When people need help with therapy or products, we put TalkTools® Instructors to work and then publish the exchange for anyone in the same situation to get help, too. This question is from Danielle, by Facebook message.

Dear Therapists

 

I need advice please! I am seeing a 5 year old child with severe childhood apraxia of speech together with dysarthria (specifically weakness of tongue and lips). So far his lip strength and movement has improved a lot, but I am really struggling with his tongue. He can protrude his tongue beautifully, retraction we are working on, but he is doing ok so far. Lateral movements we are also working on, but tongue elevation seems impossible!  Both posterior and anterior tongue movements just aren't happening! Any advice will be appreciated!!!

 

Kind Regards

 

Denise

Hi Denise,

Thank you for your email.  I understand your frustration!  I can tell you in looking at motor development, tongue tip elevation does not occur if you do not yet have retraction and stability along with lateral border stability which all allow the tongue tip to develop so it may just be a matter of continuing to work on the underlying skills necessary for tongue tip dissociation.  Often, children who have motor planning deficits in conjunction with oral motor weakness can progress at a rather slow pace and therapy can be difficult when compared to children who only have dysarthria.  I'm happy to help you sort out what might be missing!  I often find that the order I do treatment in can be as important as the exercise itself.  For example, many children with CAS and Dysarthria have difficulty isolating the motor skill I'm looking for, thus a good sensory-motor program may be useful immediately before targeting the motor task I have as a goal.

I'm not sure what education you have in TalkTools but the Three Part Treatment Plan teaches of our systematic approach to motor speech disorders based on normal development. I look forward to hearing from you!

Renee Roy Hill, MS, CCC-SLP

Hi Sara,

 

I have a student who is turning four years old next month. I have been seeing her for several months for nasal emission on /sh/, /ch/ and /j/. She never had any anatomical problems and has been seen by an ENT. Oddly, she produces /s/ and /z/ just fine in spontaneous speech. I've been trying to work off the /s/ to /sh/, or /h/ to /sh/ by raising the jaw while producing /h/, the butterfly position, etc. I don't think she is able motorically to follow the instructions but then again it could be she doesn't understand due to her age. I can tell she is trying as she will crunch her nose trying to stop the air from coming out. She is bright and discrimination training has been mastered. She understands oral versus nasal sounds. Do you have any suggestions?

Let me begin by saying there may be a few options for her and without seeing this almost 4 year old I can only give some suggestions. You will have to try each of them to see which is the most beneficial.

To begin, the difference between the /s/ and /z/ and the "sh" "ch" and "j" is the increased use of the lateral margins of the tongue resting against the upper palate.

1. If your client can say "ee" then you might want to work from that position rather than from the ones you tried. Show her a picture of the upper jaw with the sides of the tongue resting against the upper jaw. You can find this graphic in the handout for the class, "A Three-Part Treatment Plan for Oral Placement Therapy" if you have taken that class or if not it is also in the book, "Oral Placement Therapy for Speech Clarity and Feeding". Once this child can feel the sides of the tongue elevated and making contact with the upper palate you can have her freeze in that tongue position and try to say the standard "sh." Sometimes it is easier to get the "ch" from this position so I would try both.

2. If that does not work then I would see if she has the ability to elevate the sides of her tongue. The prerequisite movements for this placement would be the ability to a) lateralize her tongue tip to the back molars on alternating sides of her mouth without sliding her jaw, b) elevate and depress her tongue tip from an "ah" jaw position without moving her jaw. If she cannot do these prerequisites then the Straw Hierarchy would help develop these skills. Again you would refer to the book "Oral Placement Therapy for Speech Clarity and Feeding," for complete instructions.

3. You might also want to try the activity entitled, "Oral-Nasal Contrasts" from "Oral Placement Therapy for Speech Clarity and Feeding," as that activity works directly on mobilizing the velum.

I hope this helps,

Sara Rosenfeld-Johnson, MS, CCC-SLP

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