchy so you may want to consider adding this to his treatment plan as well.

I hope this helps.  Please let me know if you have any other questions.  Thanks so much and good luck.

Whitney Pimentel

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Ask A Therapist: Dystonic Cerebral Palsy Extension Patterns and Jaw Weakness

Posted by Deborah Grauzam on

Hi there,

I have just assessed an absolutely delightful little four year old boy with a diagnosis of Dystonic Cerebral Palsy. All four limbs are affected but the weakness is more apparent on the right side. My assessment has shown that he presented with significant jaw weakness and instability, he begins to jaw jut and slide after three seconds of trying a natural bite. In addition he has not sufficiently dissociated jaw, lips and tongue muscles. He has weak core muscles and very weak airflow when he speaks. Articulation is mainly open vowels with the occasional gutteral k/g and b produced with the upper teeth on the lower lip.

My main question has to do with his significant extension patterns. Whenever I presented food or a tool to the right side of his mouth it resulted in a huge neck extension round to the right with the left arm extending backwards. He needed his dad to consistently hold his head in midline. When I worked at midline e.g. frontal spoon feeding, horns and bubbles the extensor pattern to the right was still present but not as significant.

I am concerned that by working more on the right side (as I need to do because of his more significant muscle weakness on the right side) this will encourage further extensor patterns. Does anyone have experience of how to deal with this and suggestions on how to effectively work on his right side? I wondered if doing bilateral placement for bite blocks and chewy tubes would be advisable? Many thanks!

Hi and thank you for the question. In commenting, I would like to start with a question.  Is your client working with a PT and if so are they working on the rotation in his trunk?  You may want to work on airflow in rotation if you can cotreat.  One comment that many hear in my course is that "What you see in the body is what you get in the mouth" and this is particularly applicable to your comment about the upper teeth on the lower lip.

For your main question: Is your client in a well supported position when this occurs?  Also, does he have extensor patterns in his upper and lower extremities with any movement? You can also try working from behind (you are actually hip to hip with your upper arm keeping his head in neutral flexion and your fingers providing jaw/lower lip support) using a "v" finger position to support his jaw/lower lip. This will allow you to keep his head in neutral flexion vs extension. I would place a mirror in front of him so he can see himself ...and you.

For your next question: You answered your own question.  I think you should go outside the box and try to present the chewy tubes bilaterally.  I would work on symmetry first and then you may be able to alternate bilateral and unilateral chewy tubes ...so you can work bilaterally and then alternate sides.  Eventually you may be able to do two times right to one time left.  I might do a chew tube program before I introduced the bite block program. I hope this helps and let me know.

Lori Overland

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Ask a Therapist: Developmental Delay and Cerebral Palsy

Posted by Deborah Grauzam on

Hi, I have two clients that I need assistance with.

The first little girl is 5 years old and has developmental delay.  She is mostly non-verbal and communicates using Makaton.  We have used various bits of TalkTools equipment, combined with speech sound work (discrimination and encouragement to imitate single sounds).  So far we have worked through the straw hierarchy (as best we can given her level of understanding) and this has improved tongue retraction.  We have also used tongue depressor with pennies between the lips and she has enough strength to hold 3 pennies on each end without difficulty.  This has improved her lip closure and has stopped her dribbling but we have yet to hear her make any p, b or m sounds.  We have also been using the tubes and bite blocks for vowel sounds but she is still unable to imitate any vowels although can produce some spontaneously.  Her babble has really improved and she is making lots more involuntary vowel and consonant sounds but nothing on cue, and occasional approximation of words in the correct situation.  I have tried to work through the horn hierarchy and the bubble hierarchy but she is unable to blow.  She has just started to wobble the bubble on the wand by vocalizing but I don’t know how to get her to understand how to blow.  Do you have any ideas about where I should go next?

This is a very involved case - I will say that if she can't blow, she can't phonate and you need pre phonatory work to expand the rib cage. You may also need to order the exercises more carefully rather than bits and pieces. For example, sensory tasks such as Lori's mouse ears helps with the feel of the /m/ (see "Feeding Therapy: A Sensory Motor Approach" by Lori Overland).  Next feeding, then Oral Placement Therapy (OPT), then shaping OPT to Speech with Renee Roy Hill's Apraxia Kit.  This is a child who can't respond to "look at me and say what I say" so I'd skip the traditional auditory drills.  It sounds like Apraxia, so you need to be consistent each session and ensure there is true mastery at each level of the hierarchies.

The second little girl is the same age and has cerebral palsy. We have been doing similar things although she is able to make a noise through the horns but is unable to do so without vocalizing at the same time. She is able to blow bubbles well through a small piece of straw but is unable to coordinate her mouth to blow bubbles without physically having the straw in her mouth. Do you have any ideas for how to get around this?

Slowly shape the movement.  For example, 9x using bubble tube 1x without. Make sure they are practicing the best level in therapy at home daily and that the tube is wide enough that the lips are truly rounded - if you need a larger tube use the jaw closure kit. As far as voicing into the horn, that is a motor planning issue.  I usually use modeling, "quiet blowing" and if needed I whisper "hoo" with no voicing to help. These are the same kids that can not turn the voice on either but practice often helps. Make sure there's adequate posture to support the phonation tasks.

Best,

Robyn Merkel-Walsh

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