TalkTools | Ask a Therapist – Tagged "suckling"

Ask A Therapist: Reverse Swallow In Drinking

Posted by Deborah Grauzam on October 27, 2017

Hi TalkTools,

I have a question about the straw hierarchy. I have a 5 year old with severe phonological processing disorder and recently repaired posterior tongue tie. I have started the straw hierarchy with her. She is on straw #3 and able to take in a single sip and multiple, consecutive sips, but seems to take too big of a water bolus which causes her to pause before swallowing to make a suckling motion to manage it in her mouth before swallowing it. Any suggestions? Thank you.

Jody

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Hi Jody,

I am thinking based on what you are saying that she is demonstrating a reverse swallow. I am gathering that you are saying that this is what you are seeing on multiple swallows and not single sips. If she is not doing it on single sips I would try to stay there for an extended period of time to get her used to swallowing in the correct way and then build up to multiple sips. Your client can demonstrate tongue protrusion with the first 4 straws but cannot move to #5 without tongue retraction. I hope this helps. Please let me know if you have other questions.

Thanks,

Liz

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Elizabeth Smithson, MSP, CCC-SLP is a Speech-Language Pathologist who has over 11 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.

Ask A Therapist: Challenging Patient

Posted by Deborah Grauzam on June 01, 2015

Hi TalkTools!

I have taken your Three-Part Treatment Plan for Oral Placement Therapy class and have 3 of your books. I am using OPT within my practice and see positive results in my patients. I do have one patient who is very challenging. She is 16 years old, globally delayed and has a diagnosis of cerebral palsy, sensory processing disorder, low cognition and is nonverbal. She loves to eat and does eat a fairly typical diet despite all of this, but of course, can't chew very tough meats. She drools. She has had very little oral motor therapy integrated into her speech therapy treatment plan over the years.

I will call my patient, M. We have been working on the bite tube hierarchy following the OPT evaluation, and she is able to compress the bite tubes (red bite tube- 10, bilaterally which is an improvement from where she started; yellow bite tube- 7 on left and 5 on right- both sides of jaw are weak, but right is weaker). We are about to add purple bite tube when parent is ready. It has also resulted in less mouthing of objects, oral seeking and general calming.

M. is hypersensitive to facial touch and having her hair touched. She is also over responsive to some kinds of touch within the mouth despite use of sensory techniques from OPT (sensory program with toothette) and Beckman techniques used for several months. She has shown an improvement to tolerate tooth brushing at home since intervention.

1 - M. is using straw #1 on the straw hierarchy, but since it has been systematically cut to 1/4 inch, she is showing an increased jaw movement, which I'm thinking means she is still suckling the straw rather than using a true suck. She is getting better at not placing her lips over built in lip block. She only uses the straw for part of the evening at home with parent supervision, it is not used during the school day, but I might be able to arrange this with school staff. Do you think the reason she is not progressing on straws is that I have cut the straw too short, too soon, or is she just not getting enough practice with it? She likely has been suckling for many years now.

2 - I have not had any success using the bubble blowing hierarchy or horn hierarchy or pre-hierarchy horn, even with having a PT present to assist with positioning. She does not appear to understand how to grade her abdominal movements to exhale at all.

3 - I would appreciate any guidance you can give me regarding M., as I do want to help her with saliva control. We have had some success increasing her ability to request preferred snacks and activities with the PECS program, since she came to me with no communication system at all. I am about to visit her school to collaborate on her treatment program. Her parents are willing to work on PECS with her at home. They would like for her drooling to decrease, but they are only able to work on straws and bite tubes to a limited degree at home.

Thank you for your time.

Holly

Hi Holly,

Thanks for your question! Allow me to address each of your questions individually to make things easy to follow.

1 - Go back to the 1/2" length to see if she is moving her jaw. If not, then go to 3/8" as she is 16 years old and may need that amount of the straw to give her enough room to protrude her lips. The length is not as important as her ability to use only her lips with her tongue retracted and not biting on the straw. If she can do that without jaw movement, progress to Straw #2 cut to 3/8".

2 - Try working with an OT who can bounce her on a ball to generate airflow. Once she can do that, you can put the horn in her mouth as she is bouncing down to teach the relationship. I have also described another technique below that I use with some kids.

Whispered “Huh”

Place the open palm of M's hand 1” in front of your mouth as you say a whispered “huh” sound. Immediately place M's open palm in front of M's mouth as you model the whispered “huh” sound. Continue to alternate between your mouth and M's mouth until M tires, refuses the intervention or produces a volitional exhalation. Reward any attempt at imitation. (Goal: Associate the feel of airflow on M's hand with volitionally controlled oral airflow for speech sound production)

3 - It sounds as though you are on the right track with this young girl. Keep at it as the techniques you are suggesting are the correct ones and you are making progress. Let the parents know that the horn blowing will be the best treatment for the drooling but that you need them to do the homework at least 3 times a week or it will not work. I hope this answers your question but if not, please let me know how else I can help.

Sara Rosenfeld-Johnson, MS, CCC-SLP

Ask a Therapist: Down syndrome Feeding Question

Posted by Deborah Grauzam on September 13, 2012

Hello, my daughter is almost 2 years old and has Down Syndrome. We had the opportunity to meet Lori Overland when my daughter was about 9 months old. I feel so fortunate to have found TalkTools while my daughter was very young, although we still have some struggles. Our OT is familiar with TalkTools and is also a feeding expert. We have an issue with tongue thrust/protrusion. My daughter drinks from a straw but she sticks her tongue out. I think she may still be using the suckling action. (We have never used sippy cups.) She eats a lot of foods and we have always tried to introduce solids on the sides. She does chew and bite on things and we are slowly progressing to more challenging chewing foods. We have your straw program but have only used the first straw due to tongue issues. I believe she has what is called a reverse swallow – she sticks her tongue out to move food back before swallowing.

My daughter sticks her tongue out when playing and puts everything in her mouth. Sometimes I feel like it's a game to her to stick her tongue out. We also have some chewy tubes and a z-vibe. My daughter will sometimes bite down on the z-vibe but doesn't care for the chewy tubes. She loves to have her teeth brushed now and bites down on the toothbrush all the time. I am sad and discouraged and not sure what to do. I feel like we have worked so hard but she still has this problem. I know it can be corrected, I just don't know what our next step should be. Any guidance you could share would be wonderful. Thank you so much.

Hi, children with the diagnosis of Down Syndrome often have this issue. The first thing you need to do is see an Otolaryngologist (ENT) and have him/her look at the adenoids, tonsils and Eustachian tubes to ensure that there is no airway obstruction causing the tongue to be displaced forward for breathing. Sara Rosenfeld-Johnson explains these issues in this article.

Once there is medical clearance, you will need to do a series of feeding and oral placement activities to provoke three main goals:

1. Jaw Stability

2. Lip Closure

3. Tongue Retraction

While I cannot diagnose or create a program plan without seeing your child, a few general suggestions can be given.

A. I suggest you take Lori's course on the Down Syndrome Population and/or her Sensory-Motor Feeding course. You have a great start with slow feed for solids and the straw, however it seems you need to add a few more pre-feeding tasks to the repertoire. Maintaining tongue lateralization and Lori's tongue hugs would be helpful. Cheek toning and the upper lip stretch will be useful as well.

B. I suggest using the Honey Bear Straw Cup mid line, supporting the jaw and superimposing the correct oral motor skills for swallowing by supporting the jaw, and squirting small amounts of liquid into her mouth in sequences. This breaks the suckling habit. The straw should be no longer than 3/4 of an inch.

C. A combination of Oral Placement activities such as: Bite Blocks, TalkTools Horns and Bite Tubes would be great for her, but this type of plan really needs to be created by an experienced TalkTools Therapist. Please visit the "Find a Therapist" page. We also offer traveling clinics -- perhaps you can catch up with one of us when we are local!

Hope this helps :) Thanks for your interest in TalkTools!

Robyn Merkel-Walsh