Tagged "Lori Overland"


Ask a Therapist: Feeding Issue with child that has Beckwith Wiedmann syndrome

Posted by Deborah Grauzam on

Dear Lori,

My child who is 2 1/2 years old was diagnosed with Autism and Beckwith Wiedemann at 1 1/2 and is receiving Early Intervention and making great improvement.  His greatest issue is feeding: he eats all foods as long as they are smashed; when he bites into anything his tongue kicks the food back out and there is no chewing.  We have had endless visits to specialists and doctors but no one can correctly diagnose his feeding issue. I've been through numerous Feeding/Speech Therapists through EI and no improvement has happened and a lot of unanswered questions remain.  My OT suggested I reach out to you and do some networking and so I hope you can help and lead me in the right direction because I feel as if there are not enough resources for parents who have children with feeding issues. Thank you

I would be happy to try to help you with your son's feeding issues.  Children with Beckwith Wiedemann syndrome typically do not have good tongue mobility.   My experience has been that mobility through the lateral borders of the tongue and tongue tip are reduced so children use a protrusion retraction pattern to compensate.  If you think about eating solid foods, you take a bite and use your tongue tip and the lateral border of your tongue to move the food back to your chewing surface (about where your first molar inserts).  Food is then stabilized between the lateral border of your tongue and your cheek as you chew.  If the bolus of food is large you move the food to the opposite lateral molar ridge. When the food is well enough broken down you get sensory input to swallow.  Given the size of the lingual musculature in relation to the size of the oral cavity a true rotary chew pattern is difficult to facilitate. However, I have had children who can get increased lateral tongue movement.

In addition, many children with Beckwith Wiedemann have low muscle tone, and reduced sensory awareness which impacts breaking down food and knowing when it is adequately broken down for swallowing. When you are brushing your son's teeth you can stroke the side of the tongue from back to front (4-5x on each side) to help facilitate mobility through the lateral borders. You can also try introducing a Cheerio size piece of food on the side of your son's mouth (about where his first molars are) to see if he is better able to chew the bolus.  I teach a two day sensory motor feeding class which is available live and in self study.  I also have a feeding book that can help. These resources will help you with pre-feeding strategies which can facilitate the motor skills your son needs for safe effective nutritive feeding. You can also look on the website to see if there is a therapist in your area who can evaluate your child and plan a program. 

Best,

Lori Overland MS CCC-SLP, C/NDT

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Ask a Therapist: Sensory Processing assistance with a client that has Down syndrome

Posted by Deborah Grauzam on

Hi Lori,
 
I am a speech pathologist working with Toddlers. A few years ago I attended your conference on feeding therapy. I haven’t had to use a lot of the techniques up until now, so I am a little rusty.  I currently have a little guy with Down syndrome who is not chewing a great deal. His mom told me that at home she is noticing a great deal of gagging and sometimes vomiting because of this. We have been trying different textures; however, nothing seems to be working. He is also pretty resistant to chewy tubes and allows them in his mouth for only a short time. He either lets go or will bite down and not let go. I have been looking at the chewing hierarchy, but tools are listed (e.g., z-vibe, etc.) that I can’t remember exactly what I am supposed to do with. Do you have any suggestions on how to target this or where to start? Thank you so much for your help. I appreciate it!
 

Hello and thank you for the questions.

As often occurs, I have a bunch of questions to start.

Does this little one have other sensory issues?  Is there an OT who specializes in sensory processing involved?  Have you made observations about what this little one is doing with his lips, cheeks and tongue (for purees, and for solids).

I would assume (based on the diagnosis) that you should probably be working on cheek mobility and bilabial closure for spoon, cup etc.  If a protrusion/retraction is the primary tongue movement, work on tongue lateralization.  Does the child tolerate vibration?  If so, use the vibe fine tip for the lateral tongue massage.  Try the vibe bite and chew XL head (looks like a yellow chewy tube) if he will not tolerate chewy tubes.  You may want to go outside the box and roll the tool from the lateral incisor to the first molar if this child does not like the tool on the molar ridge. By the way, I have just written a book which should be out in June if you need a review of the class (and updated exercises!!!!).

Best,

Lori Overland

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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: Why use the term "Oral Placement Therapy" (OPT) over Oral Motor Exercises?

Posted by Deborah Grauzam on

We received the below from a therapist that works in the Academic arena and wanted to share the response.

I am interested to know why you changed the terminology you use from Oral Motor Exercises to Oral Placement Therapy?

Thank you for your question.

Oral–motor is a term that is still widely used in our field. It is appropriate to use this term when we are discussing the motor skills necessary for feeding.  The use of oral motor exercises in a feeding program has never been debated in our field. For example, the pre-feeding activities taught by Lori Overland, or Susan Morris, would be considered “Oral Motor Therapy.” While there is not a one to one relationship between the motor skills for feeding and the motor skills for speech, there is an overlap of the two systems (Morris & Klein, 2000; Overland, 2012; Rosenfeld-Johnson, 2009; Overland & Merkel-Walsh, 2013). This is how the “Three Part Treatment Plan for Speech Clarity and Feeding” was developed. There was some misunderstanding however, that we, at Talktools®, were teaching “non speech exercises” such as tongue wagging, or puffing the cheeks with air in relation to articulation therapy (Lof, 2008).

Clinicians, who represent the Board of Directors for the Oral Motor Institute, have struggled with distinguishing “oral motor therapy”, from the form of “Non Speech Oral Motor Exercises” (NSOME) presented by Gregory Lof (Lof, 2008). The term “Oral Placement Disorder” was coined by Diane Bahr and myself in 2010. Children with OPD cannot imitate targeted speech sounds using auditory and visual stimuli (i.e., “Look, listen, and say what I say”). They also cannot follow specific instructions to produce targeted speech sounds (e.g., “Put your lips together and say m”). Although the term OPD is new, the concepts surrounding the term have been discussed by a number of authors and clinicians (Bahr, 2001, in press; DeThorn et al, 2009; Hammer, 2007; Hayden, 2004, 2006; Kaufman, 2005; Marshalla, 2004; Meek, 1994; Ridley, 2008; Rosenfeld-Johnson, 1999, 2009; Strand, Stoeckel, & Baas, 2006.

Oral Placement Therapy (OPT) is a tactile teaching technique used for children and adults with Oral Placement Disorders, who cannot learn standard speech sound production using auditory and visual teaching methods alone.  It is an extension of the Phonetic Placement Therapy (Van Riper, 1954) and The Feedback Model (Mysak, 1971). It is based on a very common sequence (Bahr 2001, Crary 1993, Hayden 2004, Marshalla 2004, Rosenfeld Johnson 1999, 2009, Young and Hawk 1955):

  1. Facilitate speech movement with the assistance of a therapy tool (ex. TalkTools® Bite Block, horn,  tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue);
  2. Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);
  3. Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.

Originally, I referred to this work as “oral motor therapy” as many of the techniques I used were standardized on the adult population and taught for use with clients with the diagnosis of motor speech disorders. In the 1990s when the term “oral motor” was associated with children, it was distorted to include NSOME. Oral Placement Therapy works only on movements needed for speech clarity.  OPT facilitates the pre-requisite skills in muscle control to develop dissociation and grading in the muscles of the abdomen, velum, jaw, lips and tongue for clients who cannot approximate the standard speech sounds using the instructions. If the client can produce standard speech using adequate placement and duration using only auditory and visual cueing, OPT would not be included in that client’s program plan.

In summary, the concept of OPT was developed to distinguish muscle based movement for speech, from non speech oral motor exercises (NSOME). The use of oral motor exercises for feeding is still being used in my clinic and is often combined with OPT. While the use of therapy tools and tactile kinesthetic approaches in speech therapy are not new (Marshalla, 2012), it was time to clearly differentiate that we are not teaching non-speech movements to facilitate improved speech clarity. For more detailed information, please refer to my article published with Diane Bahr, in Communications Quarterly entitled: “Treatment of Children with Speech Oral Placement Disorders (OPDs): A Paradigm Emerges.”

Respectfully,

Sara Rosenfeld-Johnson

Click the below link for a copy of this in PDF format.

Description of Oral Placement Therapy (OPT)

REFERENCES

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Bahr, D. C. (2001). Oral motor assessment and treatment: Ages and stages. Boston: Allyn and Bacon.

Banotai, A. (2007, September).  Reviewing the evidence:  Gregory Lof’s critical take on oral-motor therapy.  Advance for Speech-Language Pathologists & Audiologists, 7-9.

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Flaherty, K., & Bloom, R. (2007, November). Current practices & oral motor treatment.  Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Boston, MA.

Fletcher, S. (2008, November). Palatometry principles and practice.  Session presented at the annual meeting of the American Speech-Language-Hearing Association, Chicago, IL.

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Hammer, D. W. (2007). Childhood apraxia of speech: New perspectives on assessment and treatment. Las Vegas, NV: The Childhood Apraxia of Speech Association. (workshop)

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Hayden, D. A. (2004). PROMPT: A tactually grounded treatment approach to speech production disorders. In I. Stockman (Ed.), Movement and action in learning and development: Clinical implications for pervasive developmental disorders (pp. 255-297). San Diego: Elsevier-Academic Press.

Hayden, D. A. (2006). The PROMPT model: Use and application for children with mixed phonological-motor impairment. Advances in Speech-Language Pathology, 8(3), 265-281.

Hayden, D. A., & Square, P. (1994). Motor speech treatment hierarchy: A systems approach. Developmental apraxia of speech: Intervention. Clinics in Communication Disorder, 4(3), 162-174.

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Kaufman, N. R. (2005). The Kaufman speech praxis workout book: Treatment materials & a home program for childhood apraxia of speech. Gaylord, MI: National Rehabilitation Services.

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Lass, N., Pannbacker, M., Carroll, A., & Fox, J. (2006, November). Speech-language pathologists’ use of oral motor treatment.  Poster session presented at the annual meeting of the American Speech-Language-Hearing Association, Miami, FL.

Lof, G. L., & Watson, M. (2008, July). A nationwide survey of nonspeech oral motor exercise use:  Implications for evidence-based practice. Language, Speech, and Hearing Services in Schools, 39, 392-407.

Maas, E., Robin, D. A., Austermann Hula, S. N., Freedman, S. E., Wulf, G., Ballard, K., & Schmidt, R. A. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology, 17(3), 277-298.

Marshalla, P. (2004). Oral-Motor techniques in articulation & phonological therapy. Mill Creek, WA: Marshalla Speech and Language.

Marshalla, P. (2007). Oral motor techniques are not new. Oral motor institute, 1(1). Available from www.oralmotorinstitute.org.

Meek, M. M. (1994). Motokinesthetic Approach. Albuquerque, NM: Clinician’s View. (3 videos)

Moore, C. A., & Ruark, J. L. (1996). Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research, 39, 1034-1047.

Moore, C. A., Smith, A., & Ringel, R. L. (1988). Task-specific organization of activity in human jaw muscles. Journal of Speech and Hearing Research, 31, 670-680.

Morris, S. E. (1989). Development of oral-motor skills in the neurologically impaired child receiving non-oral feedings. Dysphagia, 3(3). 135-154.

Morris, S., & Klein, M. (2000).  Pre-feeding skills (2nd ed). San Antonio, TX: Therapy Skill Builders.

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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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