Ask a Therapist: Tongue Thrust

Posted by Deborah Grauzam on

I have been working with a 2, almost 3, year old patient for 10 months. He initially came to me with delayed speech -- one-syllable words with limited vocabulary and reduced intelligibility. He now uses 5-6 word sentences spontaneously, intelligibility has increased, he has added new speech sounds and errors are primarily /th/ and blends. We did a lot of oral strengthening as he was a drooler and that has improved. He had a very restricted lingual frenum, corrected in December. He also has an inferiorly attached upper labial frenum, which limits some range of motion in upper lip movement. My concern:   he continues to exhibit a suckle drinking pattern. We have introduced the straw program, but I can’t get past the first one because of the suckle. Is he too young? Should that improve with the increased range of motion now that he's had the lingual frenectomy? He is at a good point with language and articulation, so I was wondering if there is something I can do to make a difference?

Tongue thrusting should be fully remediated by 24 to 36 months, so suckling at this age is atypical. I would refer the patient to an oral surgeon or ENT to seek medical advice on the frenums. It sounds to me like there may be a structural issue.

Sara Rosenfeld-Johnson wrote an article titled, “Effective Exercises for a Short Frenum,” on how to stretch the frenum (sublingual) with the use of bite blocks which I would recommend you read. See if you can get the client to touch the upper back molar with the tongue tip. If not, you can try Sara's exercises. I do this often to prove that therapy alone may not work. Sometimes you can stretch it, but it depends on length, color and location.

Robyn Merkel-Walsh

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Ask a Therapist: Straw #4 Question

Posted by Deborah Grauzam on

I have a student that will be transitioning to straw #4. The ¼ of an inch varies depending on how she puts the straw in her mouth. Do you have guidelines for this?

Thank you for the question!

In this case, the first twist must be resting perpendicular to her lower jaw. The first twist of the straw should not pass her lips, and if the twist is perpendicular to her lower jaw, she can not put more of the straw into her mouth.

Best,

Sara Rosenfeld-Johnson

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Ask a Therapist: Thickened liquids with the Straw Hierarchy?

Posted by Deborah Grauzam on

I am using your straws for therapy with several of my students. When we get to the thickened liquid steps I am not sure what food to use at the puree and pudding consistencies, as my student is allergic to wheat and dairy products. Can you offer suggestions or guidance?

This is a great question and one I hear regularly from SLPs.

“Puree” and “pudding” are suggestions for the textures and thickness required, any food that can be thickened or thinned can be used. For example, you could use a baby food fruit puree for the puree level or make a shake from any fruit. You can also use agar or a thickener to thicken a liquid. Look at the child's diet to see what foods can be used and go from there.

Good luck!

Sara Rosenfeld-Johnson

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Ask a Therapist: Teeth Grinding

Posted by Deborah Grauzam on

My child has no problems with eating or drinking, but grinds his teeth until I want to grind mine! His dentist says it's common in kids with Down syndrome. I saw your teeth grinding items and wondered if they might help? He is 5 years old, does not speak much – he imitates sounds, growls and whale noises from his favorite movies, but has no interest in forming words. He is in speech therapy through school.

Teeth grinding is generally used to help children with special needs to organize their bodies or to calm down; they are seeking stimulation to the temporomandibular joint (TMJ). This joint is where the upper jaw and lower jaw meet right below the ears. Babies suckle their thumbs or suckle on a pacifier to get the same needed stimulation. As your dentist noted, teeth grinding is common in children with the diagnosis of Down syndrome, but there are reasons and a treatment protocol. Because your son is not talking, I suspect he has weakness in the masseter muscles (muscles of the jaw) as related to his diagnosis, he too may need that additional stimulation to the TMJ.

This is such a huge issue that I have written a book on the subject called, Assessment and Treatment of the Jaw.

There is a whole chapter on why kids grind their teeth or have other habits that provide direct stimulation to the TMJ. I encourage you to read the book before you invest in any therapy tools, as it will help you identify what tools and activities would most benefit your son.

In addition, if there is a gap between what your son understands and what he can say, then his jaw weakness may be a primary factor in keeping him from using oral language. You may want to look into having him evaluated by an SLP in your area who is familiar with Oral Placement Therapy. Many SLPs have taken our introduction classes and would be able to work with your son if there are muscle-based deficits related to his difficulty in learning to talk. 

Sara Rosenfeld-Johnson

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Ask a Therapist: “Fixing” During Horn Hierarchy Exercises

Posted by Deborah Grauzam on

I use the horn hierarchy and really love the results. One of my clients, a young girl, tenses her muscles - shoulder, stomach, facial, etc, to blow and make the appropriate sound for appropriate duration. How do I stop this compensation?

The client is “fixing” – using a compensatory pattern that lets the SLP know the client does not have adequate grading skills in her abdominal muscles. Without seeing the child, there are several possibilities based on the description above:

1. The horn is too difficult for the client. Go back to the previous horn on the hierarchy.

2. The horn is not too difficult, but she does not understand how to use duration of oral airflow without clavicular breathing. In this situation, use the Duration Tube Kit to teach her duration using abdominal grading.

3. Fixing could be a habit the client has developed. Use an easier horn on the hierarchy. Explain to the client she should blow the horn while keeping her shoulders down. Once she understands the feel of the "acceptable" body posture, begin progressing through the hierarchy.

4. Tactile cueing during the exercise may help. Push down on the client's shoulders as she is blowing -- the tactile pressure inhibiting her compensatory posturing may help her understand “acceptable” body posture.

5. The client's jaw is weak and she cannot perform the jaw from lip dissociation movement needed to blow the horn. In this case, stop the Horn Blowing Hierarchy and work on jaw stability. Each week, retry the horns to see if improved jaw skills enable the client to blow the horn without the compensatory postures.

The Horn Hierarchy is a small part of the TalkTools offerings to improve speech clarity. See our website for more information on live workshops in your area or Educational self-study courses (we offer continuing education credits for workshops and self-study courses), and learn about other TalkTools therapy techniques.

Sara Rosenfeld-Johnson

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