Tagged "Chewy Hierarchy"


Ask A Therapist: Feeding Suggestions

Posted by Deborah Grauzam on

Hi TalkTools,

 

I was at the Feeding Therapy: A Sensory Motor Approach course Lori Overland taught in Manhattan this past January. I've been in love with using what I've learned and have even become a go-to feeding person at my school.  

 

I have a low-toned girl who has tongue protrusion at resting but can keep her mouth closed at times.  During all speech sounds, she produces with her tongue forward, and I am working on getting it back (have suggested use of straws).  Her teacher recently brought to my attention her difficulty with feeding.  

 

When observed eating eggs, fish, rice-softer foods with less crunch-her tongue weakness definitely shows. The food just pools in the front of her mouth until she eventually spits it out, because she can't swallow it. She turns her head to the side when chewing, which I'm assuming is her inability to dissociate her tongue from her head. With crunchier and longer foods, her teachers have done well teaching her to put it on the side. 

 

I would like to implement some of the tongue lateralization exercises as well as the chewing hierarchy for her. It seems she has so much trouble even just initiating a swallow. I appreciate any further suggestions you have, and if you have any idea how to explain why she's having difficulty with these softer foods. 

 

All the Best,

 

Lisa

 

Hi Lisa,

Thank you for your kind words about the feeding class. It sounds like you are doing a great job. Here are a few suggestions for you:

  • Check under her tongue to make sure she doesn't have a posterior tongue tie
  • Work on lateral tongue movement and the chewing hierarchy
  • Work on cheek mobility to help stabilize food
  • Use therapeutic feeding techniques at mealtime - she may be better able to swallow foods presented on the lateral molars
  • Work with her PT to establish a good seating position for feeding

Good luck!

Lori Overland, MS, CCC-SLP, C/NDT

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Ask a Therapist: Bite Tube Hierarchy for TMJ stimulation

Posted by Deborah Grauzam on

Dear TalkTools,

 

My son, David, is 4 years old and has Down Syndrome. He has in the last year started chewing on his tongue. I have tried giving him the P & Q to chew on and also the Gator Jiggler. The Gator works for a time and the P's and Q's do not seem to help at all. I looked on your website for potential ideas to no avail and was wondering if you have additional thoughts/ideas. We are a very oral family -- I chew on my pens (usually when I'm thinking), my two oldest daughters were thumb suckers until older, my 2nd daughter bites her nails, my 3rd daughter chews on her shoelaces...thanks for any ideas that you may have!!

 

Robyn

 

P.S. Sara has seen David informally the last two years at NDSC.

Hi Robyn,

I am so pleased you decided to email TalkTools with this question. I must say this tongue chewing is often seen in kids with the diagnosis of Down syndrome as well as with other children with low tone and associated muscle weakness. In my second book, Assessment and Treatment of the Jaw - Putting it all together: Sensory, Feeding and Speech, I devote an entire chapter as to why children with jaw weakness find these habits: tongue sucking is only one of them. Other kids choose teeth grinding, finger sucking, sucking on clothing, biting themselves or other, prolonged use of pacifiers or sippy cups and nail biting. What all of these "habits" have in common is the need for stimulation to the temporomandibular joint for calming. This is the joint where the bones of the upper jaw and the bones of the lower jaw meet right below the ears. This joint has more nerve endings than any other place in the human body. It is where we go to relax. In your email you mentioned you bite on a pen and your daughters bite on shoe laces or nails. The up-and-down movement of the jaw relaxes us and helps us to organize our bodies.

Because your son needs stimulation directly to the joint the two techniques you listed: P&Q and Jiggler vibrator are not giving him the correct input. The muscles that need to be activated are the masseter muscles and the tools you are using are not reaching those muscles.

We, at TalkTools, have developed many techniques to give this necessary TMJ stimulation. One which seems very appropriate for your son would be the Bite Tube Hierarchy, in which four tubes are used to not only satisfy the need for TMJ stimulation but also are used to improve speech clarity and chewing skill levels. The instructions for how to implement the technique is included with the therapy tools. There are many more options to substitute for the tongue sucking and these can be found in the book I mentioned above.

I hope this answers your question,

Sara Rosenfeld-Johnson, MS, CCC-SLP

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Ask a Therapist: Therapy Cards and Chewy Tubes

Posted by Deborah Grauzam on

Hi Sara, I am Jonathan's speech therapist, his Mom and I had a few questions for you. 1. When working with your therapy cards should we provide jaw support due to his jaw sliding or just stay on lower level cards that don't cause his jaw to slide until his jaw strengthens from the OPT exercises?

Stay on the lower level cards. As he progresses through the Bite Tubes and the Bite Blocks you can ​add higher level cards.

2. Is it okay for Joe to use the yellow chewy tube unmonitored throughout the day to replace his finger and tongue chewing even though his jaw may slide while he chews it? (The yellow tube causes his jaw to slide more than red).

No, those tubes need to be used only for exercises as stated in the program plan.  You can give him other tubes to chew on throughout the day.  TalkTools carries many other tubes for this sensory need.  Try one of the nubby ones as that may be just what he needs.

3. Is it possible his lower jaw pulls to the right during speech because of a structural issue and not muscle weakness?

I did not see any structural issue when I evaluated him in January so unless he has had an accident I would say no.  This sliding should be corrected as you progress through the jaw exercises.  It is only 4 months since I saw him and jaw weakness is a tough problem to correct. Give yourself at least one year before you start looking into other possibilities​.

Thanks for your time! These were questions concerns that come up during a conversation with mom.

Feel free to contact us at anytime

Sara Rosenfeld-Johnson, MS, CCC-SLP

677

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Ask a Therapist: Down syndrome Program Plan

Posted by Deborah Grauzam on

Hi Lori,

I recently took your "Feeding Therapy: A Sensory-Motor Approach" workshop and it was great!!  In the past year I've completed the "Oral-Motor Therapy: Assessment & Program Plan DevelopmentDVD as well and started volunteering with the local Down Syndrome Association to practice what I've learned.

My current client is a 4 year old boy with Down syndrome who has tactile defensiveness, which I believe is secondary to having been through a 'feeding' approach that pushed more on him than his oral-motor skills could handle. Overall, he is low tone, with open mouth and significant tongue protrusion.  His current team has recommended a very expensive behavioral feeding program, which I don't believe will benefit him at this time.  He will currently only drink formula from a bottle, 6 times per day.  When he drinks from the bottle he is suckling with his tongue right out underneath the nipple, and he has been fed in a reclined bouncy chair. He is not able to drink from a cup as even thickened liquid is lost all over, and his tongue is still out under the cup rim.  He tilts the cup up and gets liquid on his top lip and inadvertently in his mouth.

We've figured out a seating position we can work with (in a booster seat - not the best, but all we have right now), but don't have an OT in the picture to make recommendations.  We started on a pre-feeding program to normalize sensory response, and, where he would not let anyone touch his face at all, he is now letting us do some facial massage, tapping (with hands and with vibration) and Gator kisses, and recently started putting the end of the Gator Jiggler in his mouth.  He will not yet tolerate any tools further inside his mouth than his lips, but we have started to get some lip rounding and tongue retraction when he puts the Gator Jiggler in his mouth.  He is also letting his Mom and I hold Horn #1 and he will blow on it 5 times at this point.

He is obviously still on the bottle at this point for nutrition, but his family and I are working towards lip closure, tongue retraction and getting his cheeks active.  The attempt with the honey bear was unsuccessful as too much liquid got squeezed into his mouth so he is now refusing it.  His parents report he can use the Straw #1 from the hierarchy to suckle and get liquids that way.

I'm really on my own right now, as there are very few therapists where I live that have been trained using these methods so I wanted to make sure I'm on the right path with him.  My goals are:  pre-feeding program to normalize sensory response and allow tools on his face/in his mouth, get lip-closure and tongue retraction, activate/develop his cheeks, and later start elongating the lateral margins of his tongue to get lateralization, and start with chewing hierarchy number 1.

Here are my questions:  1)  Am I on the right track, based on the little you now know about him?  2) Should I stick with the straw hierarchy, and not introduce the recessed-lid cup as too many things might be confusing?  3)  He has very limited different tastes in his diet right now, is it okay to introduce different tastes in liquid form, or will this interfere too much with our primary goal of getting into his mouth??  4)  Can I please get your recipe for natural thickener?

Thank you so much for any assistance/direction you can give me!

Hello,

Thank you for your email. I am impressed with both your assessment and your proposed treatment plan.  Given your description of his sensory motor skills I agree that a behavioral program is not warranted at this time. It sounds like you have made some initial gains which will allow you to access his oral musculature.  I think your priorities are massage, tap and tone, the cheek stretch, Mickey Mouse /m/, lateral tongue massage and chewing hierarchy level #1. If he is drinking from Straw #1, absolutely continue the hierarchy and do not introduce the cup and the straw at the same time.  You may try naturally thickened liquids such as fruit smoothies (yogurt, fruit and ice well blended) or stage 1 fruit purees thinned out with spring water.  You can also try adding club soda to the fruit puree to add the sensory input.  As for transitioning from liquids to puree. I would start with the mickey mouse /m/ in your pre-feeding program to develop the motor plan for spoon feeding, then work toward using the vibrating spoon with nothing on it to develop the motor plan for therapeutic spoon feeding. Then try liquids he tolerates on the spoon (I might start with water and work my way to a flavor)!!!! Thanks for sharing!

Good luck.

Lori Overland, MS, CCC-SLP, C/NDT

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