Tagged "TalkTools Therapy"


#tbt: My Best Tips For Eliciting The K Sound

Posted by Deborah Grauzam on

This is a repost from Dean Trout’s Little Shop of SLP, with permission from the author.

Upon reaching out to her for permission, here's what Dean wrote: "I found TalkTools to be great for oral awareness and teaching segmentation of articulators!"

TalkTools | Dean TroutDean Trout worked for 31 years as a Speech Therapist in the public school system and for 4 years in her own speech clinic. She started 2 Gals Speech Products, LLC in 2007, spoke at several speech conferences and have been published in the ASHA Leader. Today she creates tangible things that she sells in her Etsy store as well as digital downloads in her TpT store"For you who are new to the field of SLP, I want to give tips and tricks to make your therapy more effective. ... For you more mature SLPs I want you to feel comfortable with technology and social media." 

April 10, 2017

TalkTools | K Sound (Dean Trout)I have often felt baffled as to why kids cannot produce /k/ when developmentally we make posterior sounds before anterior. Think about it, a baby’s first sounds are goo-goo and ga-ga, so isn’t /k/ just a naturally developing response? It makes me go, hmmm. Luckily there are several ways to go about teaching this sound. These tips are not in any particular order, so don’t think Tip #1 is the best. All these tips have been used successfully by several of my colleagues and me.  Please remember what works with one child does not always work with another. We are simply sharing some ideas of things to try.

TIP #1 Cue with “Clear out the Popcorn”

This tip is not EBP and I am not trying to pass it off as such.  I am just sharing an out of the box idea for when all else has failed.  In my many years of practice, I have found that the major reason a child cannot imitate a sound from our model and demonstration is simply that they don’t understand what we are telling them to do. They just don’t “get it.” It also seems that they more often than not just don’t get it when we try to show and explain how to do those sounds that are made in the back of our mouths: /k/, /g/, /r/. So to help them “get it” I try to relate the sound to something to which they are familiar. Most all of us have eaten popcorn and don’t we all, at times, get a husk caught on the back of our tongue and have to clear it out? That is what I use to help them understand what I mean by the back of the mouth or back of the tongue, etc. Every child I have had in therapy can show me with 100% accuracy where the front and back of the mouth is located on a drawing and can point to the front and back of their own mouths, but yet cannot put their own tongues there. To teach them how to find and lift the back of their tongues, we practice that horrible hacky-growly guttural sound we make when clearing out the popcorn. We do this until I feel they fully understand what I mean when I say use the back of your tongue. Once they “get it” you can shape it into a beautiful /k/ in isolation and begin your regular therapy. If they forget to get their tongue up when drilling syllables or words, just cue with “clear out the popcorn.”

If you really want to be the fun “speech teacher” why not bring some popcorn to eat in therapy? Just check for food allergies first ;)

TIP#2 Cereal

You can also get correct tongue positioning for /k/ using cereal-Cheerios or Fruit Loops. This approach is taught by Sara Rosenfeld-Johnson in her Talk Tools program. Basically, what you do is place the cereal behind the bottom front teeth and have the child place the tip of his tongue in the cereal hole and hold it there to keep the tip down while making the /k/ using the back of the tongue. This technique is explained in detail in the Talk Tools program. Here is the link to the website. http://www.talktools.com/ I highly recommend you learn how to implement this technique because it is effective. It is great for kids who front the back sounds and need the tactile cueing.

TIP #3 Tactile Cues—Holding the Tip and Blade

For years I have had kids to use their own finger to hold the tongue tip down to get the correct position for /k/ when they were substituting /t/ for/k/. Many times they will have to not just hold the tip but the tongue blade as well. You can start out with them holding only the tip down while they say /k/, but if they start making the /k/ with the blade of their tongue mid palate you will have to have them hold more of the tongue down and push the tongue further back in their mouths. This has been exceptionally effective at achieving a good /k/ sound. Many people do not like this approach, but if it works then I say use it. I have had some kids who have had to use their finger to hold their tongue down not only in isolation but through syllable and even a few into words (gasp)! However, never fear, I have never had a kid graduate from speech therapy and still have their finger in their mouth!! I never ask them to quit using their finger. They eventually get tired of using it and stop on their own. Don’t you think we sometimes worry too much about the little things?

When implementing this strategy if you are the one holding the child’s tongue via your own gloved hand, finger cot, or tongue depressor be careful of a hyper gag reflex. If you find a child with a hyper gag, you have two choices: 1) desensitize the gag reflex or 2) don’t use this approach. If the child can tolerate you inside his mouth a nice little tip is to use flavored toothpaste on a dental swab. It is just less invasive tasting.

TIP# 4 Use Gravity

Some children need a little more help learning to elevate the back of their tongue, and gravity helps! There are suggestions to have the children let their head lean over the back of their chair or have them lie on the floor. Personally, I have had no success with using the chair technique. I have had success doing therapy while the child is lying on his/her back on the floor. Initially, I just have the child lie on his back on the floor and do some deep breathing exercises to help him relax. I will sometimes lay a book on his stomach for this. They can see the book rise and fall as they breathe. After the child looks relaxed and at ease with lying on the floor, I begin therapy using the other techniques explained in this article. The one that seems to work the best is using tactile cues. I will start with a tongue blade and gently “push” the tongue tip down toward the back of the mouth. If this doesn’t work, I try having the child “cough” really hard, (similar to the clearing of the throat.) Usually, this combination of techniques works within one to two sessions, and we can go back to sitting in our chairs for therapy.

TIP#5 Getting Tongue Retraction

You cannot produce a /k/ without your tongue retracting back into the mouth. To achieve a tongue retraction response, stimulate midline of the tongue from anterior to posterior with a tongue depressor or your gloved finger. Pam Marshalla explains this very well on the websitehttps://pammarshalla.com/stimulating-tongue-back-elevation-for-k-and-g/

I suppose this sums up every tip and trick we have up our sleeves. Hopefully, this has affirmed that what you’re doing is right or maybe even got you to thinking it is ok to try something off the wall in therapy.  I am all for Evidence-Based Practice but sometimes when all else has failed you must try something unique.  It just might work for this particular student.  

I will not discuss or debate EPB, so no need to leave heated comments. 

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Diet-Shaping for Self-Limited Diets in Children With a Diagnosis of Autism Spectrum Disorder

Posted by Deborah Grauzam on

This article was initially presented at the 2016 Annual ASHA Convention, Thursday, November 17, 2016, 4:30-5:30 PM. It is available in video in full on Facebook: Part 1 / Part 2

Authors:

Robyn Merkel-Walsh MA, CCC-SLP

Lori Overland MS, CCC-SLP/C-NDT

Learner Outcomes:

1. Participants will have an improved understanding of the etiology of a self-limited.

2. Participants will be able to demonstrate understanding of a home-based diet.

3. Participants will be able to comprehend the concept of diet-shaping.

Discussion of Topic:

The CDC (2015) reports, that Autism Spectrum Disorder (ASD) impacts 1 in 68 children in the United States. In “cluster” states such as New Jersey, as many as 1 in 28 boys are affected.

Children with ASD often present with comorbid feeding issues. There is empirical evidence and an overall scientific consensus supporting an association between food selectivity and ASD (Marí-Bauset Zazpe, Mari-Sanchis, Llopis-González & Morales-Suárez-Varela, 2014). Problems with eating often occur before the actual diagnosis of ASD, and clinicians may often be alerted to the disorder when eating problems, nutritional concerns and gastrointestinal problems occur (Beckman & Cole-Clark, 2015).

Studies show that up to seventy percent of children with ASD are selective eaters and up to ninety percent have feeding problems (Volkert & M Vaz, 2010). Children with ASD are significantly more likely to refuse foods based on texture/consistency (77.4% vs 36.2%), taste/smell (49.1% vs 5.2%), mixtures (45.3% vs 25.9%), brand (15.1% vs 1.7%), and shape(11.3% vs 1.7%), (Hubbard, Anderson, Curtin, Must & Bandini,2014). Researchers at Marcus Autism Center and the Department of Pediatrics at Emory University School of Medicine conducted a comprehensive meta-analysis of published, peer-reviewed research relating to feeding problems and autism. Examination of dietary nutrients showed significantly lower intake of calcium and protein and a higher number of nutritional deficits overall among children with ASD (Korschun & Edwards, 2013). Feeding challenges in the Speech-language pathologists receive referrals for feeding issues in ASD both before and after diagnosis (Keen. 2008).

Applied Behavioral Analysis (ABA) has the most empirical research in treating ASD to date. Behavior analysis is a scientifically validated approach to understanding behavior and how it is affected by the environment (Lovaas & Smith, 1989). It has been endorsed by a number of state and federal agencies, including the U.S. Surgeon General and the New York State Department of Health (Iovannone, Dunlap, Huber, & Kincaid, 2003). Research has shown that ABA therapy is effective at increasing appropriate behaviors and decreasing inappropriate behaviors (Kodak & Piazza, 2008). Therefore, it is reasonable to believe the principles on which ABA techniques are based can help with feeding issues (Volkert & M Vaz, 2010). The problem is that behavioral therapies however, do not often take into account the complexity of the sensory-motor system or medical issues, and how they relate to self-limited diets in children with ASD. Behavioral components may be essential in a feeding program; however, they should be implemented in conjunction with a sensory-motor approach to prove the most positive outcomes.

An infant’s first “job” in life is self-regulation and modulating arousal. These hard-wired synergies impact the sensory-motor system and oral-motor development (Overland & Merkel-Walsh, 2013). Many children with autism have significant issues with arousal and self-regulation which drives behavioral responses (Barthels, 2014.) Many children with autism also have qualitative differences in motor skills, especially with posture and alignment. (Teitelbaum, 1998). These differences in motor skills may also impact the motor skills for safely handling food. Therefore, when an individual with autism is referred to a speech-language pathologist (SLP) for self-limited diet, a comprehensive feeding assessment is required, including: review of child’s medical status; gross, fine, and oral-motor development; nutritional status; and sensory processing (Arvedson & Brodsky, 2001). For example, 59 percent of autistic children who were undergoing endoscopy for GI symptoms had carbohydrate digestive abnormalities, compared with only 11 percent in unaffected children undergoing endoscopy for GI symptoms (Beckman & Cole-Clark, 2015). Issues that affect the variety in the diet may not be behavioral. Since the sensory and motor systems cannot be separated (Morris & Klein, 2000), it is very important to task analyze the child’s motor skills and how they relate to feeding before assuming that a self-limited diet is purely behavioral (Beckman & Cole-Clark, 2015; Merkel-Walsh & Overland, 2016).

Sensory processing issues can also contribute to feeding disorders (Twachtman-Reilly, Amaral, & Zebrowski, 2008). Sensory processing refers to the ability to receive messages from the senses, interpret and organize the information in order to turn it in to an appropriate motor or behavioral response. Not all children with sensory processing disorders have autism but more than ¾ or as many as 90% of children with a diagnosis of autism have some degree of sensory processing disorder (Schoen, Miller, Brett-Green & Nielsen, 2009). Children with sensory regulation disorder may not be able to organize themselves for feeding. Those with oral sensory issues may not feel the food in their mouths, or they may be overly sensitive to the feeling of the food in their mouths. They may not feel hunger or satiation. Sensory defensiveness produces a neurochemical reaction of fear that quickly becomes a hardwired automatic response. The nervous system triggers a “fright-flight-fight” response even if it is irrational (Merkel-Walsh & Overland, 2016). In addition, once a behavior is inadvertently reinforced, the behavior will reoccur (Brophy, 2013). Children with autism are at a higher risk for these problems, because many children with autism engage in ritualistic behaviors. Seemingly well-meaning parents and therapists may not realize that by reacting to food refusals they are actually increasing the chance for this behavior to reoccur (Brophy, 2013; Merkel-Walsh & Overland, 2016).

In clinical practice the speech-language pathologist needs to look at how the child with ASD reacts to touch of the extremities, the face, and oral cavity as well as oral habits such as teeth grinding, mouthing objects and eating items other than foods. A diet analysis is needed to assess if the child has intolerances to certain tastes, temperatures and textures. This will establish the child’s home base and provide a starting point for diet expansion. The therapist must look at the underlying oral sensory-motor skills to support safe, effective nutritive feeding (Merkel-Walsh & Overland, 2016).

In conclusion, children with ASD are prone to self-limited diets. In order for a speech and language pathologist to thoroughly assess and treat this disorder, the therapist must be in tune to the sensory-motor system and design a treatment plan based on the home base, and systematically and sequentially via diet- shaping.

References:

Arvedson, J. C. & Brodksy, L. (2001). Pediatric swallowing and feeding: Assessment and management (2nd Ed.). Albany, NY: Singular.

Barthels, K. (2014). There is always a reason for behavior: is it sensory or is it behavior? (Live presentation), New York, NY.

Beckman, D. & Cole-Clark, M. (2015). Diet texture transition for individuals with autism. American Speech Language Hearing Association, Denver, CO. Retrievable: http://www.beckmanoralmotor.com/media/Diet-Texture-Progression-for-Individuals-with-Autism-ASHA.pptx

Brophy, N. (2013). Behavior plan implementation in the classroom. (Power point slides), Ridgefield, NJ.

Center for Disease Control (2015). Autism Spectrum Disorders (ASDs). Retrieved from http://www.cdc.gov/ncbddd/autism/data.html

Fisher, A. G., Murray, E. A., & Bundy, A. C. (1991). Sensory integration: Theory and practice. Philadelphia, PA: F. A. Davis.

Gisel, E. G. (1994). Oral-motor skills following sensorimotor intervention in the moderately eating impaired child with cerebral palsy. Dysphagia, 9, 180-192.

Hubbard, K.L., Anderson, S.E., Curtin, C. Must, A. & Bandini, L.G. (2014). A comparison of food refusal related to characteristics of food in children with autism spectrum disorder and typically developing children, Journal of the Academy of Nutrition and Dietetics, Vol.114 (12), pp.1981-1987.

Iovannone, R. et al. (2003). Effective educational practices for students with autism spectrum disorder. Focus on autism and other developmental disabilities, 10883576,18,3.

Keen, D.V. (2008). Childhood autism, feeding problems and failure to thrive in early infancy, European Child & Adolescent Psychiatry, Vol.17 (4), pp.209-216.

Korschun, H., & Edwards, C. (2013.) Retrieved from http://www.news.emory.edu/stories/2013/02/autism_nutritional_deficits/

Kodak, T. & Piazza, C.C. (2008). Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorder. Behavior Modification, 33: 520-536.

Lovaas, O. I. & Smith, T. (1989). A comprehensive behavioral theory of autistic children: Paradigm for research and treatment. Journal of Behavioral Therapy and Experimental Psychiatry, 20, 17-29

Marí-Bauset, S., Zazpe, I., Mari-Sanchis, A., Llopis-González, A. & Morales-Suárez-Varela, M. (2014). Food selectivity in autism spectrum disorders, Journal of Child Neurology, 2014, Vol.29 (11), pp.1554-1561.

Merkel-Walsh, R. & Overland, L.L. (2016). Self-limited diets in children with a diagnosis of autism spectrum disorder. Oral Motor Institute. Vol 5, Monograph 7. Retrieved from: http://www.oralmotorinstitute.org/mons/v5n1_walsh.html

Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development. San Antonio, TX: Therapy Skill Builders.

Overland, L.F. & Merkel-Walsh, R. (2013). A sensory-motor approach to feeding. Charleston, SC. TalkTools.

Schoen, S., Miller, L.J., Brett-Green, B.A. & Nielsen, D.M. (2009). Physiological and behavioral differences in sensory processing: a comparison of children with autistic spectrum disorder and sensory modulation disorders, Frontiers in Integrative Neuroscience, Vol. 3, Article 29, 1-11

Teitelbaum, P., Teitelbaum, O., Nye, J., Fryman, J.& Mauer, R. (1998). Movement analysis in infancy may be useful for early diagnosis of autism. Psychology, 95:23, 13982-13987

Twachtman-Reilly, J., Amaral, S.C. & Zebrowski, P. P. (2008). Addressing feeding disorders in children on the autistic spectrum in school based settings: Physiological and behavioral issues. Language Speech and Hearing Services in Schools, 39, 261-272.

Volkert, V.M. & M Vaz, P.C. (2010). Recent studies on feeding problems in children with autism. Journal of Applied Behavioral Analysis, 43 (1), 155-159.

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Autism Spectrum Disorders: Clinical Parameters of Oral Placement Therapy (OPT)

Posted by Deborah Grauzam on

Authors: Robyn Merkel-Walsh M.A., CCC-SLPSara Rosenfeld-Johnson M.S., CCC-SLP

Foreword:

This article, in the original form, was published in Advance Magazine for Speech Pathologists. The article has been expanded upon and revised with current Evidenced Based Practice.

Abstract:

Autism is a developmental disability that affects, often severely, a person's ability to communicate and socially interact with others. Autism Spectrum Disorder (ASD) impacts 1 of 68 children in the United States (CDC, 2015). In “cluster” states such as New Jersey, as many as 1 in 28 boys are affected. Autism Spectrum Disorders (ASD) is an umbrella term to include related disorders such as Asperger's Syndrome, Pervasive Developmental Disorder (PDD) and Kanner's Syndrome. The intensity of symptoms varies widely; however, all people on the spectrum display impairments in communication, social relationships and patterned behaviors. What is not as clearly understood, is the comorbidity of Oral Placement Disorder (OPD). There is  acknowledgement that, at least in a subpopulation of children with autism, communicative deficits may instead stem from more basic motor and oral motor issues (Belmonte, Saxena-Chandhok , Cherian, Muneer,  George & Karanth, 2013). Therefore, it is important for therapists to evaluate and treat not only the communication deficits with the ASD population, but also the oral sensory-motor deficits that many of these children present with.   

Introduction:

Most individuals with autism are diagnosed by the age of three or younger, and the primary complaint is delayed language skills and/or the regression of language use (Wiggins, Baio & Rice, 2006). For example, parents often report that their child was able to say some words, but suddenly they stopped speaking and became socially withdrawn. At the same time, they began engaging in repetitive behaviors, their play skills regressed, and parents reported poor eye contact and limited socialization with others (CDC, 2015).

When a child is diagnosed with ASD, most likely, a Speech-Language Pathologist (SLP) will be called upon for an evaluation. It is imperative for therapists to look at not only receptive and expressive language, but oral motor skills, oral sensory-motor issues, feeding and motor planning in order to obtain global information that may be impacting the child's ability to communicate. Dr. Barry Prizant, a leader in the field of ASD, has indicated that there is increasing evidence that lack of speech and/or gestures in children with autism may be related to issues other than social-cognitive abilities. Prizant argues that clinical evidence suggests that motor speech impairments can be a significant factor inhibiting the development of speech in children with ASD (Prizant, Wetherby,  Rubin & Laurent, 2010).

Assessment:

In clinical practice, the Speech-Language Pathologist needs to look at several areas in order to devise a treatment plan. This includes 1) sensory processing 2) structure and tone 3) pre-feeding skills 4) feeding skills 5) motor planning and 6) speech sound production.

Sensory processing is important to assess, as it relates to feeding and speech in children with ASD. Acceptance of touch to the face and oral cavity, as well as oral habits such as teeth grinding, mouthing objects and eating items other than foods (PICA) are critical to assess. Some children with ASD are over-responsive to sensory stimuli while others may be under-responsive. An over-responsive child may react to sounds in the kitchen and be distracted during meals, while an under-responsive child may seek pressure in the mouth by chewing on non-edible items (Overland & Merkel-Walsh, 2014).

Structure and tone must be assessed to rule out any comorbid factors that may be impeding feeding and speech. Children with autism may also present with issues such as: dysarthria, Orofacial Myofunctional Disorders, dental malocclusions, or Ankyloglossia. Low-tone occurs in approximately thirty percent of children with ASD (Bailey, 2013). Global hypotonia also occurs with ASD (NAN, 2015). Char Boshart (2015) has carefully designed an Ebook which outlines how to assess oral structures.

Pre-feeding skills are the underlying oral sensory-motor skills that are necessary for safe, effective, nutritive feeding (Overland & Merkel-Walsh, 2013). Morris & Klein (2010) and Overland & Merkel-Walsh, have written texts describing pre-feeding skills with careful detail.

A thorough feeding assessment is a team approach. In addition to the SLP, the feeding team may include the child’s pediatrician, nutritionist, gastroenterologist and/or otolaryngologist. It is important to determine if feeding challenges are organic or behavioral. Feeding disorders in children with ASD are often judged to be behavioral, when there may be medical and/or sensory-motor underpinnings. Most children with self-limited diets have feeding challenges that are multidimensional and are not purely behavioral (Roche, Eicher, Martorana, Berkowitz, Petronchak, Dziob & Vitello, 2011). Children with ASD often have sensory processing issues which impact feeding, but they may also have oral sensory-motor challenges that are related to deficits in pre-feeding skills. An SLP who diagnoses a feeding disorder in ASD must be sure to rule out any related medical etiology such as reflux or food allergies.

Motor planning disorders can also be comorbid with an ASD diagnosis. Childhood Apraxia of Speech (CAS), according to The American Speech-Language-Hearing Association, is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody (ASHA, 2007). In assessing a child with ASD, an SLP must determine if CAS could be a factor in a child being non-verbal. Experts in CAS, such as David Hammer and Deborah Hayden, have done extensive work in the diagnosis of CAS, and standardized measures such as The Kaufman Speech Praxis Test are available to clinicians to diagnose this disorder.

Finally, speech clarity is an important part of the assessment. There are standardized measures available, such as the Goldman-Fristoe Test of Articulation-2; however when assessing a child with ASD, standardized measures may prove challenging. There may also be children who cannot be tested because they are non-verbal. Therapists should not assume that cognition is severely impaired in a non-verbal child with ASD, because there may be coexisting oral-motor issues (Merkel-Walsh, 2014). This is why the aforementioned assessment tools are so important.

Treatment:

After a thorough assessment, the SLP can create a treatment plan that will incorporate: 1) oral sensory-motor based activities 2) feeding therapy 3) Oral Placement Therapy (OPT) and 4) speech sound production.

Oral sensory-motor based activities involve activities designed to regulate the sensory system, help stabilize postural stability, orient towards the midline and establish pre-feeding skills. Massage, vibration, and tactile stimulation methods are often used to stimulate oral postures, improve stability, and improve strength and dissociation (Morris & Klein, 2000). Deborah Beckman has a systematic approach to providing oral sensory-motor therapy called the Beckman Oro-facial Deep Tissue Release©. The protocol uses mechanical muscle responses, which are not mediated cognitively, to baseline the response to pressure and movement, range of movement, variety of movement, strength of movement and control of movement for the lips, cheeks, jaw, and tongue (Beckman, 2014). Therapeutic tools may also assist with sensory-motor and pre-feeding skills. For example, a Jiggler tool can be used to superimpose lip closure, the placement skill needed for bilabial sounds and spoon feeding. Massaging the lateral margins of the tongue can provoke lateralization which is important for safely handling a small bolus (Overland & Merkel-Walsh, 2013).

Therapeutic feeding techniques are necessary for those individuals who require supports to ensure a safe, effective, nutritive feeding (Overland, 2010). Therapeutic feeding involves postural supports, adaptive utensils and cups, placement of the food and supplemental techniques to assist in handling a bolus. It also involves careful consideration of food choices, especially with children on the autism spectrum. Establishing a home base diet is critical in diet-shaping and diet expansion (Overland & Merkel Walsh, 2013). Therapeutic feeding also considers nutrition needs and diet restrictions.

Oral Placement Therapy is a tactile approach to therapy for those individuals who cannot respond to look and me and say what I say. OPT is a modern extension of Phonetic Placement Therapy (Van Riper, 1954) and The Feedback Model (Mysak, 1971). It is based on a very common sequence (Young and Hawk, 1955; Van Riper, 1978). Merkel-Walsh and Roy-Hill (2014) presented this concept at the ASHA Convention:

Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue);

Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);

Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.

Speech sound production should always proceed oral sensory-motor and OPT tasks. Speech tasks may involve repetition of target words, and may involve tactile cueing such as the PROMPT method (Prompts for Restructuring Oral Musculature Phonetic Targets). PROMPT has been found useful for children with ASD, (Rogers, Hayden, Hepburn, S., Charlifue-Smith, Hall & Hayes, A. 2006). PROMPT is a positive treatment method, as it provides cues for placement for children who cannot easily imitate oral placements for sound production. PROMPT can be used  in conjunction with language goals.

Clinical Parameters:

Once a plan is established and an OPT plan is created, therapists are often challenged by service delivery models, since individuals with ASD often present with challenging behaviors including: self- stimulatory behaviors (e.g. hand flapping or spinning), aggression, non-compliance, work avoidance and inability to attend to task. Since there are many theories on service delivery models in autism, therapists must decide which model best suits their treatment style, and which models are based on research and evidence based. With some background on oral-motor therapy and OPT, therapists know that the child must be seated appropriately in order to gain stability and appropriate positioning for the therapy to be successful. This often presents as a challenge with this population; however with help from ASD experts, it is quite easy to incorporate oral motor and OPT techniques into a therapy plan.

Greenspan, Wetherby and Prizant are advocates of language developing through play schemas in the natural setting. Floor time, modeling and hands-on life experiences are critical in this “child centered” model. Typical natural settings include the home, the park and the grocery store. This approach follows the child's "lead", the direction the child wants to go. The adult engages the child in pleasurable activities with reciprocal play and communicative exchange, so that the activity in itself is reinforcement for the child. The therapist judges what the child wants to do based on non-verbal and verbal cues. This is the basis of the SCERTS model. “SC” - Social Communication – the development of spontaneous, functional communication, emotional expression, and secure and trusting relationships with children and adults; “ER” - Emotional Regulation - the development of the ability to maintain a well-regulated emotional state to cope with everyday stress, and to be most available for learning and interacting; “TS” – Transactional Support – the development and implementation of supports to help partners respond to the child’s needs and interests, modify and adapt the environment, and provide tools to enhance learning (e.g., picture communication, written schedules, and sensory supports). Specific plans are also developed to provide educational and emotional support to families and to foster teamwork among professionals (Prizant, Wetherby, Rubin & Laurent, 2007).

Though the SCERTS is a wonderful model for therapy, the challenge in using this approach with oral sensory-motor and OPT  programs is that the therapy is definitely led by the therapist, the client does not select the activities or tools, because the therapist knows what activities are required to improve a certain muscle-memory based skill (Merkel-Walsh, 2014). The treating SLP must balance the structure needed for OPT programs with a model that fosters a reciprocal communication exchange.

Applied Behavioral Analysis (ABA) is a method of behavioral intervention developed by Ivan Lovaas PhD and Tristan Smith PhD. It consists of teaching skills by breaking them down into small steps, while rewarding the correct responses. It is data driven and quite intensive. ABA is often associated with Discrete Trial Teaching (DTT) which uses the instruction-prompt-response-reward method to help people on the spectrum complete complex tasks. The ABA method has the most empirical research to date to show progress in children on the autism spectrum (CAN, 2005). This approach is better suited to oral-motor therapy, since OPT activities are broken down into small specific steps and have preset mastery levels, such a Bite Blocks, which have a 15 second criteria for mastery. OPT tasks can easily be written into short term objectives (STO) which are the basis of program books for ABA programs. OPT progress can be easily charted and graphed to track progress.

LG Rethink Graph

Graph provided by www.rethinkfirst.com.

Therapists do not have to choose between these two models; both principles can be applied if therapy sessions are carefully planned. A challenge in following the child-centered approach is that OPT programs have pre-established hierarchies and set requirements for mastery or success; however, one must consider that therapy must be rewarding in order for the child to engage. Children on the spectrum will need consistent, highly-motivating tangible reinforcers to engage in OPT. In addition, the sessions need to be language oriented as the main goal is oral communication.

With these principles in mind, here are general parameters in structuring Oral Placement Therapy with children presenting with ASD:

• Create a calming environment ensuring that lighting and sound have been considered in relation to sensory processing issues. Meta-music, a lava lamp, or concentration tapes can all help make the session more calming and rewarding. Consult with an Occupational Therapist if a child with ASD presents with very intense sensory dysregulation.

• Select an appropriate setting that encourages 90 degree angles in the hips, knees and ankles. Make sure the feet are on the floor or flat on an elevated surface, such as the foot rest of a high chair. You may use dycem on the chair so the child does not slide, or may need additional weighted items, such as a rice bag across the lap or a weighted vest, to give additional sensory input. If this is not possible due to out of seat behavior, a Behaviorist will need to intervene prior to therapy sessions and help the SLP with a behavior plan and/or use of alternative seating such as a bean bag chair, swing and or a ball pit.

• Create a picture schedule booklet for the client or schedule board from start to end with every activity and built in breaks for gross and sensory-motor play. Ensure that you are using favorite items, sound activities toys, music, and sensory based activities for free play on breaks. This builds in Greenspan's philosophies while keeping within the structured parameters of an ABA format.

• In coordination with an ABA Therapist/Behaviorist, create a token board with a set reward for positive work. For example, 5 pennies can result in a pretzel or squish toy. It also helps to take a photo of the child engaged in the target behavior, such as sitting in a chair with "quiet hands.” Verbalize the target behavior consistently and avoid talking about the negative behavior such as "no spitting" or "stop that." Use positive verbal cues such as, "good sitting with hands down.”

• When using food reinforcers, coordinate this with feeding therapy. For example, a specific placement of a strip to the molars, as where the food is placed in the mouth impacts the skills used to break it down. Use a highly desirable drink, such as fruit juice, with a target straw from the TalkTools® Hierarchy.

• A therapy protocol should always incorporate sensory activities (Sensory Bean Bags, vibration, massage, ZVibe),  jaw activities (Bite Blocks, Jaw Exerciser, Chewy Tube etc.), respiration and phonation activities (Horns, bubbles) and additional OPT activities as needed (Lip Press, etc.). The session should always include sound drills, word imitation (verbal ims) and/or play with targeted words embedded within the structured activity.

• For many kids with ASD, the speech therapist will be involved with sensory-based food tasting programs which can be presented in a discreet trial teaching (DTT) model. First, the child needs to tolerate the new food in their proximity, then touch it, smell it, tolerate it near the mouth, kiss it/tongue touch, hold it in the mouth, chew it and swallow. These steps need to be broken down into small tasks that are highly reinforced.

• Create an OPT book with specific therapy and chart notes, so that the work is done at home and at school/clinic. The therapist must train the parent, or in some cases the babysitter or ABA therapist, so that the exercises are done daily. This is not to say that an ABA therapist should be performing speech therapy, but rather facilitate progress by practicing specifically assigned homework. In some cases, challenging behaviors are much easier for a ABA therapist than for the parent. In addition, parents can videotape sessions to follow at home. Video modeling is a very common procedure in ABA programs.

• Since the main goal is expressive communication, it is imperative that the therapist recognizes the clients strengths in terms of jaw-lip-tongue dissociation and planes of movement as taught by Debra Hayden's PROMPT System Hierarchy, Nancy Kaufman’s “Kaufman Praxis Level 1” and Lori Overland's/Sara Rosenfeld-Johnson's oral motor developmental norms references. This will help the speech therapist select the first words for drill and repetition in order to translate muscle-motor memory into speech production. For example, if the child's lip closure is a goal, and he/she is working on TalkTools® horn level 1, simple CV, VCV, VC words with picture cards should be used to elicit productions such as: me, bee, apple (ae-po), up and so forth. The words should be practiced in every session with the help of facial cues (PROMPT), and lip reading cues to 80% mastery. When this occurs, the therapist can then fade cues and move to higher level targets such as CVC forms.

• To evoke new productions spontaneously, David Hammer, an expert in the field of apraxia, recommends use of repetitive games and toys within each session. For example, if target words are in/out use a simple activity, such as small animals that go in and out of a paper towel tube, and repeat this each session so that the client can predict what utterances are expected. Prediction of outcome reduces anxiety and also follows along with Dr. Edythe Strand's research on the need for repetition in order to solidify a motor plan.

Conclusion:

In summary,  OPT for children with ASD is an essential part of their speech therapy program in addition to pragmatics, language, sensory integration and total communication. While engaging children with ASD may be challenging, if speech therapists follow the lead of experts in the field of autism, OPT is actually quite easy to deliver as long as the therapist combines the principles of behavior modification with natural language development. Since OPT hierarchies are very task oriented and data driven, (e.g., each TalkTools® horn has a pre-established criteria for mastery), therapists can present activities in specific sequences with consistent positive reinforcers which is in line with the experts suggestions for systematically teaching target behaviors in an ABA format, while the SCERTS approach opens pathways for carryover and language acquisition with improved speech clarity.

Click here to learn more about the course Robyn Merkel-Walsh teaches on Autism & OPT



Robyn_color_lowRobyn Merkel-Walsh MA, CCC-SLP is a speech pathologist with over 20 years of experience in both the Ridgefield Public Schools, and in her private practice located in Bergen County, NJ. She is the author of The Smile Program, A Sensory Motor Approach to Feeding, and other educational materials. Robyn is a certified TalkTools Instructor on Tongue Thrust, Autism and Oral Placement Therapy. Robyn is the acting chair of the Oral Motor Institute. She can be reached at robynslp95@aol.com.

   

Sara R JSara Rosenfeld-Johnson MS, CCC-SLP is the founder of Innovative Therapists International, and TalkTools® based in Charleston, South Carolina. She is the author of Oral Placement Therapy (OPT) for Speech Clarity and Feeding, The HOMEWORK Book, Assessment and Treatment of the Jaw, OPT for /s/ and /z/ as well as many other education materials.  Sara specializes in assessment and treatment of motor speech and feeding disorders.  She is a national and international speaker on the topic of Oral Placement Therapy.  She can be reached at srjohnson@talktools.com.

Thanks to Rethink for providing the graph above. 

REFERENCES

American Speech and Hearing Association (ASHA), (2007). Positions statement: childhood apraxia of speech. Retrieved from:  asha.org: http://www.asha.org/policy/PS2007-00277/.

Bailey, E. (2013). 7 characteristics and traits of  autism spectrum disorders. Health Guide. Retrieved from: http://www.healthcentral.com/autism

Beckman, D. (2014). About Beckman oral motor intervention. Retrieved from: http://www.beckmanoralmotor.com/about.php.

Belmonte, M.K., Saxena-Chandhok, T., Cherian, R., Muneer, R., George, L. & Karanth P. (2013). Oral motor deficits in speech impaired children with autism. Frontiers in Integrative Neuroscience; 7:47.

Boshart, C. (2015). Oral facial illustrations and reference guide. Ebook.

Cure Autism Now (CAN), (2005). Applied behavioral analysis and other skills-based therapies, https://www.autismspeaks.org/site-wide/cure-autism-now

Center for Disease Control (CDC), (2015). Autism Spectrum Disorders. Retrieved from http://www.cdc.gov/ncbddd/autism/data.html.

Center for Disease Control (CDC), (2015).  Autism Spectrum Disorder signs and symptoms. Retrieved from: http://www.cdc.gov/ncbddd/autism/signs.html.

Merkel-Walsh, R. (2014). Solving the puzzle of autism: using tactile therapy techniques. Live presentation. Charleston, SC: TalkTools®.

Merkel-Walsh, R. (2015). Conversations in speech pathology. Retrieved from: http://www.conversationsinspeech.com/.

Merkel-Walsh, R. & Overland, L.L. (in press). Diet-shaping: a useful technique for children on the autism spectrum. Retrieved from The Oral Motor Institute: http://www.oralmotorinstitute.org.

Mysak, E. (1971). Speech pathology and feedback therapy. Charles C. Thompson Publisher.

Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development. San Antonio, TX: Therapy Skill Builders.

National Autism Network (NAN), (2015). C0-occuring Conditions. Retrieved from: http://nationalautismnetwork.com

Overland, L. (2010). A sensory-motor approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20, 3, 60-64.

Overland & Merkel-Walsh (2013).  A sensory-motor approach to feeding. Charleston, SC: TalkTools®.

Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., (2010). The SCERTS Model. In K. Siri and T. Lyons (ed), Cutting-Edge therapies for autism: New York, NY: Skyhorse Publishing.

Prizant, Wetherby, Rubin & Laurent, (2007). The SCERTS model. Retrieved from: http://www.scerts.com/index.php?option=com_content&view=article&id=2&Itemid=2.

Roche, W.T. , Eicher, P., Martorana, P., Berkowitz, M., Petronchak, J. Dzioba, J. & Vitello, L. (2011). An oral, motor, medical, and behavioral approach to pediatric feeding and swallowing disorders: an interdisciplinary model. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20, 3, 65-74.

Rogers, S. J., Hayden, D. Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006). Teaching young nonverbal children with autism useful speech: A pilot study of the Denver Model and PROMPT interventions. Journal of Autism and Developmental Disorders, 36(8), 1007–1024.

Van Riper, C. (1978). Speech Correction: Principles and Methods (6th Edition). Englewood Cliffs: Prentice-Hall.

Wiggins L, Baio J., Rice C. (2006). Examination of the time between first evaluation and first autism spectrum diagnosis in a population-based sample. Journal of Developmental Behavior Pediatrics; 27:S79.

Young, E. H., & Hawk, S. S. (1955). Moto-kinesthetic speech training. Stanford, CA: Stanford University Press.

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Podcast: A Case for Oral Placement Therapy

Posted by Deborah Grauzam on

Recently, TalkTools® Presenter Robyn Merkel-Walsh, MA, CCC-SLP joined Jeff Stepen, MS, CCC-SLP on his podcast, Conversations in Speech Pathology. In the podcast, Robyn discusses common misconceptions about Oral Placement Therapy (OPT). Click below to listen to the podcast.

We encourage everyone to add their thoughts for discussion in the comments section on the Conversations in Speech Pathology page.

  TalkTools_Robyn Merkel-Walsh_Podcast
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Early Oral-Motor Interventions for Pediatric Feeding Problems: What, When and How

Posted by Deborah Grauzam on

"Early Oral-Motor Interventions for Pediatric Feeding Problems: What, When and How"

Authors: Cecilia J. Manno, Catherine Fox, Peggy S. Eicher and MaryLouise E. Kerwin

JEIBI VOLUME 2, ISSUE NO. 3, Fall, 2005

Abstract

Children with developmental delays often have feeding difficulties resulting from oral-motor problems. Based on both clinical experience and a review of published studies, oral-motor interventions have been shown to be effective in improving the oral function of preterm infants and children with neuromotor disorders, such as cerebral palsy. However, oral-motor problems may be under identified in other populations of children with developmental difficulties. The purpose of this paper is to provide a conceptual framework for understanding oral-motor skill development and problems that can occur in any infant and young child and to review oral-motor treatment techniques and their empirical support. Keywords: dysphagia, feeding behavior, oral stimulation, oral-motor, behavioral intervention.

Oral-motor problems in children are easy to recognize when the child coughs and chokes while eating. However, the majority of feeding problems present initially in more subtle ways, such as difficulty introducing spoon feedings or advancing texture, or limited variety of foods accepted (Kerwin, 1999). For some children, these more common feeding problems may reflect a specific oral-motor problem, such as uncoordinated tongue movement during lateralization or dysfunctional oral transport of the food bolus to the back of the mouth to initiate the swallowing reflex. Children with neurological disorders, or those born prematurely often exhibit oral-motor problems (Gisel, Alphonce, & Ramsay, 2000; Lau & Hurst, 1999; Sullivan, Lambert, Ford-Adams, Griffiths, & Johnson, 2000). Increasing evidence suggests that oral-motor problems are under-recognized in children with problems other than cerebral palsy (Ramsay, Gisel, McCusker, Bellavance, & Platt, 2002; Reilly, Skuse, Wolke, & Stevenson, 1999), including children with autism disorders (Amato & Slavin, 1998).

Oral motor skills develop within a system that changes rapidly both in structural growth and neurological control during the first three years of life (Arvedson & Lefton-Greif, 1996; Bosma, 1986). During this period, children engage in a great variety of oral motor experiences as they satisfy their basic needs for food and comfort and begin to explore their world. Developmentally, a feeding problem exists when a child is “stuck” in their feeding pattern and cannot progress (Eicher, 2002; Kerwin, 2003; Palmer & Horn, 1977). Because oral motor skills represent a sequential progression of increasingly complex movement patterns, any disruption in practice can interfere with or limit positive oral motor practice, resulting in the loss of advancement in skill development and the learned behaviors that ensue (Illingworth & Lister, 1964). The challenge of treating children with feeding problems comes in identifying the specific areas that interfere with skill advancement for the individual child (Rudolph & Link, 2002; Stevenson & Allaire, 1991). Understanding each of the active factors interfering with skill advancement and the interaction of those factors enables the treating team to: 1) identify the specific factors contributing to the feeding problem; and then 2) ameliorate them to allow the child successful practice leading to positive learning, skill advancement and mastery (Kerwin & Eicher, 2004).

The following case history will serve as an example of some of the common, but more subtle, oral motor problems in children that require early, intensive intervention: bottle dependence, difficulty advancing texture, food refusal and food selectivity. Joey is a 4-year-old boy with hypotonia (i.e., low muscle tone), mild cognitive and motor delays, severe speech delay, poor social relatedness, and a tendency to perseverate. He will eat only yogurt, Dutch apple dessert and pureed banana baby foods, and will drink only apple juice from a sippy cup. Joey’s mother reports that Joey always loved bottle-feeding, but preferred to drink lying down rather than while being held. He gagged and vomited every time spoon-feeding was attempted. At 15 months, his parents were able to introduce cream soups with a tablespoon while semi-reclined in a bouncy seat. Through the efforts of weekly feeding therapy, yogurt and the two fruit baby foods were successfully introduced. He has recently become interested in the green colored small fish crackers, but he only shaves the tails down with his front teeth. At age 2, the pediatrician advised getting rid of the bottle. When his parents stopped offering the bottle, Joey no longer accepted milk. Desperate to get fluids into him, his parents resorted to apple juice via dropper. He now accepts only apple juice and only through a sippy cup while lying down.

Joey’s feeding patterns demonstrate components of food refusal, food selectivity, failure to advance texture, and bottle dependence. Despite being four years old and having only mild motor and cognitive delays, Joey is stuck in a very abnormal feeding pattern with high risk of serious short- and long-term health and developmental consequences. The purpose of this paper is to elucidate the contributing factors to oral-motor skill development and practice, review the existing literature for empirical evidence regarding these interventions, and elaborate on possible intervention strategies that could be used to treat these feeding difficulties.  

Development of Oral-Motor Skills

        Oral-motor ontogeny follows a stepwise progression building on the suckle reflex to acquire the more complex oral-motor milestones suck, munch, and chew (Bosma, 1986; Ogg, 1975). Just as with gross motor skill development, milestone acquisition is not driven by maturation alone. Rather, the emergence of each oral-motor milestone is also dependent upon successful practice (Eicher, 2002; Illingworth & Lister, 1964; Pinnington & Hegarty, 2000). Infants are born with a biologically driven suckle reflex which fades around four months of age (Ingram, 1962). When the infant uses the reflex successfully with breast or bottle feedings, they master suckling and its coordination with breathing (Herbst, 1983). In addition, this practice occurs contemporaneously with neuronal growth and development that together enable the infant to acquire volitional control over the suckle response (Arvedson & Lefton-Greif, 1996; Bosma, 1986; Miller, 1993). If an infant does not experience successful practice with the suckle reflex before the reflex fades at four months of age, the suckle pattern may not be mastered (Illingworth & Lister, 1964). As a result, the infants may not be able to successfully initiate nutritive sucking (i.e., nipple feeding) without the propelling effect of the suckle reflex even if the child practiced non-nutritive sucking. This reciprocal, dynamic influence between the child’s practice during feeding and oral-motor skill development continues until the child has accomplished the most advanced skill, rotary chewing (Smith, Weber, Newton, & Denny, 1991).

        Oral-motor skill development is integrally linked with increasingly complex tongue movements (Gisel et al., 2000; Morris & Klein, 2000). In the typical pattern of development, the tongue first moves liquids through a nipple in an anterior/posterior (in/out) pattern (i.e., suckling); and then liquids and pureed foods with a superior/inferior (up/down) pattern (i.e., sucking; Ayano, Tamuro, Ohtsuka, & Mukai, 2000; Tamura, Matsushita, Shinoda, & Yoshida, 1998). The tongue moves chewable foods with a lateral (side to side) pattern over to the molar surface and back to the center, splitting and separating the food until it is ground down enough and recollected to swallow (Ayano et al., 2000). As the child’s oral motor function advances, s/he learns to stabilize the jaw, working the tongue off this stable base first centrally with sucking and then laterally with munching (Meyer, 2000; Morris & Klein, 2000). Range of movement increases to allow sweeping anteriorly, posteriorly, laterally, and with tongue tip elevation.

        In summary, the child’s feeding experience and practice directly influence oral-motor pattern and oral-motor pattern directly influences feeding response (Bosma, 1986). If the utensils or food taste and texture do not change, the child does not learn to accept new foods and does not practice the new patterns necessary to manipulate the new food and transport it through the pharynx safely and efficiently (Gisel et al., 2000). Lack of appropriate and successful practice may result in the loss of previously acquired oralmotor skills and/or failure to acquire more advanced skills.

Factors Influencing Oral-Motor Skills

        In addition to appropriate and successful practice, other factors can also negatively influence oralmotor skill development. Feeding and swallowing movements and behaviors are very complex and clearly involve much more than just activities in the mouth, throat, and stomach (Gisel, Birnbaum, & Schwartz, 1998). The sensory motor systems provide both the structural foundation and the sensory information that enable a child to practice and master oral-motor skills (Morris & Klein, 2000). Because the dynamic feeding process involves internal activities such as breathing, digestion, and elimination; structural alignment, control and sensory input are important from top to bottom.

Structural Alignment

        In the clinical feeding lore, there is an old adage, “If you want the lips, you must first get the hips,” meaning that support for function in the mouth comes from structures below (Morris & Klein, 2000). Biomechanical alignment means that structures of the body are aligned to allow the most efficient muscular interaction. For example, when the pelvis is in a neutral position, the structures of the spine line up biomechanically. A neutral position of the pelvis not only makes sitting up straight much easier, but also provides the spinal alignment and base of support for the rib cage, shoulder girdle, and head position. Figure 1 depicts a typical head-forward position resulting from loss of the biomechanical alignment of the spine that in turn results in poor head-shoulder-trunk alignment. In the head-forward position, the tongue and jaw muscles are helping to stabilize the child’s neck. As a result, the jaw is depressed and food and liquid are often lost during meals because the tongue and jaw are not able to move as freely for oral-motor function compared to a head in a neutral position (Patrick & Gisel, 1990). Several studies have demonstrated that proper biomechanical alignment is associated with improved swallowing, feeding and speech functioning (Gisel, Schwartz, Petryk, Clarke, & Haberfellner, 2000; Hulme, Gallacher, Walsh, Niesen, & Waldron, 1987; Kumin & Bahr, 1999; Larnert & Ekberg, 1995).

www.talktools.com content Early Oral Motor Interventions.pdf

Figure 1. Typical head-forward position that results from poor head-shoulder-trunk alignment

       Biomechanical alignment becomes even more important when we consider that many muscle groups cross multiple joints and can work together or in competition with one another to adapt and complete a desired task (Howle, 2002). For example, muscles of the neck can function in several ways: 1) as respiratory muscles to assist with breathing, 2) as swallowing muscles, and 3) as postural muscles to help maintain head and neck alignment. These muscle groups learn to work together to maintain all of these functions (McFarland, Lund, & Gagner, 1994; Palmer & Hiiemae, 2003). However, when lifesustaining activities, such as breathing, become more difficult, muscles will be recruited from other functions to complete the desired task. For example, when breathing is challenged, muscles of the neck are automatically recruited to help, impacting head alignment and swallowing control. In this situation, less efficient or “compensatory” motor patterns develop. If these compensatory motor patterns persist, skill refinement will be difficult and lack of mastery will result in persistent immature oral-motor patterns (Macie & Arvedson, 1993; Pinder & Faherty, 1999).

Sensory Motor Input

        The motor and sensory systems work together in an exchange that creates proactive and reactive responses to sensory input from the environment (e.g., tactile, kinesthesia and proprioceptive cues) and internal sensory information from the body (e.g., arousal, hunger, satiety, pain, fatigue, “lump in the throat”, or the need to stool). When used in combination, the child is able to generate an appropriate response for the desired task, resulting in positive practice. Integrated sensory information is essential for developing motor planning skills that incorporate both motor control and motor learning (Roley, Blanche, & Schaaf, 2001). All of these factors must work in a coordinated process for the child to receive positive feedback from safe oral motor and swallowing skill development. This positive feedback provides information to help the child develop the internal desire that will enable the child to develop selfgenerating progress towards mastery of feeding and swallowing skills.

Muscle Tone & Oral-Motor Patterns

        Low muscle tone in the facial muscle can result in an open mouth posture. Because stability of the jaw allows the tongue to dissociate movement patterns within the mouth, this open lax jaw precludes dissociation resulting in an immature anterior/posterior pattern in which the tongue and jaw move together. Moreover, wide jaw excursions decrease the ability to manipulate food within the oral cavity increasing the possibility of food falling out of the mouth or failure to chew smaller pieces of food due to the inability to grade movement. Because their tongue moves in and out, as opposed to side to side, these children are not exhibiting the oral-motor pattern that would enable them to adequately chew foods. The lips and cheeks work together providing enough tension within the mouth to contain the food and with the lips provide negative pressure to begin the swallowing process. If the lip and cheek muscles become shortened through compensatory motor movements and/or lack of practice, they will not be able to attain full muscle length required for lip closure. Therefore, tonal and muscle imbalance of these structures can leave the lips in an open position. This can result in losing food anteriorly or the inability to contain the food while manipulating it (Alper, & Manno, 1996; Ernsperger, & Hanson, 2004). The resulting pattern appears as though the child is pushing food out the front of the mouth, such as the oral-motor pattern that is typical of many children with Down Syndrome (Kumin & Bahr, 1999).

Medical Influence on Oral-Motor Patterns

        Although any medical illness, if severe enough, can interrupt successful practice with feeding and contribute to development of a feeding problem, the two most common medical issues that interfere with feeding are respiratory and gastrointestinal (Eicher, 2002). Sensory inputs from the respiratory and gastrointestinal tracts directly influence oral motor patterns through the swallowing center in the brainstem (Miller, 1986). Because the upper respiratory tracts use the same structures as the upper digestive tracts (i.e., back of the mouth, and throat), breathing is neurologically programmed to supercede feeding (Daniels, Devlieger, Minami, Eggermont & Casaer, 1990). Any respiratory illness that makes breathing more difficult will negatively impact feeding and swallowing. For example, a child with asthma whose rate of breathing is increased may drool and refuse to swallow because the increased respiratory rate does not allow enough time for swallowing between breaths (Timms, DeFiore, Marin, & Miller, 1993).

        Recent research is beginning to document the impact of respiratory problems on the feeding and growth of preterm children (Lau, Smith, & Schanler, 2003). Although full-term and preterm infants did not demonstrate significant differences in feeding difficulties at their first oral feeding, by the time solid foods were introduced, preterm children were more likely to demonstrate feeding difficulties (Burklow, McGrath, Valerius, & Rudolph, 2002). Regression analysis indicated that medical factors, especially breathing assistance, accounted for more of the variance in feeding difficulties than preterm status alone. However, pacing the bottle feedings in a sample of preterm infants with respiratory diagnoses resulted in the development of more efficient sucking patterns, increased weight gain, decreased incidence of bradycardia during feeding and shorter hospital stays compared to infants bottle-fed traditionally (LawMorstatt, Judd, Snyder, Baier, & Dhanireddy, 2003).

       In addition to respiratory issues, gastrointestinal issues can also influence oral-motor functioning (Henderson, Woolf, & Marryatt, 1976; Hyman, 1993; Sivit, Curtis, Crain, Cruess, & Winters, 1988). Frequent nausea, fullness from constipation, delayed emptying, or discomfort from gastroesophageal reflux or other irritants reduce the child’s interest in eating as well as impacting the timing and degree of contraction of the muscle pattern required to complete the swallowing process (Mendell & Logemann, 2002; Waring, Feiler, Hunter, Smith, & Gold, 2002). As a result, the child becomes more protective of the airway and mouth; s/he may pull the tongue up or back to minimize entry into the mouth, and tongue movement is restricted (Mendell & Logemann, 2002). These changes may result in the use of more immature tongue movement patterns, less efficient tongue transport, and increased residual after the swallow (Mendell & Logemann, 2002). This can lead to preference for purees and foods that do not require increased tongue manipulation.

Case Illustration

       When a child presents with a feeding problem, a comprehensive assessment needs to evaluate what oral motor pattern the child is using, and also what factors (medical, motor or learned patterns of behavior) are contributing to maintain the child’s use of that pattern. Let’s return to the example of Joey. Joey’s first symptoms of a feeding problem occurred with the introduction of spoon feedings. Gagging and vomiting prevented him from successful practice with a spoon. At that point, gastrointestinal issues should have been considered as interfering with feeding development. However, his history of wanting to drink the bottle lying down suggests the possibility of sensorimotor issues also playing a role. Perhaps his low tone increased his difficulty with head control when upright, his perception of alignment or orientation in space, or impacted his respiratory efficiency. Each or all could have been contributing factors to his difficulty practicing spoon-feeding. Any child who is unable to initiate spoon-feeding after 3-4 months of practice should be evaluated. Because Joey vomited when the spoon touched his tongue, caretakers changed the food on the spoon to enable him to practice without putting the spoon in his mouth. With liquid soups, they could pour the “food” in without touching his tongue. Sensorimotor issues were not addressed, as he remained reclined in a bouncy seat. With practice he was able to transition to a couple of smooth baby foods. However, his pattern was not changing since he never really accepted the spoon into his mouth and on top of his tongue. Thus he continues to use an immature nipple pattern for spoon feedings because that is all he has practiced.

       At this point, the oral-motor pattern Joey has practiced dictates what foods he will accept; they all have to be able to be transported like a liquid. Foods that do not flow like a liquid are refused resulting in his food refusal. He can’t advance texture because he doesn’t let pieces of food into his mouth, and doesn’t have the tongue pattern necessary to manipulate them resulting in failure to advance texture. In addition, he has no experience eating in an upright position, which influences appropriate alignment and the muscle groups necessary to eat and swallow. Thus Joey now has multiple feeding problems resulting from medical and sensorimotor issues that initially prevented normal spoon practice. His lack of practice with normal patterns and increased experience with abnormal compensatory patterns in turn resulted in his food selectivity, failure to advance texture and ultimately food refusal.

Treatment

        Treatment is most successful when the history of the child’s feeding progression is understood and a thorough assessment of the contributing factors has been done. Oral motor treatment should not start until medical issues are identified and controlled or stabilized, and issues of postural alignment and support have been addressed. To be most successful in providing oral motor stimulation, any medical issues need to be stable. This will help the child be more amenable to accepting any stimulation in the oral cavity and practice the oral-motor patterns that are needed. Since oral movements are refined motor movements, and they are distal to the pelvis and trunk, trunk alignment must be obtained to gain the best practice. Improving neck elongation and jaw stability will set the other oral structures in the correct alignment for active acceptance, manipulation and transport of food through the pharynx.

        Oral stimulation should be viewed as preparation for eating; therefore, oral-motor practice with food should follow oral stimulation so that the movements facilitated during oral stimulation can be coordinated to practice food manipulation, transport and swallow. In other words, oral stimulation is a means to an end, and should not typically be done in isolation. Oral stimulation is typically begun periorally (i.e., outside the oral cavity) then transitioned to intraoral facilitation (e.g., Rendón-Macías, et al., 1999). More detailed descriptions and illustrations are contained in Alper and Manno (1996), DeGangi (1994), Gisel et al. (1998), Palmer and Heyman (1993) and Morris and Klein (2000)

Specific Oral-Motor Techniques

       Facial/Oral Muscle Tone. If there are facial muscle tone issues, the use of tapping, pressure, vibration and speed of input can change tone (Morris & Klein, 2000). Figure 2 depicts a diagram of the facial muscles. Fast tapping, light touch, vibration and a fast pace alerts the system and can increase tone while slow tapping, deep pressure, vibration and a slowed pace tends to decrease tone. When the facial muscles are shortened or inactive, such as in children who are defensive about foods and utensils entering the mouth, stretching these muscles will improve the muscle length to enable a more mature movement patterns. For example, many children who refuse food will hold the upper lip in retraction showing their top teeth. The lips are in extension and there is tension throughout the face. In this position the child will not be able to use the upper lip actively to remove food from a spoon, drink from a cup without spillage, or place the tongue behind the teeth to receive the food. When the labial elevator muscles (i.e., levator labii superior, levator anguli oris and risorius) are stretched downward throughout the entire muscle, the upper lip can become more active.

TalkTools | diagram of facial muscles

Figure 2. Diagram of facial muscles

        Stimulation of the orbicularis oris muscle improves flexion of the lips for mouth closure and puckering. Active use of this muscle assists in food containment, straw drinking and closure to provide the negative pressure necessary for transporting food through the oral cavity and swallowing. Active closure of the lips is needed to attain a single bolus swallow as opposed to a sequential swallow (i.e., multiple swallows in a row on a single bolus). Sequential swallowing is typical in children who are not transitioning to higher textured foods or who transport their food to the back of the mouth to swallow. This existing oral-motor pattern may be functional (i.e., the child successfully gets the food into the esophagus); however, prolonged practice with this type of pattern limits the child’s ability to advance to more mature oral-motor patterns

        Tongue & Transport. Stimulation to the tongue can be effective to change the movement of the tongue. Initially, implements (e.g., NUK, Ark probe) can be utilized to facilitate these movements. Then, modifying the method used to present the spoon with food and/or presenting small amounts of meltable foods (e.g., cheerio, cheese puffs) should be introduced to all the children to practice the new tongue movements with food.

        When a child presents with a midline pattern (i.e., the tongue moves in and out with little side to side motion), s/he will not be able to efficiently chew and swallow a variety of foods. He may not be able to move the food laterally to the molars to grind down the food in preparation for swallowing. This will lead to the child learning to swallow foods whole or partially chewed. If the tongue movements are not altered, the child will continue to practice this less efficient movement and will not be able to advance to higher textured foods. The use of pressure on the middle of the tongue or the lateral sides of the tongue can facilitate the intrinsic and extrinsic lingual muscles to widen, thin out, narrow, elongate and flatten. Pressure on the lateral borders of the tongue can thin out the muscle and the tongue will move to that side. Stimulation to the anterior part of the tongue will facilitate a tongue tip. This serves to facilitate movement, increase acceptance of tactile sensation and acceptance of implements in the mouth.

        Doing oral stimulation techniques alone provides sensation and movement but typically does not translate into accepting foods. Once the movement is active, food must be presented to use the pattern. For children who don’t accept foods other than purees, the lateral movement pattern can be practiced by placing purees over the molar surface so that the tongue will shift to either side of the mouth to accept the food, and then to transport the food to the back of the mouth in preparation for a swallow. Foods such as lollipops or lifesavers on a string can be presented to the child to practice moving the tongue from midline, to side and across midline so that the tongue practices moving food within the oral cavity. The meltable foods, such as cereals, can be placed over the molar surface for the tongue to get and then move over to the other molar for several sequences before softening, chewing and swallowing. As the child becomes more facile with this technique, foods are added into meals to practice these patterns for entire meals or for therapeutic meals.

Swallowing. Shifting from a sequential swallowing pattern to a single bolus swallow in spoonfeeding can be practiced using the spoon. Many therapists are taught to use Nuk brushes and other similar implements to present tastes and foods to children that refuse foods. Since we use a spoon to eat with, practicing the oral-motor pattern needed with the appropriate utensil will lead to more efficient learning.

        To facilitate a single bolus swallow, the entire bowl of a dry spoon can be placed on the tongue applying downward pressure to encourage the tongue to make a bowl then move back to initiate a swallow. If the child does not close his lips around the spoon, he is asked to and/or his lips are closed around the spoon to learn the correct sequence (Chigira, Omoto, Mukai, & Kaneko, 1994). All presentations of the spoon should be done with the child’s head in a neutral position and with him facing forward. Since there is no food on the spoon and no threat of aspiration, he is learning the correct sequence of movement for a single bolus swallow in a safe manner using the utensil that is used for feeding. As he becomes more proficient with this pattern, a small amount of food is placed on the spoon. The amount of food on the spoon is increased gradually until he can accept a level spoonful of food while always ensuring that he is continuing to exhibit the appropriate oral-motor pattern.

Grading Jaw Movement. Some children have difficulty grading the amount of mouth opening and closing needed for a variety of foods. When a child demonstrates wide jaw excursions, he will have difficulty using his tongue to manage the food. Providing jaw stability by placing your hand under the jaw will help the child to take bites and to keep the mouth closed while the tongue does the work of manipulating the food. As the child practices, thinner foods can be placed between the molars to chew using minimal jaw excursions.

Empirical Support for Oral Stimulation and Oral-Motor Therapy

Oral-Motor Therapy

        While the majority of published studies report on the efficacy of oral-motor therapy for high-risk infants born prematurely or children with neuromotor difficulties, a few case studies suggest the promising use of oral-motor treatment techniques for children with low muscle tone (Kumin, Von Hagel, & Bahr, 2001) and retardation/autism (Larrington, 1987).

       High-Risk Infants. Sensorimotor interventions (e.g., proper positioning and external support of the cheeks and mandible during bottle feeding) improve oral feeding of preterm infants (Case-Smith, 1988; Einarsson-Backes, Deitz, Price, Glass, & Hays, 1994). Using a two-group design, Gaebler and Hanzlik (1996) compared 5 minutes of pre-feeding stroking to 5 minutes of pre-feeding stroking and introral prefeeding stimulation in a sample of 18 premature infants. Assessments occurred on days 1, 3 and 5; the group that received oral stimulation fed significantly better than the control group on day 3 only. A more recent study has demonstrated that those preterm infants who received daily 15-minute oral stimulation program consisting of stroking the peri- and intraoral structures for 10 days before the start of oral feedings, achieved full oral feedings seven days sooner than the infants in the control group (Fucile, Gisel, & Lau, 2005). In addition, infants in the experimental group demonstrated greater overall intake, rate of milk transfer, and amplitude of the expression component of sucking. In contrast, there were no differences between experimental and control infants on sucking stage maturation, sucking frequency, amplitude of the suction component of sucking or endurance of sucking.

        Children with Neuromotor Disorders. An elegant series of studies investigating sensorimotor intervention on eating skills of children with cerebral palsy (average age ~ 5 years) has been conducted by Gisel and colleagues (Gisel, 1994; Gisel, Applegate-Ferrante, Benson, & Bosma, 1995, 1996). Oral-motor therapy, which was designed to increase tongue lateralization, lip control, and vigor of chewing, was delivered before the lunch meal for 5-7 minutes/day, 5 days/week for 10-20 weeks. Using a between subject experimental design, children’s spoon feeding, biting, and chewing improved with oral-motor therapy (Gisel, 1994). Using a within-subject design, spoon feeding, chewing, and swallowing improved after oral-motor therapy (Gisel et al., 1996). In addition, more children advanced food texture with oralmotor therapy (Gisel et al., 1995). One interesting finding was the discovery that eating efficiency (i.e., meal duration) was not a good outcome measure but rather is a diagnostic indicator of the severity of the feeding impairment.

         A relatively new type of intervention for oral-motor difficulties in children with neuromotor impairments is an intraoral appliance, Innsbruck Sensorimotor Activator and Regulator (ISMAR; Gisel, Schwartz, & Haberfellner, 1999). The ISMAR was designed to achieve two goals: 1) jaw stabilization, and 2) activation/mobilization of the oral and pharyngeal structures. Although there were some difficulties in achieving tolerance and compliance with ISMAR (see Johnson et al., 2004), children with neuromotor disorders demonstrate significant improvements in spoon-feeding, biting, chewing, cup drinking, swallowing, and drooling after one year of ISMAR (Haberfellner, Schwartz, & Gisel, 2001; Johnson et al., 2004). These functional changes in feeding skills appear to be a function of jaw stabilization. Furthermore, these improvements in feeding were maintained for one year after ISMAR therapy was stopped (Gisel, Haberfellner, & Schwartz, 2001). Finally, use of ISMAR was associated with significant improvements in sitting and ambulation providing preliminary evidence for the dynamic interplay among oral-motor, postural, and ambulatory functions (Gisel et al., 2000).

Behavioral Interventions Targeting Oral-Motor Problems

        Within the field of applied behavior analysis, several researchers have designed interventions using behavioral principles to improve specific oral-motor problems, such as swallowing dysfunction (Hagopian, Farrell, & Amari, 1996; Hoch, Babbitt, Coe, Duncan, & Trusty, 1995; Lamm & Greer, 1988), cup drinking (Patel, Piazza, Kelly, Ochsner, & Santana, 2001), and failure to advance texture (Luiselli & Gleason, 1987; Shore, Babbitt, Williams, Coe, & Snyder, 1998). The hallmark of all these interventions is 1) analyzing the “task” into small, discrete steps, 2) manipulating the antecedent condition by presenting food or liquid in a way that allows the child to complete the behavior expected successfully, and 3) clear consequences for completing or not completing the task. For example, in the swallowing induction procedures, swallowing was broken down into its component steps from food entering the mouth to the initiation of the swallowing reflex at the faucal arches. The researchers used forward or backward chaining with prompts (verbal and physical prompts on the tongue) to initiate swallowing. Although the data suggest that the intervention is promising (Kerwin, 1999), the technique assumes competent oral-motor tongue and jaw movements. Although the children had increased swallow frequency, increased food acceptance and increased quantity of food consumed orally, it is unclear from the study results if the oral-motor pattern acquired indirectly would allow the child to continue advancing oral-motor skills with other food textures. The current research literature suggests that a more expedient intervention might be direct targeting of the oral-motor movements.

Combined Use of Oral-Motor Therapy and Behavioral Techniques

        Successful eating requires effective oral-motor patterns. The behavior analyst can be instrumental in assisting members of other disciplines in teaching children these skills. Because behavior analysts are skilled in task analyses, they can also help members of the other disciplines task analyze their interventions and learn to look for and document specific responses that they expect from each procedure (see Kumin et al., 2001 for example of task analysis of oral-motor treatment). Perhaps an ideal avenue for future investigation is combining the best of both approaches together to maximize the child’s benefit from systematic, gradual steps with clear instruction and consequences in the context of meaningful oralmotor facilitation and therapy (Bailey & Angell, 2005). Peterson and Ottenbacher (1986) demonstrated this combined approach in teaching lip closure to three children with mental retardation.

Conclusion

        Children requiring early, intensive intervention often have complex feeding and swallowing issues that requires a team approach in order to fully evaluate and treat the underlying issues. Low tone, abnormal sensory processing, altered postural alignment and movement patterns are often present in these populations. These issues place them at risk for having abnormal postural alignment of the pelvis, trunk, shoulder girdle, which leads to a forward head posture. This alters the biomechanics of breathing and swallowing and the corresponding sensory input. With altered sensory perception the child may have difficulty motor planning postural alignment and control for acquisition and mastery of feeding and swallowing behaviors. Once medical stability and postural alignment have been obtained, oral stimulation can be an effective adjunct to feeding treatment. Oral stimulation should provide the child with the necessary sensory and movement input to adequately prepare the child for controlled practice with food. The use of varying foods in multiple therapeutic practice situations a day is the key to increasing the frequency of positive practice and thus increasing the acceptance of variety and volume of foods consumed in children exhibiting oral-motor difficulties.

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