Goals of Oral-Motor/ Feeding/Speech Therapy
1. To increase awareness: Somatosensory (Bahr, 2001; Clark & Ostry, 2005; Fisher, et al., 1991; Schmidt, 1988 ; Morris & Klein, 1987) and Metalinguistic (Klein, et al., 1991; Koegel, et al., 1986). 2. To normalize oral tactile sensitivity 3. To improve the precision of volitional movements of oral structures for speech production (Dewey, 1993; Robin, D. A., 1992; Newmeyer, et al., 2007). 4. To increase differentiation of oral movements (Morris & Klein, 1987; Bahr, 2001). dissociation: The separation of movement, based on stability and strength, in one or more muscle groups. grading: The controlled segmentation of movement through space based upon dissociation. fixing: An abnormal posture used to compensate for reduced stability which inhibits mobility 5. To improve feeding skills and nutritional intake 6. To improve speech sound production to maximize intelligibility
Sensory and Oral-Motor Issues Related to Feeding and Speech
Renee Roy Hill, MS, CCC-SLP
When to Address Feeding Skills
At Birth: Pre-feeding activities will increase feeding safety for future feeding and prepare the oral musculature for future speech Early feeding skills are a precursor to the development of the oral musculature (Morris & Klein, 1987) At Any Age: Therapeutic feeding and non-food activities will improve feeding safety, coordination for chewing and swallowing and speech (Bahr, 2001; Mackie, 1996 a, b; Morris & Klein, 2000; Rosenfeld-Johnson, 2001)
Populations Appropriate for OralMotor Therapy
Who do we work with? Any client who displays oral-motor and sensory difficulties as compared to their typically developing peers for feeding and speech:
Reduced mobility Reduced agility Reduced precision Reduced endurance
The Importance of the OralSensory System
The ability to manage food is based first on the ability to monitor where the food is: a. Hyposensitive- an under-reaction to tactile input b. Hypersensitive- an over-reaction to tactile input c. Mixed Sensitivity- Any combination of hypo, hyper, or normal sensitivity d. Fluctuating Sensitivity- Responses change over time e. Tactile Defensiveness- A learned tendency to respond negatively or emotionally to tactile input
Assessing the Oral Sensory System
Always: 1. Start from the outside and work your way in 2. Be systematic 3. Begin with the least input if unsure Assessment: 1. Body - Knees, Hands, Shoulders, Cheeks, Lips 2. Oral Cavity - Lips, Buccal Cavity, Upper and Lower Gum Ridges, Blade of Tongue, Lateral Margins of Tongue, Gag Reflex? Palate
Assessing the Oral Sensory System
Assessing the Oral Sensory System
Sensory Issues Related to Feeding
Hypersensitivity- may respond negatively to new texture, flavor, temperature, choking, gagging, food avoidance, negative experiences Hyposensitivity- may need more sensory input (increased flavor, temperature, texture), choking, gagging, food avoidance, negative experiences Mixed Sensitivity- may only tolerate food in certain areas of mouth, choking, gagging, food avoidance, negative experiences Fluctuating Sensitivity- may like a food one day and not the next, difficult to predict, food avoidance, negative experiences Tactile Defensiveness- may develop an aversion to food secondary to negative experience at a previous time, food avoidance, refusal of anything to the mouth
Sensory Issues Related to Speech
Hypersensitivity- may avoid oral-motor placements secondary to increased sensitivity Hyposensitivity- may have difficulty monitoring specific oral-motor placements during speech practice and conversational speech Mixed Sensitivity- may have mixed information within the oral cavity as to where oral-motor placements for speech occur. May avoid certain placements while over compensating in others Fluctuating Sensitivity- may have difficulty developing accurate motor plans for speech due to fluctuating responses within the oral cavity Tactile Defensiveness- may not allow the therapist to assist with tactile cues to teach accurate oral-motor placements for speech sound production
Dissociation: Lips from Jaw
Muscle Movement
Following normal speech development
Why is feeding so important to an Oral-Motor therapy program?
Spoon feeding: Positioning in conjunction with proper spoon placement in the oral cavity will address the following goals:
Phoneme Ex.
(ah, uh) (m, p, b)
1. Open
Closed to Open Open to Closed 2. Protrude Retract 3. Lower Lip Retraction/Tension Lower Lip Protrusion/Tension
Improved oral feeds Lip Closure (m, p, b) Tongue Retraction (all sounds except th) Jaw Grading (co-articulation)
(oo, oh, w, ee, ih) (f, v) (sh, ch, j, r, er)
Feeding Activities for Lip Dissociation
Muscle Movement
Dissociation: Tongue from Jaw
Phoneme
(all sounds except th)
1. 2. Retraction- Protrusion: Equal range of motion (balance) Retraction (becomes more prominent movement) Protrusion (reduces) 3. Retraction (stability) Lateralization of tip a. Midline to both sides b. Across midline
Spoon feeding:
Lateral Placement
Front Placement
Spoon Slurp
4. 5.
Retraction - Tip Elevation/Depression Retraction - Back of Tongue Side Spread
(t, d, n, l, s, z, sh, ch, j, k, g) (stability for co- articulation, er)
Jaw picture
Back of tongue side spread
Pre-Feeding Exercises for Improving Jaw (chewing) Skill
Gloved Finger Infadent Ark Probe/Z-Vibe Red Chewy Tube Yellow Chewy Tube Purple ARK Grabber Green ARK Grabber
Why is feeding so important to an Oral-Motor therapy program?
Solids: (Cubes or Julienne): A preference for soft foods is frequently seen with children who have oral-motor deficits. Introduction of chew solids is important for all clients with reduced skill in the jaw. Gradually increasing food textures, while acknowledging each clients taste preferences, is an integral component of oral-motor therapy. Goals to be addressed include:
Tongue Lateralization Jaw Mobility Jaw Stability Tongue Retraction Independent Feeding
Feeding Activities for Jaw Strengthening
Feeding: chewing on back molars
Shape: Cube or Julienne Stick Begin to introduce first stage solids at 7 to 9 months if a munch-chew is present
Cube right
Why is feeding so important to an Oral-Motor therapy program?
Cup Drinking: Choosing the right cup is very important. Thickened
liquids are easier for the client to control, when learning a new muscle movement. As the skill level increases, the liquids can be thinned. Specific goals of cup drinking may include:
Why is feeding so important to an Oral-Motor therapy program?
Straw Drinking: Many children evidence poor oral movements with spoon fed foods, despite attempts at intervention. Straw drinking of these traditionally fed spoon foods may improve functioning. Begin with a large diameter straw and a slightly thickened liquid (e.g. nectar). As the oral functioning improves, reduce the diameter of the straw while increasing the thickness of the liquid (e.g. yogurt). Specific goals may be:
Lip Closure Tongue Retraction Tongue-Tip Elevation or Depression Jaw Grading
Lip Rounding Tongue Retraction Increasing Facial Agility/Mobility Jaw Stability Independent Self-Feeding
1 2 3 4 5 6 7
Tongue Lips Jaw
4 3 2 1
Articulation Resonation Phonation Respiration
The Oral-Motor Component
Oral-motor therapy is used in conjunction with other speech therapies. Oral-motor therapy does not replace the need for direct work on speech production. Oral-motor therapy should not be used in isolation for the remediation of speech sound errors and speech clarity.
References
1. 2. Bahr, D. C. (2001). Oral Motor Assessment and Treatment: Ages and Stages. Boston: Allyn and Bacon. Clark, H. & Osrty, D. J. (2005). Contributions to Speech Motor Control. American Speech and Hearing Association. San Diego, California. 8. 9. 10. 11. 12.
References (cont.)
Morris, S. E., & Klein, M. D. (1987). Pre-feeding skills: A comprehensive resource for feeding development (2nd ed.). San Antonio, TX: Therapy Skill Builders. Newmeyer AJ, Grether S, Grasha C, White J, Akers R, Aylward C, Ishikawa K, Degrauw T. (2007). Fine motor function and oral-motor imitation skills in preschool-age children with speech-sound disorders. Clinical Pediatrics, 46(7):604-11. Robin, D.A. (1992) Developmental apraxia of speech: Just another motor problem. American Journal of Speech-Language Pathology, 1, 19-22. Rosenfeld-Johnson, S. (2001). Oral-Motor exercises for speech clarity. Tucson, AZ: Innovative Therapists International. Schmidt, R.A. (1998). Motor control and learning: A behavioral emphasis (2nd ed.). Champaign, IL: Human Kinetics.
3.
Dewey, D., Roy, E. A., Square-Storer, P. A., & Hayden, D. (1988). Limb and oral praxic abilities of children with verbal sequencing deficits. Developmental Medicine and Child eurology, 30, 743-751.
Fisher, A.G., Murray, E. A., & Bundy, A. C. (Eds.). (1991). Sensory Integration: Theory and practice. Philadelphia: F.A. Davis.
4.
5.
Klein, H. B., Lederer, S. H., & Cortese, E. E. (1991). Childrens knowledge of auditory/articulatory correspondences. Journal of Speech and Hearing Research, 34, 559-564.
Koegel, L. K., Koegel, R. L., & Ingham, J. C. (1986). Programming rapid generalization of correct articulation through self-monitoring procedures. Journal of Speech, Language, and Hearing Research, 51, 24-32.
6.
7.
Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills (2nd Edition). San Antonio, TX: Therapy Skill Builders.
