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

I need your advice for a client with Treacher Collins Syndrome. The child has had his left lip and palate repaired, his face & skull are severely deformed. We have been doing OPT for 1 year: greatest improvement is in blowing (from not able to blow to Horn #4, Bubble Bear 1 feet; he can do depressor press with 14 coins and 6" button pull, /m/ sound ok but not /b/; many sounds backing as /g/, talking in simple sentences now).

His jaw is very problematic: he cannot open his jaw to more than 4-5mm, I let him bite on straws of different diameter, gum pressed flat and wrapped with gauze, Bite Block #2 held on first molar area. He's on oxygen mask at night, his doctor said he'll have us do OPT for half a year, and if he still can't open his jaw, he'll consider cutting his tongue out to prevent sleep apnea. Mommy is unwilling to let doctor cut his tongue nor open his trachea, and so she asked if I can train him to stick out his tongue so he has more space in his oral cavity to breathe? Can you give me some advice?

Thanks, Louisa

Hi Louisa. Have you tried using the Progressive Jaw Closure Tubes? Start with the smallest and have him bite and breathe through. When he can do this as you count slowly to 50 and without any compensatory posturing, go to the next larger tube. In this way you will see if the problem is muscular or structural. If it is muscular, then by going through the hierarchy to the largest one you should see some good results. If it is structural (boney, skeletal) then at one point he will not be able to progress.

To teach him to stick out his tongue, you can then go back to the smallest tube and ask him to push his tongue forward into the tube numerous repetitions. That will give him the jaw from tongue dissociation you are looking for.

Best

Sara Rosenfeld-Johnson