B.4.

1 MOTOR SPEECH DISORDERS IN

CHILDREN
(NOTES)
c) Anatomic development of speech production systems
Speech production involves coordination within and between the subsystems.
The major subsystems involved in speech are:
1. Respiratory system
2. Phonatory system
3. Resonatory system
4. Articulatory system
Respiratory system:
It is the major source of air in speech production. It consist of the nasal cavity,
pharynx, trachea, bronchi, bronchioles, lungs, alveoli and diaphragm.
New born:
• diaphragm of new born has bellows like displacement unlike the piston
like effect in adults.
• Rest breathing rate is 30-80 breaths/min
• Fetal haemoglobin gradually replaced by adult haemoglobin.
Infancy:
• During this period, respiratory regulations are influenced very slightly by
the properties of utterances to be produced, as vocalizations are mostly
influenced by laryngeal and supra laryngeal systems.
2 months: Alveolar development begins
3 to 7 years:
• 3 years: Respiratory function not closely geared to linguistic
requirements till this age.
Rest breathing rate is 20-30 breaths/min
Functional maturation is especially evident during the period of 3-7
years.
• 7 years: Lung architecture remodelled to adult patterns.
Essential convergence on adult like pattern
Children continue to use greater subglottal air pressure than adults for
speaking.
7 to 10 years: During this stage, the child converges to have an adult like
pattern of respiratory activity.
• 8 years: number of alveoli reaches adult value (about 30,000)
• 10 years: refinement of respiratory pattern, functional maturation
achieved.
Rest breathing rate is 17-22 breaths/min
12 to 18 years:
• During this stage, the structures of respiratory system have achieved
their adult sizes.
• This greatly influences their capacities however it doesn’t really affect
the patterns of activity used during speech.
• Increase in lung capacities especially in boys.
Phonatory system:
It is the system responsible for the production of the sound.
The adult and paediatric larynges are not identical. Differences are seen in the
position, configuration, sizes of cartilages, histology of vocal folds.
Infancy:
• Laryngeal position high in neck.
• Smaller in size compared to body size.
• Laryngopharynx is relatively shorter.
• Subglottic portion is the narrowest.
• Epiglottis is omega shaped.
• Thyroid lamina has 110–120 degree angle.
• Half of glottal length is cartilaginous.
Histology:
at birth the vocal folds are about 2.5 mm to 3 mm and increase upto 5.5 mm at
the end of 1st year.
The mucosal layer is very thick and the vocal ligament is not developed.
The lamina propria of the vocal fold lacks clearly defined layers.
3 to 7 years:
at 4 years the vocal ligament appears.
At 6 years the two layers of ligament begin to be differentiated.
8 to 12 years:
• 8 years: sex differences begin to emerge in laryngeal tissues.
• 12 years: differentiation of lamina propria is complete
Voice changes begin in boys.
Length of vocal fold in pubescent girls: 12-17 mm
Length of vocal fold in pubescent boys: 15-25 mm
12 to 18 years: both respiratory and phonatory system achieve maturity.
• Thyroid laminae in men is 90* and women is 120*
• Vocal fold length in women is 21 mm and in men is 29 mm
• Epiglottis has leaf like shape.
• Glottis forms the narrowest part.
• Adult morphology of vocal fold achieved.
• About 1/3rd part is cartilaginous.
Resonatory system:
Birth: newborn has a vocal tract anatomy that resembles that of a nonhuman
primate.
1 to 2 years: stable jaw closing pattern
rapid growth of lips between 1 to 2 years of age
3 years: laryngopharnx is well developed.
4 years: hypertrophy of nasopharyngeal tonsils (adenoids) common, resulting
in constriction of nasopharyngeal portal and a velic-adenoidal pattern of
velopharyngeal closure.
5 years: essential convergence on adult shape of vocal tract
6 to 8 yrs: adultlike precision of jaw movement achieved, comparable
regulation of lips and tongue comes later.
9 years: atrophy of nasopharyngeal tonsil, pattern of velopharyngeal closure
may change in consequence.
12 years: essential maturation of voval tract for girls, growth for boys
continues until 18 years of age.
Articulatory system:
The Articulatory system consists of the oral cavity comprising of lips, the
tongue, the teeth, the palate (hard and soft) and the pharynx.
It has both passive and active articulators
Facial muscle:
At birth: facial muscle are more developed than other striated muscle.
18-24 months: mature swallowing pattern is developed in child where the
masticatory muscles play a predominant role rather than facial muscle.
Lips:
There is an increase in height, width and convexity in lips according to Buke
(1980). During infantile growth lips double in width.
Growth studies generally point to 2 growth spurts. In 1st growth spurt, the
acceleration is between 10-17 months, takes better shape till adolescence.
The 2nd growth spurt, coincides with growth acceleration of the mandible,
especially in males
Tongue: Biological function is to sense taste and to move food around in oral
cavity for chewing and swallowing
New born: The tongue of the newborn fills the oral cavity
By 18-24 months posterior part of the tongue begins to descent into the
pharyngeal cavity and no longer pre-dominant in the oral cavity.
The tongue attains its adult size by the age of 16.
Soft palate:
Subtelny described growth of soft palate form 3-18 years of life.
From the age of 3 to the age of 18, he found that soft palate increases in length
from 20mm to 35mm and also increase in thickness form 6-9mm.
The greatest growth occurred during the first 2 years of life. There was leveling
of growth upto the age of 4-5. Steady increase in length occurred through the
age 18. Studies have also found that the angle of inclination of the soft palate
changed with age.
Teeth:
The usual order of primary/milk tooth eruption is:
• Central incisors: lower jaw - between the ages of 6 and 10 months
upper jaw - between 8 and 13 months
• Lateral incisors in both the upper and lower jaws - between 8 and 16
months, with the lower set usually showing before the upper
• First set of upper and lower molars - between 13 and 19 months
• Upper and lower canines - between16 and 23 months
• Second set of upper and lower molars - between 25 and 33 months
From about the age of six onward, baby teeth will start becoming wobbly and
fall out, so that the adult teeth can grow.
Usual order of permanent teeth:
• First molars - between 6 and 7 years
• Central incisors - between 6 and 8 years
• Lateral incisors - between 7 and 8 years
• Canine teeth - between 9 and 13 years
• Premolars - between 9 and 13 years
• Second molars - between 11 and 13 years
• Third molars (wisdom teeth) - between 17 and 21 years, if at all
Jaw:
Newborns: have small, slightly retruded (pulled back) lower jaws (mandibles)
which are approximately 30 percent of adult size at birth
1 year: There is significant jaw growth in the first year of life. By six months
parents will notice their baby’s lower jaw beginning to line up with the baby’s
philtrum (area above the upper lip) and bridge of the nose when viewed from
the side
The mandible reaches adult like structure by 15-16 years in females and 18
years in males.
d) Development of neural pathways of speech motor control (brain
maturation, reflexes, sensory and motor)
Neural pathway is the connection formed by axons that project
from neurons to make synapses onto neurons in another location, to enable a
signal to be sent from one region of the nervous system to another.
MARKERS OF NEURAL DEVELOPMENT
• Establishment of neural interconnections
• Growth of synaptic density
• Expression of neurotransmittors and modulators
• Myelination of fiber tracts
• Hemispheric lateralization
5 months GA: by this time the full complement of neurons is established,
meaning that the brain has as many neurons as it will ever have.
Birth: neuronal cell formation is complete and the neurons have completed
their migration to their target sites
3 months: the dendritic density is greater in right hemisphere than left and the
density is greater in oral motor area of cortex than in brocas area
6 months: there is a peak in development of inner layers of cortex in language
areas
8-9 months: corticocortical connections are being established and an adult like
metabolic activity is observed across regions.
15 months: Hippocampus is fully matured, giving the infant an important
neural system for memory, there is also a rapid acceleration in number of
cortical synapses.
24 months: dendritic density increases in brocas area to catch up with oral
motor cortex, dendritic density in left hemisphere is almost equal to the right.
48 months:there are peaks in the overall metobolism, and in the development
of outer layers of language cortex.
72 months: dendritic density of brocas area is now greater than that of the oral
motor corte
e) Dysarthria in children – cerebral palsy – disorders of tone (spastic, flaccid):
definition, etiology, characteristics and associated problems
Dysarthria is a speech disorder caused by muscle weakness. Dysarthria is
a motor speech disorder resulting from neurological injury of the motor
component of the motor–speech system and is characterized by poor
articulation of phonemes.
Causes of dysarthria: Brain damage causes dysarthria. It can happen at birth or
after an illness or injury. Anything that causes brain damage can cause
dysarthria, such as:
• Stroke
• Brain injury
• Tumors
• Parkinson's disease
• Amyotrophic lateral sclerosis, or ALS
• Huntington's disease
• Multiple sclerosis
• Cerebral palsy
• Muscular dystrophy
Cerebral Palsy: Cerebral palsy is a term used to describe a set of neurological
conditions that affect movement.
Its disorder of posture and movement which is caused by permanent and non-
progressive insult to developing brain.
Types of C.P: Cerebral palsy (CP) is classified according to the type of body
movement and posture problem and damage.
1.monoplegia: affects one limb
2.hemiplegia: affecs one side of the body
3.diplegia: affects symmetrical parts of the body
4.quadriplegia: affects all four limbs
Etiology:
pre-natal: cerebral dysgenesis, cerebral malformation, congenital
infection
perinatal: birth trauma
post-natal: ischaemia, meningitis, head trauma,
hydrocephalus, hyper-bilirubin-anaemia.
Associated problems:
• Hearing impairment
• Visual impairment
• Cognitive impairment
• Epilepsy
• Respiratory
• Dental
• Urinary problems
• Swallowing difficulty
• Speech difficulty

1.Spastic dysarthria (cerebral palsy):

Definition: Spastic C.P is the most common type of CP, in almost 70-80%.
Spasticity is a form of hypertonia, or increased muscle tone.
Spastic dysarthria is a type of dysarthria associated with bilateral upper motor
lesion, muscles can be stiff and move sluggishly through a limited range;
speech is laboured and words may be prolonged.
Characteristics:
• Associated with damage to cerebral cortex (upper motor neuron).
• Weakness,
• Loss of skilled movement, stiff and jerky movements
• Spasticity, Increased muscle tone, tense and contracted muscles
• Reduced range and slowness of movement
• Hyperactive reflexes, increased deep tendon reflex.
Speech characteristics:
• Slow rate, effortful and deteriotes with fatigue;
• Dysphagia
• Strained and strangled, harsh voice quality,
• Imprecise articulation
 • Mono-pitch
• Imprecise consonants
• Hypernasality

2.Flaccid dysarthria (cerebral palsy):

Definition:
Flaccid C.P. is a neurological condition characterized by weakness or paralysis
and reduced muscle tone without other obvious cause (e.g., trauma)
Flaccid dysarthria is a motor speech disorder with neuropathology of damage
to the motor units of the cranial or spinal nerves that supply speech muscles
(lower motor neuron); speech problems caused mostly by muscle weakness
and hypotonia.
Characteristics:
• Limp or floppy limbs
• Minimal or no neck control, Frequent falls and clumsiness
• Developmental delays
• Extreme flexibility
• Slow movements and reflexes
• Soft or weak voice
• Feeding difficulties
• Fatigue
Speech characteristics:
• Hypernasality
• Imprecise consonants
• Breathiness (continuous)
• Mono-pitch
• Nasal emission
• Audible inspiration
• Harsh voice quality
• Short phrases
• Monoloudness
f) Dysarthria in children – cerebral palsy – disorders of movement
(hyperkinetic, hypokinetic) and disorder of balance (ataxia): definition,
etiology, characteristics and associated problems
1.hyperkinetic dysarthria (cerebral palsy):
Hyperkinetic is used to describe unusually high muscle tone, which creates fast
uncontrolled movements and tension in the muscles. Hyperkinetic dysarthria is
a motor speech disorder that most often associated with diseases of the basal
ganglia control circuit.
Chorea (random involuntary movements of the limbs, trunk, head, and neck),
myoclonus (rapid and jerky muscle contractions), tics, dystonia (sustained
muscle contraction), and essential tremor are all examples of hyperkinetic
movement disorders.
The involuntary movements associated with these disorders frequently
interfere with voluntary movements. When these interfere with speech
production, the result is hyperkinetic dysarthria.
Characteristics:
• Involuntary movement.
• Tremors.
• Poor posture.
• Unsteadiness.
• Abrupt movements.
• Drooling
Speech characteristics:
• Imprecise consonants
• Prolonged intervals
• Variable pitch and Excess loudness variation
• Harsh voice quality
• Inappropriate silences
• Distorted vowels
• Irregular articulatory breakdown
• Hypernasality
2. Hypokinetic Dysarthria (cerebral palsy):
Definition: A type of motor speech disorder resulting from damage to the
basal ganglia (extrapyramidal system) resulting in slow movement, limited
range of movement, and rigidity; may affect all aspects of speech. The most
common cause is “parkinsonism”.
Characteristics:
• slow and reduced range of movement.
• Rigidity, tremors.
• Difficulty swallowing
• drooling
• Poor posture.
• Unsteadiness.
• Slow, writhing movements
Speech characteristics:
• Prosodic errors: mono-pitch, reduced stress, and mono-loudness
• inappropriate silences
• Short rushes of speech
• imprecise consonants.
• repeated phonemes
• palilalia (the compulsive, increasingly rapid repetition of a word or
phrase)
• A harsh or breathy voice quality
• Low pitch
Respiratory problems:
• muscles of the chest and the diaphragm are not coordinated during
breathing.
• Reduced range of movement in their respiratory muscles.
• shallow breath support
• short breathing cycles
3. Ataxic Dysarthria (Cerebral Palsy):
Definition: Children with Ataxic cerebral palsy has trouble in balance and
coordination.
Ataxic dysarthria is a disorder of sensorimotor control for speech production
that results from damage to the cerebellum, characterized by speech errors
relating primarily to timing, range and force, giving equal stress to each
syllable; articulation problems.
Characteristics:
• Poor balance and lack of coordination
• Wide-based gait
• Depth perception usually affected
• Inability to walk in straight line
• Tendency to fall and stumble
Speech characteristics:
• Slurred speech
• Dysphagia
• Drooling
• Scanning speech, also known as explosive speech, in which spoken
words are broken up into separate syllables,
• monotone voice
• drunken speech
g) Dysarthria in children – lower motor neuron and other syndromes with
motor speech disorders:
Lower motor neuron:
All voluntary movement depends upon excitation of LMN by UMN. Lower
motor neurons innervates the skeletal muscle fibres.
They originate from motor component of cranial nerve nuclei in brainstem.
A Lower Motor Neuron lesion is a lesion which affects nerve fibres travelling
from spinal cord to the relevant muscle.
Clinical features:
• Flaccid cerebral palsy( Flaccid dysarthria)
• Weakness
• Muscular atrophy
• Hypotonia
• Fasiculation
• Hyporeflexia
Lower motor neuron syndromes with motor speech disorders:
1.Spinal Muscle Atrophy (SMA):
It is an autosomal recessive hereditary disease caused by mutation of SMN 1
gene. The muscle weakness occurs due to progressive degeneration of the
alpha motor neuron from anterior horn cells of spinal cord.
It is classified in 4 types based on patients age at the onset.
− Type 1: between birth to 6 months
− Type 2: between 6 to 12 months
− Type 3: between 2 to 15 years
− Type 4: adult type
It causes flaccid paralysis resulting in flaccid or lower motor neuron dysarthria.
characteristics:
• floppy muscle tone
• Feeding problems and dysphagia
• Respiratory problems
• Facial weakness
 • Lower motor neuron dysarthria
• Limited mobility
• Curvature of the spine

2.Poliomyelitis:
Acute poliomyelitis is a disease of the anterior horn motor neurons of the
spinal cord and brain stem caused by poliovirus.
Flaccid asymmetric weakness and muscle atrophy are the hallmarks of its
clinical manifestations.
Characteristics:
• severe muscle pain
• flaccid tone
• fasciculation
• areflexia
• dysphagia
• dysphonia
• respiratory failure
3. Guillain Barre Syndrome:
GBS is an immune-mediated, rapidly progressive, predominantly motor,
neuropathy that often leads to bulbar and respiratory compromise.
It is a common cause of acute flaccid paralysis in children.
Characteristics:
• flaccid dysarthria
• Paraesthesia
• Symmetric ascending weakness
• Facial weakness
• Involvement of respiratory muscles.
• Tachycardia
• arrhythmia
• Bladder dysfunction
4.Myasthenia Gravis:
It is a rare autoimmune disease in which antibodies attack postsynaptic
acetylcholine receptors on the NMJ of skeletal muscle.
Destruction of these postsynaptic neurons result in a progressive weakness of
the skeletal muscles.

signs and symptoms:

• fluctuating fatigable muscle weakness that worsens with activity.
• generalized weakness
• bulbar muscle weakness
• proximal limb weakness
• flaccid paralysis

5.Lambert Eaton Myasthenic Syndrome:

It is a rare presynaptic disorder of neuromuscular transmission in which
release of acetylcholine is impaired due to an autoimmune attack directed
against the voltage gated calcium channels on the presynaptic motor nerve
terminal.
Often causes damage to lower motor neurons resulting in flaccid paralysis.
Clinical characteristics:
• Proximal muscle weakness
• Depressed tendon reflexes
• Post tetanic potentiation
• Autonomic changes
• Cancer in 40% patients

6.Congenital myopathy:
Group of muscle disorders caused by genetic defects in contractile apparatus
of the muscle. It damages the lower motor pathway.
Major presentation is “floppy infant syndrome”.
Characteristics:
• Hypotonia
 • Static muscle weakness
• Reduced tendon reflex
• Swallowing problems
• Respiratory problems
7.Beckers Muscular Dystrophy:
It is an X-linked recessive inherited dystrophinopathy characterized by slowly
progressing muscle weakness of the legs and pelvis.
Signs and symptoms:
• Muscle weakness, gradually increase difficulty with walking
• Severe upper extremity muscle weakness
• Toe-walking
• Difficulty breathing
• Skeletal deformities of chest and back
• Pseudohypertrophy of calf muscles
• Muscle cramps.
Beckers muscular dystrophy is often associated with flaccid paralysis
(dysarthria) as the muscle weakness is prominent in facial, jaw and neck
musculature.
8.Duchene Muscular Dystrophy:
It is an inherited disorder of progressive muscular weakness. It is a severe form
of muscular dystrophy caused by flaw in the gene that controls the muscle
health. Mutation at locus Xp21. Mostly seen in boys.
In patients with DMD, speech problems precede muscle weakness. It is often
associated with lower motor neuron dysarthria.
Signs and symptoms:
• Walk on forefeet
• Increased muscle tone
• Fatigue
• Late onset of speech
• Facial weakness
h) Childhood apraxia of speech and nonverbal oral apraxia: definition,
characteristics and classification
Apraxia: it is a motor disorder caused by damage to brain which causes
problem in Motor Planning/Programming i.e inability to group and sequence
the relevant muscle with respect to each other.
It can be acquired (due to traumatic brain injury) and developmental (since
birth)
There are different types of apraxia
1. Ideational apraxia
2. Ideomotor apraxia
Ideational apraxia:
It is inability to make use of an object or a gesture in a correct way and have
difficulty in carrying out the sequential actions in order to use it. Disturbance in
the concept of an object.
Ideomotor apraxia:
It is a disturbance of performance of an object or gesture. The concept of the
object is present but sequence of movement to use it is absent.
Typically affects voluntary movements more often than spontaneous or
automatic movements. Errors can be inconsistent on repeated attempts of
same function.
Types of Ideomotor apraxia:
1. Limb apraxia
2. Nonverbal oral apraxia
3. Apraxia of speech

1.Limb Apraxia: Inability to sequence arms, legs, hands or feet

2.Nonverbal oral apraxia:
Also known as “buccofacial apraxia,” “facial apraxia,” “orofacial apraxia,” or
“lingual apraxia.”
Definition: Nonverbal oral apraxia is a deficit in the ability to sequence
nonverbal, voluntary movements of the tongue, lips, jaw, and other associated
oral structures.
Characteristics:
Nonverbal oral apraxia is commonly seen in individuals with left hemisphere
damage
The orofacial movements affected are protruding the tongue, whistling, biting
the lower lip, and puffing out the cheeks.
Groping behaviour: individual with this type of apraxia may grope for the
correct position of the mouth
Delay performing the action, only partially complete the movement, or
perform the movement slowly and awkwardly.
Patients with apraxia can make spontaneous movements of the oral
mechanism like, deep breathing, swallowing, smiling, etc without any difficulty.
3.Apraxia of speech:
Definition:
It is neurologic speech disorder reflecting an impaired capacity to plan or
program sensorimotor commands necessary for directing movements that
result in normal speech ~ (Duffy)
It is a deficit in the ability to select and sequence the motor commands needed
to correctly position the articulators during voluntary production of phonemes.

Causes of apraxia of speech

• Stroke (affecting frontal and parietal lobe)
• Degenerative diseases
• Trauma
• Tumor
• Primary progressive aphasia
• Injury to perisylvian area of the left hemisphere of the brain
• Injury to insula and basal ganglia
Childhood apraxia of speech (CAS)
CAS is an uncommon speech disorder in which a child has difficulty in planning
and programming accurate movements for speaking.
CAS can be congenital, or it can be acquired during speech development. Both
congenital and acquired onsets can be idiopathic
Characteristics of childhood apraxia of speech:
• Inconsistent errors
• Inappropriate prosody
• vowel distortions
• Limited consonant and vowel phonetic inventory
• Initial consonant deletions, Voicing errors
• Greater ease in producing automatic versus volitional utterances
• Presence of groping behaviors when attempting to produce speech
sounds or coordinate articulators for purposeful movement;
• Increased difficulty with longer or more complex syllable
• Sequencing errors (e.g., Metathesis, migration),
• The presence of error patterns in the child's speech does not indicate a
phonological problem, rather a motoric problem.
• Delayed language development
• Expressive language problems, like word order confusion and
grammatical errors
• Problems in literacy
• Problems with social language/pragmatics.
• Gross and fine motor delays
• Motor clumsiness, oral apraxia, Limb apraxia
• Feeding difficulties
• Abnormal oro-sensory perception (hyper- or hyposensitivity in the oral
area).
Unit 2: Assessment of motor speech disorders in children
a) Case history and developmental neurological evaluation – primitive postural
and oropharyngeal reflexes, cranial nerve examination
case history: The history provides basic facts about the onset and course of the
problem, patient's awareness of impairment, and the degree to which the
problem is disabling or handicapping. Factors affecting how history-taking is
approached include the patient's cognitive abilities and personality, whether or
not the patient perceives a problem, reports from other professionals, and the
severity of the speech deficit. If patients have cognitive limitations, significantly
reduced intelligibility, and inadequate augmentative means of communication,
or if they do not perceive a speech deficit, then the history from them will be
limited.
Age, education, occupation, and marital and family status should be noted. It
may be important to establish if there was a history of childhood speech,
language, or hearing deficit
Onset and course: Information about the onset and course of the speech
deficit is useful to neurologic diagnosis, prognosis, and management decisions.
It also reveals something about the patient's perception of the problem.
The patient's perception of deficit: It is important to establish the patient's
perception of the problem. This can provide useful confirmatory information.
Consequences of the disorder: This information is useful for determining
disability and handicap
Cope up techniques: This provides information about what the patient and
others have done to manage the speech disorder. It is useful for determining
prognosis and future management recommendations.
Developmental neurological evaluation:
A neurological examination is the assessment of sensory neuron and motor
responses, especially reflexes, to determine whether the nervous system is
impaired. This typically includes a physical examination and a review of the
patient’s medical history.
Primitive reflexes: infantile, infant or new born reflexes are reflex actions
originating in the central nervous system that are exhibited by normal infants,
but not neurologically intact adults, in response to particular stimuli
1. palmar grasp reflex:
Stimulus: palm stimulated response: fingers closed except thumb
Duration: 5 months gestation to 4 months post partum
Concerns: no palmer grasp reflex may indicate neurological problems
2. moro reflex:
Stimulus: suddenly but gently lower the baby’s head
Response: arms and legs are extended
Duration: prenatal to 4 - 6 months postpartum
Concerns: May signify CNS dysfunction if lacking, signify sensory motor
problem if persists, May delay sitting & head control if persists, indicate injury
to one side of brain if asymmetrical
3.asymmetric tonic reflex:
Stimulus: Prone/supine position, turn head to one side
Response: Limbs flex on one side, extend on other side
Duration: after birth 3 months
Concerns: Facilitates bilateral body awareness. Facilitates hand-eye
coordination
4. symmetric tonic reflex:
S: Baby sitting up and tip forward R: Neck and arms flex, legs extend
S: Baby sitting up and tip backward R: Neck and arms extend, legs flex
Duration: After birth – 3 months
Concerns: Persistence may impede many motor skills and cause spinal flexion
deformities
5. Babinsky reflex:
Stimulus: Stroke bottom or lateral portion of foot
Response: Great toe turns downward
Duration: birth to 4 months
Concerns: Test of the pyramidal tract (i.e. ability to perform conscious /
voluntary movement)
Postural reflexes:
1.stepping reflex:
Stimulus: Infant upright with feet touching surface
Response: Legs lift and descend
Duration: After birth – 5-6 months
Concerns: Essential forerunner to walking
2. crawling reflex:
Stimulus: Prone position on surface, stroke alternate feet
Response: Legs and arms move in crawling action
Duration: Birth – 3-4 months
Concerns: Precursor to later voluntary creeping
3.swimming reflex:
stimulus: Infant held horizontally
Response: Arms and legs move in coordinated swimming type action
Duration: 2 weeks after birth – 5 months
Other: Recognition of reflex led to popularity of infant swim programs
4.parachute reflex:
Stimulus: Infant held horizontally
Response: Arms and legs move in coordinated swimming type action
Duration: 2 weeks after birth – 5 months
Other: Recognition of reflex led to popularity of infant swim programs
Oral reflexes:
1.sucking reflex
S: touch at the corner of lips R: sucking action
Duration: In utero - 3 months postpartum
Concerns: No reflex problematic for nutrition
2.rooting reflex:
S: touch cheek R: head moves toward stimuli
Duration: Weeks prenatal - 3 months postpartum
Concerns: No reflex problematic for nutrition, No reflex or lack of persistence
may be sign of CNS or sensorimotor dysfunction.
3.swallowing reflex:
Stimulus: liquid or food touches posterior part of tongue
Response: swallow response
Duration: throughout life
4. gag reflex:
Stimulus: touch back of tongue
Response: reflexive contraction of back of tongue
Duration: throughout life
cranial nerve examination:
Name Function Activity
Olfactory nerve Sense of Blind fold the client and present the
stimuli following to smell and identify:
coffee seeds, camphor, perfume, curry leaf

optic nerve Sense of sight Place colours infront of the client ask
balance him/her to name them:
Red, green, yellow, blue, black.
oculomotor Eye ball Ask the client to move the eye ball to left,
trochlear movement right, up and down
abducent
trigeminal nerve Chewing a) clinician should apply moderate pressure
sensation of on clients mandible and ask to close the
the face mouth
b) blind fold the client and check for the
sensation of face by touching the skin
surface with a cotton swab.
Facial nerve Taste a) Ask the client to taste the following and
sensation, identify it: Honey, salt.
movement of
facial b) ask the client to :
expression smile, pucker, blow, raise eyebrow

Vestibulo - Maintenance a) draw a line on the ground and ask the

cochlear nerve of balance client to walk on the line
b) ask the client to listen to the following
sounds: clap, squeezes, bell, tuning fork
Glossopharyngeal Secretion of Take a tongue depressor and touch the
nerve saliva, sense of back part of the tongue (gag reflex)
test, movement
of pharynx
Vagus nerve Movement, Ask the client to take a deep breath and say
secretion /a/. ask to dry swallow
Accessory nerve Movement of Ask the client to turn the head and feel the
the head and sensation of sternocleidomastoid muscle
shoulders
Hypoglossal Movement of Ask the client to make tongue movements:
nerve tongue protrude, retract, lateral, up and down.
b) Assessment of oral sensory and motor capacity – Oral peripheral
mechanism examination, neuro- muscular status:
assessment of speech mechanism is a two-fold process that includes
1. determine the structural integrity of the speech mechanism: administer
OPME, determine the size, shape and adequacy of the structures.
2. determine the functional integrity of the speech mechanism: administer
neuromotor speech exam, determine the adequacy of system to produce non
speech and speech related movements.
OPME: Its purpose is to identify or rule out structural or functional factors that
relate to a communicative disorder. Assess the size, shape and adequacy of
oral, lingual structures, resonatory and laryngeal structures, respiratory
structures. Determine if they perform their function for nonspeech and speech
related purposes. While performing OPME observe the following.

Neuro-muscular status:
neuromuscular processes are the foundation of all voluntary movement in the
body. As the evaluation is administered, the clinician needs to constantly
assess the patient’s muscle strength, speed of movement, range of motion,
accuracy of movement, motor steadiness, and muscle tone. Darley called these
six processes the “salient features” of neuromuscular function.
Muscle Strength: If a muscle within the motor speech mechanism does not
have adequate strength, it may not be able to perform its speech production
tasks adequately. Muscle strength is assessed, For eg, a patient is asked to
press his or her tongue against a tongue blade or asked to count out loud from
1 to 100 (a task known as “stress testing” the speech mechanism).
Speed of Movement: Accurate speech requires very rapid muscle movements.
The tongue and vocal folds, in particular, make many rapid movements during
the production of speech. Speed of movement is assessed through tasks that
concentrate on alternate motion rates (AMR) and sequential motion rates
(SMR). Both AMR and SMR tasks are included in the protocol
Range of Movement: Range of movement is how far the articulators can travel
during the course of a movement. Instances of reduced range of movement
include an inability to fully open the jaw or completely adduct the vocal folds.
Prosody, especially, could be affected by reduced range of movement in the
articulators. Range of movement is assessed most directly in which the patient
is asked to extend or hold the articulators in various positions.
Accuracy of Movement: Clear speech production requires accurate movements
by the articulators. An accurate movement is one in which strength, speed,
range, direction, and timing are precisely coordinated (Darley et al., 1975). If
any of these are out of sync, the result can be an inaccurate movement,
causing such problems as a distorted consonant or intermittent hypernasality.
The AMR and SMR tasks are good for assessing the accuracy of movement, as
are conversational speech and spoken paragraph reading
Motor Steadiness: Motor steadiness is the ability to hold a body part still.
There are several disorders in which involuntary movements prevent motor
steadiness, ex. tremor. These can affect the laryngeal musculature and lead to
a tremulous vocal quality during speech. Motor steadiness is assessed by tasks
that require a patient to hold a position or prolong a vowel. A breakdown in
motor steadiness will reveal itself in an inability to maintain a still position or
to produce a prolonged vowel that is smooth and steady
Muscle Tone: Normal muscle tone is the constant amount of muscle
contraction that is always present, even when a muscle is fully relaxed.
Damage to the nervous system can either decrease or increase muscle tone,
depending on where the damage occurs. Decreased muscle tone is associated
with muscle weakness or paralysis. Increased tone is associated with muscle
spasticity or rigidity. Abnormal muscle tone can be inferred by listening to the
patient’s speech or by looking at the affected body parts.
Other components in neuromuscular assessment are:
Vital signs: Confirmatory signs are additional clues about the location of
pathology. In the context of speech examination, they are signs other than
deviant speech characteristics and the salient neuromuscular features that
characterize them that help confirm the speech diagnosis. Examples of
confirmatory signs within the speech system are atrophy, reduced tone,
fasciculations, poorly inhibited laughter or crying, reduced normal reflexes or
the presence of pathologic reflexes, pain.
Sensation: it provides valuable information of how the information from
outside world is integrated by the nervous system.
Functional mobility assessment: it includes assessing rolling, upright tolerance,
getting in and out of bed and chair, walking, stepping, and climbing, changing
directions, lifting, carrying, and reaching, etc.
c) Assessment of speech sub-systems – quantitative and qualitative
Speech subsystems include: articulatory, respiratory, resonatory and
phonatory system.
Respiratory system: it includes assessment of the respiratory volumes and
lung capacities, respiratory efficiency, etc.
• observe the breathing patterns for speech and non-speech activities.
• s/z ratio: it is the ratio of maximum phonation time for /s/ to /z/. it is
measured in seconds. Normal s/z ratio is 1:1, 1:4 is abnormal ratio,
indicating respiratory deficiency.
• MPT: it is the sustained vowel production following as deep an
inhalation is possible. Measured in seconds. Sustain the vowel /a/.
normal MPT for adult females is 15 to 25 sec and 25 to 35 for males.
• Pulmonary function studies (PFT’s)
• Spirometry: it uses a device called spirometer (wet/ dry) which measures
the air/lung volume. Wet spirometer consist a bell inverted in a vessel of
water. In dry spirometer there is a hand-held spirometer.
Phonatory system: it includes subjective and objective examination.
Subjective rating scales: it involves analysis of voice/ phonation solely by
listening. Clinician should consider a number of factors. Usually, this scale
assesses the parameters of phonation such as roughness, breathiness, strain.
Clinician based: GRBAS, CAPE-V, Buffallo III
Patient based: V-RQOL, VHI-10, VHI-30.
Objective rating scales: it includes Visi-pitch, CSL/MDVP, MultiSpeech, etc.
Resonatory system: resonatory system includes the cavities that shape the
utterances like oral cavity, nasal cavity, etc. While assessing for nasal
resonance check if hypernasality/ hypo-nasality is present.
Subjective measurement: use mirror fogging technique. Keep the mirror
underneath the nares and observe for any fog on it during a non-nasal sound.
If fogging appears, hypernasality is seen. For hypo-nasality do the same task
with a nasal sound.
Objective measurement: it could be performed by using Nasometer.
Nasometer refers to the instrument that measures and give feedback on the
presence of nasality in speech production, by measuring the movement of
velopharynx.
Voice assessment: It can be assessed using various instrumentation such
• Computerized Speech Lab (CSL)
• Multispeech
• Visi-pitch
• Laryngo-strobo-video-endoscopy
• FEESST
Loudness: it could be subjectively measured in volume and objectively
measured using SLM in decibels.
Speech Rate: speech rate could be assessed using :
• DDK rate: ( AMR and SMR)
• WPM – words per minute
• SPS – Syllables per second
d) Assessment of speech intelligibility and comprehensibility
Intelligibility is a measure of how comprehensible speech is in given
conditions. Intelligibility is a perceptual judgment that is based on how much
of the child's spontaneous speech the listener understands. Intelligibility can
vary along a continuum ranging from intelligible to unintelligible.
It is affected by the level (loud but not too loud) and quality of the speech
signal, the type and level of background noise, reverberation and, for speech
over communication devices, the properties of the communication system.
Clinical uses of intelligibility measures:
• Index of severity
• Index of functional limitation.
• Measure of change over time: treatment progress, recovery,
degeneration.

Rating scales and other estimates that are based on perceptual judgments are
commonly used to assess intelligibility
7point Intelligibility Rating Scale AYJNIHH
Speech sample Rating
Scale
Normal 0
Client/Child’s speech can be understood without difficulty 1
however listener feels that the speech is not normal
Client/ child’s speech can be understood with little effort but 2
occasionally listeners need to ask for repetition
Client/ child’s speech can be understood with concentration and 3
effort especially by a sympathetic listener
Client/child’s speech can be understood with difficulty and 4
concentration by family members but not by others
Client/child’s speech can be understood with difficulty and 5
efforts, if the context is known by the listener
Client/child’s speech cannot be understood at all even when the 6
context is known
Write down procedures: they are generally the best approach. Listeners try to
identify exactly what the intended message was and calculate the percentage
understood. It is possible at several linguistic levels:
• Single words (spontaneous or imitated)
• Sentences (spontaneous or imitated)
• Conversation
1. single word approach: One of the most flexible approach is:
(CSIM) childrens speech intelligibility measure – by Wilcox and morris.
• CSIM includes 50 test items.
• It is not norm-referenced.
• CSIM can be administered multiple times because unique test is created
each time. Each item has 12 similar sounding words.
• Child imiatates the clinician and record the sample and give it to
unfamiliar listeners, listeners write down what they comprehend and
calculate the actual percentage understood by the listener.
2. sentence level procedure:
A] for a very young and unintelligible child:
Beginner’s inteligibilty test (BIT)
• originally designed for hearing impaired child but can be used for all
populations.
• It is used
• BIT is NOT norm referenced.
• Includes 4 sets of 2 to 5 word sentences. It uses one set each time so
that it could be administers at regular intervals.
• Child imitates or reads the sentences which are recorded and given to 2
unfamiliar listeners who write down what they hear.
• Calculate the percentage of words correctly identified.
B] for older children 7+ years:
Assessment of inteligibilty of dysarthric speech ( sentence portion)
• NOT Norm referenced
• Select 5 sentences from each list of 5 to 8 word sentences ( 20 total
sentences, 138 total words).
 • Child imitates or reads the sentence which is recorded and transcribed
by 2 unfamiliar listeners
• Total percentage understood by the listener is calculated.
3. conversation:
• record true interaction
• Avoid narratives as they may induce abnormal prosody which may
influence scores.
• Have unfamiliar listeners transcribe what they hear.
• Calculate the percentage understood.

Comprehensibility: Comprehensibility refers to whether listeners can

understand the message communicated by a speaker.
comprehensibility as how “effortful” the speech is to understand and
described the language features that are most relevant for determining this at
different ability levels.
Measurement of comprehensibility:
• Answer open ended questions about the content of a spoken message.
• Answer yes/no questions about the content of a message.
• Re-tell the narrative.
Comprehensibility vs intelligibility:
• Intelligibilty measures deliberately omit contextual information.
• Both measure employ orthographic transcription.
• Both measures provide percentage correct scores.
• They both provide different, yet complimentary information.
f) Speech assessment with specific reference to childhood apraxia of speech –
Phonetic and phonemic inventory, phonotactics and syllable sequencing,
variability of errors, speech intelligibility, fluency and prosody
According to WHO comprehensive assessment is conducted to identify and
describe
• impairments in body structure and function, including underlying
strengths and weaknesses in speech sound production and
verbal/nonverbal communication;
• co-morbid deficits or conditions, such as developmental disabilities,
medical conditions, or syndromes;
• limitations in activity and participation, including functional
communication, interpersonal interactions with family and peers, and
learning;
• contextual (environmental and personal) factors that serve as barriers
to or facilitators of successful communication and life participation; and
• the impact of communication impairments on quality of life of the child
and family
Comprehensive assessment for childhood apraxia of speech typically includes
• Case history
• Oral mechanism examination
• Motor speech assessment
• Hearing screening
• Speech sound assessment (single-word testing and connected-speech
sampling)
• Analyse the phonemic and phonetic inventory
• speech intelligiblity
• Fluency and prosody
• Spoken language assessment and literacy assessment
Motor Speech Assessment: This is critical for differentiating CAS from
childhood dysarthria and other speech sound disorders and for identifying
both oral apraxia and apraxia of speech—either of which may occur in the
absence of the other.
• Motor speech assessment is an evaluation of movement accuracy
• Nonspeech articulatory postures (e.g., smile) and sequences (e.g.,
Protrude–smile) versus speech sounds and words
• Well-practiced/automatic versus volitional speech
• Speaking tasks that require single postures versus sequences of postures
• Speech production at the single syllable, bisyllable, multisyllable, phrase,
and sentence levels; and
• Sequential and alternating movement repetitions.
Phonetic inventory: A phonetic inventory in its simplest form lists the speech
sounds that a child can physically articulate irrespective of how he/she uses
them in words. Thus, it will include speech sounds that are used both correctly
and incorrectly by the child.
Phonemic inventory: lists the speech sounds that a child is able to use
correctly in their speech and provides a basic measure of their productive
phonological knowledge (PPK). A child is judged to have PPK of a speech sound
if it is used correctly, at least once within the speech sample.
Phonotactics: the study of the rules governing the possible phoneme
sequences in a language.
inventory Syllable-word shapes present in the sample (record as C V CV VC CVC
Syllable-word shape inventory constraints Shapes absent from the sample, or
only present in highly rehearsed contexts
Variability of errors: Sequencing errors may consist of inaccuracies,
inconsistency (i.e., not producing the same sound or syllable in each
repetition—whether correct or not), or mis-ordering sounds, this is variability
of the errors.
In preschool children, consistency and accuracy of repetitions are likely to be
more useful performance indicators than repetition rate.
Intelligibility is a perceptual judgment that is based on how much of the child's
spontaneous speech the listener understands. Intelligibility can vary along a
continuum ranging from intelligible to. Intelligibility is frequently used when
judging the severity of the child's speech and can be used to determine the
need for intervention.
Assessment of Fluency and prosody: fluency refers to continuity, smoothness,
rate, and effort in speech production and includes 3 components: accuracy,
rate and prosody. Fluency problems include atypical rate, rhythm, and
disfluencies, excessive tension, speaking avoidance, etc. fluency disorders may
include stuttering or cluttering. Speech clarity and fluency may temporarily
improve when the person is asked to slow down or pay attention to their
speech. Assessment of speech fluency includes recording of a speech sample
and assessing the frequency,type, and duration of disfluencies.
g) Test materials – checklist for childhood apraxia of speech, screening test
for developmental apraxia of speech
Few measures to assess CAS: To assess for CAS, we need to assess children’s
speech production on single word tests, such as
• Goldman-Fristoe Test of Articulation (GFTA)
• Single Word Test of Polysyllables, as well as in repeated words and
phrases, and connected speech.
• Polysyllable words and diadochokinesis tasks stress the motor system
and may elicit errors
however poor accuracy and inconsistency on polysyllable word production is
also present in children with speech delay and phonological disorder.
Screening test for developmental apraxia of speech:
8 subtests
• Subtest I: Expressive Language Discrepancy
• Subtest II: Vowels and Diphthongs
• Subtest III: Oral-Motor Movement
• Subtest IV: Verbal Sequencing
• Subtest V: Articulation
• Subtest VI: Motorically Complex Words
• Subtest VII: Transpositions
• Subtest VIII: Prosody
Subtest I: Expressive Language Discrepancy : the subjects expresive language
was compared to his or her language comprehension age to determine the
discrepancy often accompanying DAS.
Subtest II: Vowels and Diphthongs: the subject was instructed to imitate words
containing vowels and dipthongs presented by the examiner.
Subtest III: Oral-Motor Movement: the subject was instructed to imitate
nonspeech oral movements using his/her tongue and lips.
Subtest IV: Verbal Sequencing: it refers to placements of syllables in proper
order over a paired of time. The sounds /p/ /t/ /k/ were paired with the vowel
/a/ and presented verbally in different orders to the subject.this subtest
includes two parts.
Subtest V: Articulation : the subject was instructed to imitate words presented
by the examiner. Besides marking substitutions, omissions and distortions,
errors in phonemic characteristics and their position were also marked.
Subtest VI: Motorically Complex Words : the subject was instructed to imitate
three multisyllabic words presented verbally by the examiner. The subject was
give three trials to imitate the word using correct sound and syllable order.
Subtest VIII: Prosody : short samples of the subject’s connected speech were
observed. The examiner then subjectively evaluated.
Screening Test for Developmental Apraxia of Speech, 2nd ed. (STDAS2)
• Individually-administered, norm-referenced screening measure to
identify the possible presence of developmental apraxia of speech in
children, ages 4 through 12-11 years.
• There are three areas: Prosody, Verbal Sequencing and Articulation.
• “Prescreening” of receptive and expressive language abilities is
conducted prior to administration of the STDAS-2.
• The STDAS-2 assesses the “likelihood” of apraxic speech development.
• Children scoring in the “Very Likely” classification are then candidates
for trial treatments for developmental apraxia of speech (DAS) or,
further neurologic testing
• If a student scores at or above the 10th percentile in receptive language
and the student demonstrates weaker expressive capabilities
The Kaufman Speech Praxis test- Nancy Kaufman (1995)
• This test for children was designed to identify the level of breakdown in
a child’s ability to speak. It can be used as an initial diagnostic tool as
well as measurement progress.
• Test items are organized from simple to complex motor speech
movements using meaningful words whenever possible.
• It is norm- referenced, providing standard scores and percentile
rankings for ages of 2; 0- 5; 11 and a severity scale.
The Verbal Motor Production Assessment for Children (Hayden & Square
(1999)
• Identify children with motor issues that have negative effects on the
development of normal speech motor control, focal oral motor control,
sequencing, connected speech and language control and speech
characteristics.
• The test pinpoints where the child begins to have difficulty with items
and is arranged from basic to complex skills. It is standardized and yields
for children aged 3-12 years. A treatment approach that complements
the VMPAC is PROMPT.
The Apraxia Profile (Lori Hickerman (1997)
• This is a criterion referenced assessment designed to identify and
describe apraxic characteristics present in children and determine the
point in the co-articulation process at which a child’s specific skills
breakdown.
• Its purpose is to evaluate articulation movements and movement
sequences verbally and non verbally in children aged 3-13 years.
• It can also be used to chart a child’s progress and to share information
with parents, teachers and other professionals
h) Protocols for non-verbal and verbal praxis specific to Indian languages
Indian tests:
• Banumathy (2008) established a
protocol called ‘assessment of oral motor, oral praxis and verbal praxis
skills’ to identify developmental apraxia of speech in the age range of 4-
14 years of Kannada speaking individuals.
• The protocol includes mostly rating scales that are different for each
task.
• The rating scales are task oriented and are not the same across different
tasks because the tasks are not comparable.
• This is basically profiling of child’s abilities in each task
Oral motor assessment protocol

Oral praxis assessment protocol:

Verbal praxis assessment tool:
• isolated verbal movements
• sequential verbal movements, assessment of diadochokinetic (DDK)
tasks
• word level praxis assessment
• sentence level praxis assessment
• analysis of spontaneous speech

Protocol for appraisal of verbal praxis in typically developing children

-Radhika Sivarajan and R Manjula.
i) Differential diagnosis- dysarthria and other developmental disorders:
Neurologic motor speech disorders (MSDs) include the dysarthrias, of which
there are several types, and apraxia of speech.
By definition, MSDs reflect organic abnormalities in brain regions and networks
involved in the planning, programming, control, or execution of speech.
There is overlap among the speech features associated with the different types
of MSDs but they are perceptually distinguishable to experienced clinicians
because each type has a relatively distinct pattern of abnormalities.
dysarthria Severe phonological disorder
Decreased strength and Ni incordination,weakness or paralysis of
coordination of speech musculature speech musculature.
that leads to imprecise speech
production, slurring and distortions.
Difficulty with involuntary motor No difficulty with involuntary motor control
control for chewing, swallowing, due for chewing and swallowing
to muscle weakness and
incoordination
Articulation may be noticeably Consistent errors that can usually be
different due to impression, but grouped into categories
errors generally consistent
Erorrs are generally distortions Errors may include substitutions, omissions,
distortions, etc.
May be less precise in connected Errors are generally consistent as length of
speech than in single words sentence/words increases
Typically no significant discrepancy Sometimes differences between receptive
between receptive and expressive and expressive language skills.
language skills.
Rate, rhythm and stress are Typically no disruption of rate, rhythm or
disrupted in ways specifically related stress
to the type of dysarthria
Monotone voice difficulty Good control of pitch and loudness, not
controlling pitch and loudness limited in inflectional range for speaking

dysarthria Verbal apraxia

No weakness, incoordination or Decreased strength and coordination of
paralysis of speech musculature speech musculature that leads to imprecise
speech production, slurring and distortions.
No difficulty in involuntary motor Difficulty with involuntary motor control for
control for chewing, swallowing, chewing, swallowing, due to muscle
unless there is oral apraxia. weakness and incordination.
Inconsistencies in articulation Articulation may be different due to
performance, the same word may imprecision, but errors are generally
be produced several different ways. inconsistent.
Errors include SODA errors, Errors are generally distortions.
simplification.
No of errors increases as the length Maybe less precise in connected speech
of the word or sentence increases. tham in single words.
Well rehearsed “automatic” speech No difference in how easily speech is
is easier, “ on demand” speech is produced.
difficult.
Generally good control of pitch and Monotone voice, difficulty controlling pitch
loudness and loudness.
j) Differential diagnosis - childhood apraxia of speech and other
developmental disorders:
CAS Versus Speech Delay or Other Speech Sound Disorders: Many of the
behaviors and signs associated with CAS are also found in children with more
broadly defined speech sound disorders. In addition, it is important that the
diagnosis of CAS not be based solely on the severity of a child’s speech sound
disorder, as this may result in over diagnosis.
CAS vs Dysarthria:
• Differentiating CAS from some types of dysarthria presents a significant
challenge because these disorders can share several speech, prosody,
and voice features (e.g., imprecise consonant, inconsistent pitch or
loudness, inappropriate or aberrant stress patterns).
• For example, vowel distortions can be a result of oral hypotonicity or
dysarthria, especially if the error is made in isolation and not influenced
by connected speech
• Polysyllabic production accuracy, along with an assessment of
diadochokinetic rates, may be sufficient to identify CAS and rule out
dysarthria
• Several maximum-performance tasks may also help differentiate CAS
from (spastic) dysarthria or establish the presence of both
CAS Vs fluency disorders:
• Less commonly, but on occasion, there is a need to differentiate
between apraxia and dysfluency (stuttering, cluttering), given that there
can be some overlap in symptoms
• Also, similar to children without motor speech disorders, children who
are suspected of having CAS may go through periods of disfluency
 Unit 3: Management of childhood dysarthria
a) Team approach in rehabilitation of motor speech disorders in children:
Team approach: it is an approach by different professionals in concern with
the people with communication disorders. The differennt professionals like
audiologist, speech pathologist, pyschologist, physiotherapist, epidemologist
or occupational therapist, special educators, etc. all this professionals work
together. They find out results for the problems and those results are put
together in order to make the differentially able people to fulfil their daily
activities.
Epidemologists: an epidemologist studies occurrence of the disease or other
health related issues in specified population. They involve a range of activities
like:
− Identifying risk factors for disease and injury and death.
− Describing natural history of disease.
− Identifying population at greates risk for disease,etc.
Special educators: they assess and work with different children with
disabilities. A special educatior works with this childrem primarily to teach
them basic literacy and life skills. The majority of special needs students, have
mild to moderate disbilities. The teacher often modifies the general education
curriculum by writing individualized education plan (IEP) objectives to meet
each disabled students needs. A large percentage of special education teachers
work with students from elementary to secondary school level.
ENT ( Otolaryngologists) : A distinguished ENT specialist is comfortable in
dealing with almost all types of ear ailments such as hearing disabilities as well
as ear infections. Likewise, he should be able to address typical nose-related
problems like allergies, sinuses, blockage, etc. they also specialize in ailments
of throat such as larynx infection, etc.
Physiotherapist : Physiotherapy is a science-based healthcare profession which
views movement as central to health and well being. Physiotherapists aim to
identify and make the most of movement ability by health promotion,
preventive advice treatment and rehabilitation.
Audiologists: they are licensed professionals and have a clinical educational
background that emphasizes diagnostic evaluation of auditory (hearing) and
vestibular (balance) systems, amplification technology (especially hearing aids),
cochlear implant mapping, hearing science, aural rehabilitation and assistive
device fitting. Audiologists are also involved in the prevention of hearing loss
and other communication disorders.
Occupational therapist: promotes health by enabling people to perform
meaningful and purposeful occupations. These include (but are not limited to)
work, leisure, self care, domestic and community activities. Occupational
therapists work with individuals, families, groups and communities to facilitate
health and well-being through engagement or re-engagement in occupation.
Speech language pathologists: they identify, define and diagnose disorder of
human communication and assists in localizing and diagnosis of disease and
conditions. They work with people who have a variety of different speech
related problems, as well as swallowing and feeding issues.
Neurologists: A neurologists is a medical doctor or osteopath who has
diagnosis and treatment of nervous system disorders, including brain, spinal
cord nerves and muscles. Neurologist reviews current condition, mental status,
function of cranial nerves, etc.
Psychologists: they are involved in assessment, diagnosis, treatment and
prevention of mental,emotional and behavioral disorders.
b) Neuro-developmental therapy
• Neurodevelopmental Treatment (NDT), often referred to as the “Bobath
approach,” is among the most widely used systems for treating children
with cerebral palsy.
• It was first developed in the 1940s and has evolved, reflecting current
motor control theories.
• The speech-language pathologist (SLP) treating a child with neurological
difficulties should be aware of the relationship between these theories
and the development of speech, language, and feeding skills
• It highlights the relationship between several processes of development.
• A basic principle of NDT is an integrated approach to both treatment and
development that addresses skill acquisition in a holistic framework.
• NDT teaches clinicians to assess and analyze a child’s movements to
determine what components may be missing or interfering with
movement.
• These components are then incorporated into an intervention plan.
• An NDT SLP should be able to assess and treat problems such as:
− the scapula stability of a child who is not using his or her hands
for the selection of symbols or manipulation of toys; or provide
jaw stability
− if this interferes with lip and tongue movements for feeding and
speech sound production;
− or enhance thoracic-abdominal control of a child not producing
appropriate breath groups.
• A unique aspect of NDT for the SLP is the facilitation of body alignment
and postural control to attain stability in functional activities through
therapeutic handling.
• For the SLP, postural control is the basis of oral/pharyngeal,
respiratory/phonatory, and articulatory coordination for the functions of
swallowing and communication.
• NDT strives to achieve this through facilitation of movement using
therapeutic handling.
 • The goal of handling is to develop a functional skill. Facilitation is a
handling strategy used to “make a posture or movement easier or more
likely to occur”
• NDT emphasizes on “reflex-inhibiting postures,” but Bobath realized that
passive positioning does not change movement or function.
• NDT uses inhibitory handling to redirect an excessive or unintentional
movement such as jaw extension during sound production or
swallowing. It may be used to elongate a shortened muscle (hypertonus)
to provide a greater range of movement, such as neck elongation for
alignment of oral structures. Typically, inhibition and facilitation are
used together through therapeutic handling
• the therapist’s handling during a functional task causes changes in
specific connections and may result in context-specific neuronal use.
• Selection of neuronal groups, is based on the varied sensory information
that results from a child’s experiences.
• The motor system is being manipulated through the movement
facilitated by the therapist.
• Sensory receptors send information back to the central nervous system
leading to changes within the sensory system.
NDT for respiratory skills:
• NDT techniques that target respiration/phonation involve activation of
intercostal and abdominal muscles through movements that include
lateral flexion and trunk rotation while encouraging sound play through
modeling.
• The purpose of handling for improved respiratory control is to facilitate
checking action of the chest wall for vocalization.
NDT through play:
• play provides a rehearsal for later “real” experiences and allows for
repetition and interaction.
• These aspects of play are also important to an SLP who may wish to
prepare the child’s trunk for phonation and the oral area for articulator
movements during the activity.
c) Non speech oral-motor exercises: its application for children with
dysarthria
Non-Speech Oral Motor Exercises (NS-OME):
• Any technique that does not require the child to produce a speech
sound but is used to influence the development of speaking abilities
• A collection of nonspeech procedures that influence tongue, lip, and jaw
resting postures, increase strength, improve muscle tone, facilitate
range of motion, and develop muscle control
• OMEs are activities that involve sensory stimulation to the lips, jaw,
tongue, soft palate, larynx, and respiratory muscles which are intended
to influence the physiologic underpinnings of the oropharyngeal
mechanism and thus improve its functions.
• OMEs may include active muscle exercise, muscle stretching, passive
exercise, and sensory stimulation.
• The rationale for NSOMExs is that these will increase levels of tension,
endurance and power of weak muscles.
Guidelines:
• Begin stimulation with outer body parts and move in toward the
midline.
• Use firm, slow touch rather than light, quick strokes. Use visual
feedback
Clark (2003) indicated that NSOMTs consist of a broad range of therapeutic
activities that can be categorized as
− active muscle exercise:
− passive muscle exercise
− sensory stimulation
Active exercises:
1.Strength training : They use isotonic or isometric muscle exercises. At a
physiological level, strength training targets force, endurance, and power.
strength training is designed to increase muscle tension.
Isotonic exercise movements result in changes of muscle length with muscle
tension remaining relatively constant
isometric exercise movements are designed to create muscular tension
without changing muscle length appreciably
2.stretching: The movement of a muscle or muscle group outside of its typical
operating range is referred to as stretching. This is done to increase or
decrease the muscle tone.
tone disorders result in weakness, which adversely affects the execution of
skilled movement.
Clark (2003) pointed out that stretching can be carried out by either the client
(active stretching) or the practitioner (passive stretching).
Passive exercises:
This involves the movement of a muscle or muscle group with assistance by a
clinician or through the use of exercise machines Passive exercise includes
passive range of motion (PROM) and passive stretch. The purpose of passive
exercise is to:
• maintain joint flexibility and soft tissue integrity and enhance vascular
circulation
• facilitate sensory input to a muscle or muscle group and possibly modify
tone
• It is hypothesized that a slow passive stretch acts to reduce the stretch
reflex
• Conversely, a passive quick stretch is designed to stimulate muscle
spindles, thereby increasing muscle tone.
d) Management of drooling:
Drooling or sialorrhea refers to an unintentional loss of saliva and other oral
contents from the mouth.
Although drooling may be encountered in healthy children, it is commonly
observed in neurologically impaired children and carries a considerable social
stigma.
In addition to cosmetic and hygienic considerations, serious medical
complications and psychosocial consequences may arise from this situation
At rest, approximately 65% to 70% of the saliva is produced by the
submandibular glands, 20% to 25% by the parotid glands, 5% by the sublingual
glands and the remainder by the minor salivary glands located on the palate,
buccal mucosa and tongue.
In the resting state, the rate of salivary secretion has been estimated to be 0.3
to 1 mL/1.7 m2/min
Causes of drooling:

Assessment: (history)
Age of onset: Drooling in the neonatal period should alert the physician to the
possibility of esophageal atresia or withdrawal from maternal substance abuse.
A mild degree of drooling is normal during infancy.
Chronicity: An acute onset suggests an infection or drug intoxication. Drooling
of long duration may be developmental or secondary to a structural lesion,
neuromuscular disorder or mental retardation.
Severity: The severity can be gauged by the frequency of bathing, wiping and
need for bibs or clothing changes.
Precipitating factors: Any precipitating factors such as ingestion of food and
teething should be noted.
Developmental history: A thorough developmental history is of extreme
importance. Generalized delay in all aspects of developmental milestones
suggests mental retardation.
Drug use: A detailed drug history is important because the use of medication
may lead to drooling.
Psychosocial history: Any psychosocial or emotional stress should be noted as
a potential cause of the drooling
Measurement: measurement of drooling using radioisotopes can be done.
The procedure consists of injecting a radioisotope into the subject, having the
radioisotope excreted in the saliva and sampling the saliva periodically.
From the measured radioactivity in the bibs and the salivary samples, the
amount of drooled saliva can be calculated .
Severity scale of drooling:
• Dry: never drools
• Mild: only lips are wet
• Moderate: lips and chin wet
• Severe : clothing soiled
• Profuse: clothing, hands and tray moist and wet.
Management: ( speech therapy)
Modification of Situational Factors:
Certain factors may lead to increased drooling. Treatment of dental problems,
chronic nasal obstruction with obligate mouth breathing, enlarged tonsils,
extra-esophageal reflux disease, and poor posture may lead to a significant
decrease in the frequency and severity of drooling and obviate the need for
further therapy
Oral Sensorimotor Intervention:
it is intended to increase coordinated muscle function in the oral cavity and to
improve swallowing and control of secretions, as well as focuses on speech
production in some instances.
The position, mobility, strength of the tongue, lips, jaw, and head control are
the most important aspects of an oral sensorimotor program
Therapy may focus on facilitating lip closure, tongue control, and purposeful/
volitional swallowing of saliva as well as food and liquid, guidance regarding
use of optimal positioning, special equipment (e.g., wheelchair design), and
adaptive feeding utensils.
Oral facial facilitation using:
• Icing
• Brushing
• Vibration
• Manipulation
• Oral motor sensory exercises
Oral Appliances: Prosthetic devices may be helpful in some patients and are
usually made by the dentist.
Pharmacologic therapy/ medication: Pharmacotherapy alone may have a
useful role in many patients, especially those with mild to moderate drooling
and mild to moderate cognitive deficits. Few medicines can reduce the
secretion of saliva by inhibiting the part of autonomic system i.e
parasympathetic system such as “ robinul, artane, cogentine and sal-tropine”.
Surgical Treatment Options: surgery involves either changing the direction of
the diection of the ducts or removing the salivary gland tissue.
• Laser surgery: it allows a quicker recovery
• Botulinum toxin injections: done under anesthesia, the toxin is injected
into the parotid glands, lasts upto 8 months.
• Radiotherapy: or use of x-rays to destroy part of the salivary glands , is
only used in severe cases and not usaually in children.
Surgical options:
− submandibular duct rerouting
− Submandibular duct excision
− Parotid duct ligation
− Transtympanic neurectomy
Alternate therapy:
1. Behavior modification and biofeedback:
− seem applicable for a small group of patients who are highly motivated
(along with the families and other caregivers) and who have the
intellectual capacity to follow instructions with demonstration.
− One goal of behavior modification is to increase the sensory awareness
of the drooling in order to promote mouth closing and swallowing more
frequently on the basis of verbal or gestural reminders.
2. Hypnotherapy: has been used in some patients with variant amount of
success.
3. Bibs : they are useful in protecting skin and clothing.
e) Behavioral management of respiratory, phonatory, resonatory and
articulatory subsystems
The speech subsystems do not act independently. Motor speech treatment
should be thus taken in a heirarchial manner.
− First order targets: Respiration and Resonance
− Second order target: Phonation
− Third order target: Articulation and Prosody
Management goals:
1. restore lost function.
2. Promote the use of residual function ( compensate)
3. Reduce the need for lost function ( adjust)
Duration of treatment: it should be provided for as long as it is necessary to
accomplish its goals. It depends upon the etiology, prognosis, specific goals,
needs, etc.
Behavioral management includes:
− Improving physiologic support for specch
− Compensatory speaking strategies
− Developing augmentative means of communication
− Controlling the environment and communicative interactions.
Guidelines:
− Begin early, take baseline data to establish goals
− Increase physiologic support
− help patient to be able to self- monitor.
− Implement principles of motor learning.
ARTICULATORY SYSTEM:
1. Strengthening exercises: it should be used only after establishing that
weakness of the oral articulators is clearly related to dysarthria
Exercises need to overload the muscles in some way. Need to do 5 sets of 10
repetition each. The first few minutes should be used to increase attention to
the face, awareness of movement, etc. It increases the stability, speed, range,
strength and accuracy of movement of oral muscle groups of articulation.
2. relaxation exercises: improve muscle tone in patient with spasticity or
rigidity.ex. shaking the head and the open jaw, chewing to promote tongue
and jaw relaxation.
3. stretching exercise:
Tongue stretching: hold tongue tip with a guaze pad, pull straightforward, pull
left and right and hold each position for 10 sec.
Lips stretching: clinician carefully pulls out lip and away from the face and hold.
Jaw stretching: patient holds maximum opening with and without physical
assistance and holds jaw lateralized to left or right.
4. traditional articulation treatment:
• Integral stimulation: watch and listen imitation tasks.
• Phonetic placement: increase awareness of how sounds are produced by
using hand on assistance.
• Phonetic derivation: using the intact non speech gestures to establish a
target such as blowing to facilitate production of /u/
• Intelligibility drills, minimal contrast drills, etc.
RESONATORY SYSTEM:
Below are few behavioural techniques used in treatment of resonatory
systems.
• Decreasing speaking rate, change level of effort
• Monitoring nasal airflow and resonance features
• Increasing precision of speech by exaggerating movements
• Speaking with a greater open mouth posture
• Resistance training CPAP
• Encouraging the client to facilitate elevation of the palate
• Repeat a series of nasal and voiced plosives and vowel sounds eg /nba/
• Repeat a series of fricatives, nasal and vowel sounds /sma/
PHONATORY SYSTEM:
1. for phonatory incompetence:
• Pushing techniques
• Holding breath excercises
• Head turning toward the affected side
 • Lee Silverman Voice Treatment (LSVT)
• Smith accent method
2. Phonatory stenosis:
• Head and neck relaxation
• Easy onset of phonation
• Smith accent method: used for modification of both phonation and
respiration. It helps improve prosody and voice, breath control.
RESPIRATORY SYSTEM:
Below are few behavioural techniques used in treatment of respiratory
systems.
• Producing consistent subglottal pressure
• Pulling, pushing and bearing down during speech or nonspeech tasks
• Slow and controlled exhalation
• Optimal breath group
• Postural adjustment
• Smith accent method
f) Prosthetic appliances in treatment of childhood dysarthria:
• A prosthetic method refers to any physical alteration. A number of
mechanical and electronically prosthetic are available to improve speech
and/ or assist in communication.
• Some may be temporary - used only until physiologic recovery or the
effects of behavioural management allow them to be discarded.
Respiratory system:
• Prosthetic devices such as head, neck, chest/or abdomen straps, braces,
girdles are used to prop and maintain the patient in an upright or sitting
position and add stiffness to an otherwise flabby mechanism.
• Leaning into a flat surface during expiration or using an expiratory board or
paddle mounted on a wheelchair and swung into position at the abdominal
level may help increase reparatory force for speech.
Laryngeal system:
• Portable amplification system – Persons with inadequate loudness but
adequate articulation and those who have responded sub optimally to
behavioural intervention to improve loudness may benefit from this. Using
this, intelligibility improves.
• Artificial larynx: Some patients who are aphonic, severely breathy or lacking
sufficient respiratory support for speech but who have good articulation
skill may benefit from this.
• Neck braces or cervical collars: Patients with movement disorder or
significant neck weakness may benefit from this. It helps to stabilize the
head and neck during speech.
• Vocal intensity controller: can provide feedback about excessive or
inadequate loudness. This can be accomplished with a loudness monitoring
device that samples vocal intensity from throat microphone and provides
feedback if intensity is below a predetermined threshold. It is useful in mild
to moderate PD.
Resonatory/velopharyngeal system:
• Palatal lift prosthesis: Any dysarthric patient having moderate to severe
velopharyngeal paralysis and consequent valving incompetence may be an
excellent candidate for immediate fitting of the prosthesis.
 This would facilitate VPC by mechanically displacing the velum upwards and
backwards, towards the posterior pharyngeal wall, where contact would
normally occur. This prosthesis is made up of light acrylic resin material
with holes for dental retention.
• Nose clip: Intelligibility improves by simply manually occluding the nares
during speech
• Nasal Obturator: inserted into the nares for the purpose of occluding nasal
airflow during speech, improves intelligibility in a person with flaccid
dysarthria
Articulatory system: A few prostheses are used to improve orofacial and
articulatory function:
• Jaw sling: is used to close mouth.
• Bite- block: is a small piece of acrylic material that is custom fitted and held
between the lateral upper and lower teeth. It is used to stabilize the jaw
and also helps to inhibit abnormal, involuntary movements.
• Delayed Auditory Feedback: is an instrumental procedure used to control
the rate of speech of the individual by giving feedback of the speech at
varying delayed intervals and is specially used with hyperkinetic dysarthria.
• Pacing devices can be useful in modifying rate.
g) AAC in management of motor speech disorders- role of devices, AAC team,
candidacy and pre-requisites, symbol selection, techniques, assessment for
AAC, effective use of AAC:
Augmentative and Alternative communication devices are any device that
facilitate or compensate, temporarily or permanently, any impairment or
disability in the production or comprehension of spoken or written language.
Classification of AAC:
Aided: Systems that utilize an external device.
• Light technology- communication boards, books, Tangible symbols,
symbol communication charts.
• Medium tech systems –devices containing a battery or a switch but
which are very simple.
Unaided: Systems are those which are independent of a device. Signs &
gesture systems
Role of AAC devices: AAC can play at least 4 different roles in early
intervention. The roles an AAC system plays will vary depending on an
individual child’s needs. These roles are as follows:
• Augmenting existing natural speech.
• Providing primary output mode for communication
• Providing an input and output mode for language and communication
• Serving as language intervention strategy.
AAC team:
Speech Language Pathologist: assess current speech, language and cognitive
skills, identify most appropriate AAC system, recommends advance
communication skills for potential use of AAC.
Occupational Therapist: recommends appropriate positioning, access,
environmental control units, identify switch-based activities.
Physiotherapist: recommends positioning, seating systems, wheel chair, etc.
Medical Nurse, Caregivers and family, Engineer and Special educators are also
a part of AAC team.
Candidacy and pre-requisites:
Candidates of AAC must possess certain pre requisites:
− Chronic expressive communication disorders.
− Adequate cognitive capabilities
− Adequate linguistic abilities
− individuals demonstrating impairments in gestural, spoken, and/or
written modalities
Assessment of individual is necessary to find if the person is a candidate of AAC
or not.
Pre-requisites:
There are no prerequisites to initiate an AAC intervention program. There are
prerequisites skills an augmented communicator should demonstrate before
he/she is given access to a sophisticated AAC device such as:
1. Fine motor skills
2. Sensori-motor integration
3. Cognitive functioning
4. Level of receptive communication
5. Current expressive communication including non-conventional behaviours.
6. Motivation level for communication
7. Persons with whom student desires to communicate
8. Student interests

• Initial intervention strategies may include teaching object recognition and

developing choice-making skills.
• Gestures and signs may be introduced when indicated. As symbolic skills
improve, intervention activities will often focus around use of symbols to
express simple and complex messages.
Symbol selection:
Symbols/message to communicate: usually unaided symbols which can be
displayed on a communication board or monitor are selected. The selection of
the symbols depends on-
a) social content of communication: look for content of communication,
components of AAC system that needs to be used, teach the child methods to
use communication to realize ones needs & desires.
b) means to represent: select one of the following;
i. symbol representation
ii. Non symbolic representation
c) vocabulary: selection of this depends on needs & preference of the AAC
user.
Points to consider when selecting a symbol system includes:
• Does the system offer the breadth of vocabulary required? How easy are
the symbols to draw quickly if necessary?
• Will the AAC user need to use grammar in her/ his utterances, are the
graphic representations meaningful and adequate as possible?
• Are there facilities for the user to generate new meanings from existing
symbols?
• The physical design factors that can be manipulated include: Number of
items, Size of items, Placement of items, Colour of items.
Techniques & guidelines in AAC intervention for clients with Motor Speech
Disorders:
• Individual AAC user’s capabilities should be assessed thoroughly.
• Should choose AAC intervention as early as possible
• AAC intervention should focus on current & future needs of the
individual.
• Once AAC intervention is initiated should not prevent or stop the other
non-verbal/functions/socially acceptable behaviours that are present &
which facilitate communication
 • AAC intervention should also include paradigms of ongoing assessment
so that progress can be monitored.
• AAC intervention should include a long term & many short-term goals.
• AAC therapy should be given in natural environments & in appropriate
functional contexts.
• During the course of intervention should try to minimize/eradicate the
barriers to communicate (social, environmental, physical etc, in MSD
more specifically the physical).
• Should work in a team or with the team.
Assessment for AAC:
Standardized Assessment Scales:
• Augmentative Communication Interaction Checklist
• Interaction Checklist for Augmentative Communication (INCH)
• Assessment Guide and Kit for clients who require Augmentative and
Alternative Communication Rehabilitation
• Tool for Assessment of Communicative Competence in Kannada -
Dissertation
• Test for assessment of symbol performance in Aided communication
(TSPAC) – Dissertation
• AAC Assessment Protocol - AIISH
(Protocol followed at AIISH):
Pre assessment criteria includes:
• The client should have at least fleeting attention skills
• Intentional communicative behaviors should be observed
• Evidence for the client to differentiate between people and objects
• Client’s motivation for at least one item or activity.
Evaluation of intelligibility: Intelligibility assessment process must include
documentation of:
• Articulation and phonological skills
 • Oral motor skills,
• Intelligibility in single word, Phrase and sentence contexts
• Intelligibility across familiar and unfamiliar listeners.
Determining a Motor Response for Assessment:
• Direct selection modalities that the nonspeaking person is able to
motorically access easily
• Use of scanning techniques for selection
Assessment of Receptive Language, Cognitive, and Academic Capabilities:
Formal evaluation of receptive language, cognitive and academic skills assist in
the AAC feature matching process.
Adapting test procedures:
• Reducing the traditional number of choices
• For older children and adults is the use of yes/no verbal scanning
Assessment of Symbolic Language Abilities for Aided AAC Systems:
Necessary to best match a nonspeaking individual to an appropriate AAC
system. AAC picture-based symbolic skills:
1. Expressive use of picture symbols
2. Receptive understanding of picture symbols
3. Picture symbol sequencing
4. Categorization and association with picture symbols
5. Complex picture symbol sequencing
Written language AAC assessment skills
• Letter identification:
• Sight word reading
• Sight word spelling
• Word prediction
• Abbreviation expansion
Assessment of an AAC system:
Aids are described by referring to their three primary features and their
portability.
• Methods of access
• Symbol System (vocabulary)
• Output modes
• Portability
Effective use of AAC:
Consideration of daily routine
• The consumer’s interests & daily routines are essential in determining
the content & organization of an AAC system.
• Most children with developmental disabilities lead highly structured lives
with minimal variation in activities from day to day.
• It is important that the vocabulary developed from an AAC system
provide the individual with the support necessary to interact within his
daily structure.
• AAC vocabulary should reflect the individual’s needs interests &
routines.
Activity based communication boards
• Activity based communication page allows a person to socially interact,
direct the actions of others, comment, ask questions & make choices.
• Once vocabulary or messages for an activity have been generated
through scripting, strong consideration to the physical organization of a
single activity-based page needs to be made.
 Unit 4: Management of childhood apraxia of speech
a) Principles of motor learning:
− Motor learning has been defined as a set of processes associated with
practice or experience leading to relatively permanent changes in the
capability for movement (Schmidt & Lee, 2005).
− Motor-learning principles may provide important insights into how to
enhance (re)learning/organization of the speech motor system and,
ultimately, the quality of life of individuals with MSDs
− Principles of motor learning are crucial to AOS treatment, and they are
embedded in the treatment principles for virtually all of the specific
approaches to AOS treatment
b) Integral stimulation – dynamic temporal cueing (DTTC):
• Given by Miller (1954), Developed further by Strand & Skinner (1999)
• The method involves imitation, and emphasizes both visual and auditory
models. Integral stimulation has long been used in treating dysarthria and
acquired apraxia of speech.
• This term is still used to describe treatment that requires the child to
imitate utterances modelled by the clinician. Attention is focused both on
the auditory model as well as visual attention to the clinician’s face.
• Integral stimulation (“listen to me, watch me, do what I do”) utilizes a
“bottoms up” approach starting with short, phonetically simple utterances
and gradually progressing to more phonetically difficult stimuli.
• For non-verbal child, with very severe childhood apraxia, Edythe Strand
developed a variation of integral stimulation called Dynamic Temporal and
Tactile Cueing for speech motor learning (DTTC).
• DTTC is based on a technique described John Rosenbek and others in 1973
(the Eight-step Continuum for Treatment of Acquired Apraxia of Speech)
• DTTC allows for what Strand calls ‘a continuous shaping of the movement
gesture’, with the goal of
(1) improving motor planning
(2) programming speech processing as speech and language acquisition
progresses
The steps in DTTC are as follows.
1) Imitation
In its implementation, DTTC begins with direct, immediate imitation of natural
speech.
2) Simultaneous production with prolonged vowels:
If the child cannot imitate, the therapist makes the task easier and more
‘supported’ by introducing simultaneous production. The SLP says the
utterance with the child, very slowly with touch/gesture cues as required. The
utterance is slowed by sustaining the vowel (e.g., “sea” produced as si::::: and
not as sssssea).
3) Reduction of vowel length
The rate of stimuli production is increased (i.e., vowel length is reduced) to
sound more natural.
4) Gradual increase of rate to normal
Practice continues at this level to the point where the child synchronises
effortlessly with the therapist at normal rate, with normal movement gestures,
and without silent posturing.
5) Reduction of therapist’s vocal loudness, eventually miming
the therapist reduces volume eventually reaching a point where the therapist
is producing a mime, as the child actually says it aloud. The gesture and touch
cues may still be needed at this point, and will be necessary in the next step,
the integral stimulation method proper.
6) Direct imitation
The SLP ensures that the child is comfortable with moving to this harder level
in which the child watches the adult’s face while an auditory model is
provided. The child attempts to repeat the model and if successful does so
many times. If unsuccessful, the therapist may backtrack to the simultaneous
level.
7) Introduction of a one or two second S-R delay (least support)
Once the child is directly imitating the therapist’s model with normal rate,
prosody he or she can vary, and appropriate articulatory gestures, the
therapist inserts a new requirement: a one to two second delay before the
child imitates, so that the child produces a very slightly delayed.
8) Spontaneous production
Finally, the therapist elicits the spontaneous utterances.
c) Multisensory and tactile cueing techniques (moto kinesthetic speech
training, sensory motor approach, PROMPTS, Touch cue method & speech
facilitation)
1. Moto-kinesthetic Speech Training Method
• It was developed by young and hawk (1938)
• In this approach the SLP directly manipulates externally, parts of the
clients speech mechanism.
• Rationale: articulation learning requires coordination of muscular
activities, control on air current, facial expressions.
• Clinician indicates where the movement is to occur, the direction in
which the articulators are to move, and the manner in which the sounds
are to be produced.
• The SLP guides the muscular actions that act on the air current. The
clinician says the syllables while manipulating the clients articulators,
and the client watches the clinicians face.
• Client receives kinesthetic, tactile, auditory and visual stimulations
simultaneously.
• No auditory discrimination training is done and sounds are not produced
in isolation, but in syllables, words, phrases and sentences.
2. Sensory-Motor (McDonald) Approach
• Eugene McDonald in 1964.
• The goal is to increase the number of phonetic contexts in which the
target phoneme is produced correctly rather than to teach a new sound.
• Greater specificity in the sequences of the overlapping ballistic
movements through which speech sounds are produced.
• 3 objectives:
− Heighten the child’s responsiveness to the patterns of auditory,
proprioceptive, and tactile sensations associated with overlapping
ballistic movements of articulation.
− Reinforce the child’s articulation of his error sound
− Facilitate the correct articulation of the sound in systematically varied
phonetic contexts
• The client imitates the clinicians auditory stimuli and describes tactile
and kinesthetic sensations by indicating which two articulators touched,
in which direction the tongue moved and which syllable was stressed..
3. PROMPT:
− The prompts for restructuring oral muscular phonetic targets (PROMPT)
approach to treatment was initially developed by Chumpelik (1984) for
children with developmental apraxia of speech.
− Its distinctive feature is its use of tactile cues to provide touch pressure,
kinesthetic, and proprioceptive cues to facilitate speech production.
− The PROMPT approach uses highly structured finger placements on the
patient's face and neck to signal articulatory target positions, as well as
cues about other movement characteristics, such as manner of
articulation, degree of jaw movement, and syllable and segment
duration.
− Procedure: the treatment generally progresses in stages of motor-
speech hierarchy.
Level1: focuses on attaining postural support for speech.
Level 2: stresses control of phonation, including voicing.
Level 3: involves movement on a single plane with voicing focused on jaw
movements.
Level 4: additional planes of movement are added with an emphasis on
control of lip retraction and rounding and symmetry and coordination of lip
movements.
Level 5: involves control of tongue height and location.
Level 6: sequenced movements on multiple planes.
Level 7: focuses on supra-segmentals in sequenced motor movements.

4. Touch-cue method:
The touch-cue method uses tactile cues as well as simultaneous auditory and
visual cues.
It incorporates three stages of treatment, beginning with nonsense syllable
drills, then putting those learned movement sequences into both real and
nonsense words, emphasizing the distinctive feature contrasts, and finally, in
the third stage, moving to spontaneous speech.
Stage 1:
− If a child is capable of producing a phoneme in isolation
− Series of nonsense syllable drills
− Facilitate the teaching of the topographic cues,
− Developing accurate self-monitoring of productions.
Stage 2:
− Previously learned sequential movements into monosyllabic words using
the CVC configuration
− Real words and nonsense words that emphasize contrasts in place,
manner, and voicing aspects of productions
− Auditory, visual, and tactile cues is manipulated
− Faded throughout stage II, with the introduction of graphic or picture
stimuli
Stage 3:
− Apply the sequencing and self-monitoring to multiword utterances
− And then in spontaneous speech.
5. Speech facilitation:
The intraoral stimulations- facilitate tongue placement.
The intraoral stimulation is provided by six types of phonodental guides:
1. Oral acrylic modifiers
2. Orthrodontic wire guides
3. Denture guides
4. Dental floss guides (knotted and stretched)
5. Various types of stemmed wire guides
6. Cue sticks.
Extraoral manipulations- facilitate the movement involved in a phoneme
elicitation.
The finger and hand format involves placing a finger on the side of the nose to
cue nasalization, touching the larynx with the finger to cue phonation, and
pressing the palm of one hand below the client’s ribcage to cue breath
expiration, with the amount of hand pressure used to activate sudden or
gradual expiration. Four principles:
1. A rapport established between the ‘stimulator’ and respondent
2. Position and movement for each phoneme is taught.
3. Timing, rate, pressure, duration, & stress
4. Auditory and visual sensory stimuli
d) Gestural cueing techniques (signed target phoneme therapy, adapted
cueing techniques, cued speech, visual phonics, & Jordon’s gestures)
1.signed target phoneme therapy:
• Shelton and Graves (1985) used it for a 5 year old child with
Developmental Apraxia of Speech.
• Visual memory and an “internalized visual stimulus” could assist a child
with DAS in recalling what articulatory gestures to make
• The visual cues- hand shapes from the American Manual Alphabet
• Only the targeted phoneme(s) in a stimulus are cued gesturally by the
clinician
• The child is not required to produce the cue during his or her oral
response
• Both consonants and vowels are dealt within the technique
2. Adapted Cueing Techniques:
• Given by Klick (1985)
• Manually presenting visual cues created to accompany orally presented
speech
• Enhance oral stimuli and to increase the frequency of correct responses
for both consonants and vowels on the part of the client, particularly
during sequential speech movements
• Vowels are cued along two dimensions, which are the place of
articulation and the degree of jaw closure
• All vowels are signalled by variations of the letter c hand shape. The
hand is held with the fingers pointing towards the cheek.
• Jaw closure is represented by the degree of closure between the fingers
and thumb of the c hand shape.
• Moving the hand toward the front, middle, or back of the oral tract cues
placement.
3. Cued Speech
• given by Cornett (1972)
• Differentiate each speech sound with a set of 12 cues: 8 hand shapes
and 4 basic hand positions, which, when used in combination, result in
total of 32 possible cues.
• Hand shapes represents consonants from different viseme groups
• Hand positions involves four locations about the face
4. Visual Phonics
• International Communication Learning Institute (1981)
• Visual and kinaesthetic method using a system of hand signs and written
symbols was developed
• 45 signs or sounds are tested and subsequently taught.
• Progress from production in isolation to production in words and then to
sentences.
5. Jordan’s gestures: Jordan (1988, 1991).
• Point of constriction within the oral cavity necessary for production of
the target consonant sound
e) Miscellaneous techniques (melodic intonation therapy, multiple phonemic
approach, & instrumental feedback)
Melodic Intonation Therapy:
Melodic Intonation Therapy would be classified as a rate-and-rhythm type of
apraxia treatment. It is based on the observation that individuals with aphasia
or apraxia of speech can sing the words of a song much better than they can
say the same words in conversation.
In the MIT program, the rhythm and melody aspects of the program are
emphasized primarily in the beginning steps of the program. The patient’s
intonation is then modified into a more natural prosody in the final steps.
Good candidates for this program are those who
− experienced a stroke
− have non-fluent aphasia/restricted verbal output,
− have good auditory comprehension
− demonstrate poor articulation and repetition abilities and are
motivated.
− adequate attention span.
The MIT program is divided into three levels
The overall sequence of treatment is to first incorporate melodic intonation
into the target utterances, then gradually shift to saying the words with
exaggerated prosody, and finally saying the words with normal prosody.
1.Elementary Level
• First the clinician demonstrates the melody by humming and singing the
target word. The clinician taps the patient’s hand on each syllable of the
word or phrase. The patient does not respond, but only listens carefully.
• The clinician and patient sing the target word and tap out the syllables
together.
• The clinician and patient begin by singing and tapping the word
together, but the clinician stops about halfway through. The patient is
required to complete the word alone.
• The clinician sings and taps the target first; the patient then repeats it
immediately.
 • When the patient repeats the word from Step 4, the clinician
immediately asks a question such as, “What did you say?” The patient
attempts to say the target word in response to this question.
2.Intermediate Level:
• The four steps of this level follow the general sequence found in the
elementary level, except that delay of several seconds are inserted
between the clinician’s presentation of the target word and the patient’s
response.
• The length and complexity of the target words and phrases in this level
are approximately the same as in the elementary level
3.Advanced Level:
• The steps in this portion of the program also concentrate on the delayed
repetition of target phrases.
• However, the melody used in the patient’s utterances is now modified to
match normal speech intonation through a procedure called speech-
song.
• The words are not actually sung in a melody.
• In the final step, the clinician asks a question, the patient waits about 6
seconds, and then answers with the correct target phrase using normal
intonation
Multiple phonemic approach:
It is a horizontal approach to the treatment of articulation disorders.
The approach was developed by McCabe and Bradley in 1975 at the University
of North Carolina
It involves working on multiple targets within one session, either individually or
simultaneously, at a less intense practice level. This provides more exposure to
not only multiple sounds but also helps to facilitate generalization and
carryover as it works largely with coarticulation and connected speech.
Consist of three phases: Establishment, Generalization, Maintenance
Phase 1: establishment: the goal of phase 1 is to elicit correct productions of
the target sounds and then stabilize them at a voluntary level in order to
facilitate generalization or transfer.
Phase 2: Generalization: it is designed to facilitate the carryover or
generalization process on multiple levels including: position, contextual,
linguistic unit, sound, situational.
Typically, therapy at this phase follows the progression of linguistic units.
Phase 3: maintenance:
It involves stabilizing the sound productions learned earlier.
The process of stabilization ensures that the corrected sound production will
persist even after being discharged from the therapy and moving to a new
target sound.

Instrumental feedback:
Also known as biofeedback, it refers to feedback of a physiological function,
usually by providing visual information about an individuals performace.
It is useful in non speech motor learning. Biofeedback approaches such as
spectrograms and electropalatography have been used in treatment for
children with SSD.
A study funded by Apraxia Kids was the first to investigate the use visual
feedback of the tongue as a way to teach production of speech sounds for
school-age children with CAS.
This study involved using ultrasound to provide a real-time visual display of the
tongue while children talk
In this approach, the ultrasound transducer is held under the chin, and the
ultrasound images are then used to teach children how to move their tongue
into different positions to produce certain speech movements.
Speech-language pathologists can use this information to provide the child
with cues about the tongue.
g) Other approaches: Vowel and diphthong remediation techniques
(Northampton (Yale) vowel chart and Alcorn symbols), Nancy Kauffman’s
speech praxis treatment kit
Vowel and Diphthong Remediation Techniques:
1. Northampton (YALE) Vowel Chart
• Davis and Hardick (1981); revised in 1925
• Visual, written (printed) cues to facilitate speech production are used.
• Orthographic symbols are present consisting of letters of the English
alphabet : Consonants and vowels
• Vowels into three groups – back round vowels, front vowels, and
diphthongs – and is used as an articulation/pronunciation guide.
• These symbols are presented along with an auditory presentation of the
targeted vowel phoneme
2. Alcorn Symbols:
• Given by Streng (1955)
• Visually represent the mouth shapes assumed during production of
vowels and diphthongs
• Help the child is to associate the written symbol and the oral movement
(Davis and Hardick, 1981)
• Useful for Very young children
• The symbols can also be combined with letters

Nancy Kauffman’s speech praxis treatment kit

• It is a Systematic treatment program that trains how to simplify words,
making it easier for children to communicate
• These kits are useful for children with age group of 2 to 6 yrs.
• Phonological processes are used and explained
• It focuses on child’s speech motor skills beginning by shaping the
consonant, vowel, and syllable shapes/gestures.
Kit I:
• 200 pictures of nouns and verbs ordered from simple to complex at the
basic level, Consonants /p/, /b/, /m/, /t/, /d/, /n/, /h/
• Teach children the best word approximations
• Simple bisyllables are taught first
• If the child is not, the user is required to choose a variety of appropriate
stimulus materials
Kit II:
• Child who is having more difficulties with complex consonants
• These serve as a way to move into more refined and integration skills
• Blends, polysyllables and difficult consonants like /r/, /s/, /g/, /l/, /f/ etc
h) Use of AAC in childhood apraxia of speech
The variety of prostheses used as part of augmentative and alternative
communication (AAC) systems are as appropriate for those with AOS as for
those with dysarthria.
These tools of behavioral intervention-including pictures, letter and word
boards, electronic and computerized devices-can be very useful for some
patients with AOS.
Several studies have documented the success of AAC strategies (Amerind sign
language, Bliss symbols, HandiVoice) for people with AOS, occasionally with
some carryover of treatment effects to improved verbal communication
Sign/ total communication
• Jaffe (1984) defines total communication as a combination of speech
with all models of communication. Total communication to CAS as an
initial remedial strategy.
• Visual feedback via watching their own hands during gestures.
• Fine motor competence is not required, Meaningful gross motor
movements inherent in signs.
• The clinician can assist the client by holding and shaping the hands,
which is not possible in the mouth in order to assist oral communication.
• The iconicity of sign language may facilitate language development and
Other methods:
− Bliss symbols
− Rebus symbol
− Communication boards
− PECS
Role of AAC in intervention:
• Augmenting existing natural speech.
• Providing primary output mode for communication
• Providing an input and output mode for language and communication
• Serving as language intervention strategy.
• The most common and well-known role is to provide an output mode for
communication.
Unit 5: Feeding and swallowing disorders in children
a) Embryology- periods and structures of development
Embryology is the branch of biology involving the study of prenatal
development that includes the embryo and the fetus.
Embryonic Period (Weeks 1 to 8):
Prenatal development begins at fertilization with formation of a zygote.
By the 3rd week, three germ layers (ectoderm, mesoderm, and endoderm) are
formed from which all tissues and organs of the embryo develop.
All major organ systems are formed during the 4th to 8th weeks of
development.
By the end of the 8th week, the embryo begins to have a human appearance.
Fetal Period (Week 9 to Birth):
9 to 12 Weeks:
At the beginning of the 9th week, the head makes up half the length of the
fetus. At 9 weeks, the face is broad, with widely separated eyes, fused eyelids,
and low-set ears. The legs are short with relatively small thighs. By the end of
12 weeks, the upper limbs reach the final length.
13 to 16 Weeks:
By the 13th week, body length has more than doubled. Ossification of the
skeleton begins during this period.
17 to 20 Weeks:
Somatic growth slows down, but length continues to increase. Fetal
movements are beginning to be felt by the mother. Eyebrows and head hair
become visible at 20 weeks
21 to 25 Weeks:
Substantial weight gain occurs during this timeBy 24 weeks, the lungs begin
producing surfactant.
26 to 29 Weeks: The lungs are capable of air exchange. The CNS is beginning to
mature. Control of body temperature begins. The eyes are open at the
beginning of this period
30 to 34 Weeks:
By 30 weeks, the pupillary light reflex of the eyes can be elicited. By 34 weeks,
white fat makes up about 8% of body weight. The presence of white fat is a
developmental milestone for normal feeding potential because the infant then
begins to show some nutritional reserves.
35 to 40 Weeks:
At 36 weeks, the circumferences of the head and the abdomen are
approximately equal. The expected time of birth is 38 weeks after fertilization
or 40 weeks after the last menstrual period. By full term, the amount of white
body fat should be about 16% of body weight.
Head and Neck Development:
The head and neck are developed from the branchial apparatus, which consists
of branchial arches, pharyngeal pouches, branchial grooves, and branchial
membranes.
Branchial arches are derived from the neural crest cells and begin in the 4th
week.
By the end of the 4th week, four pairs of branchial arches are. The fifth and
sixth pairs are too small to be seen on the surface of the embryo.
The branchial arches contribute to formation of the face, neck, nasal cavities,
mouth, larynx, and pharynx.
Facial Development:
The mandible is the first structure to form from the first branchial arch during
the 4th week.
The auricles of the external ear begin to develop by the end of the 5th week.
The nasal cavity is separated from the oral cavity by the oronasal membrane,
which ruptures at about 6 weeks. If the oronasal membrane is not ruptured it
might lead to difficulty in suck, swallow and breathing simultaneously.
At 16 weeks, the eyes begin to migrate and are situated more anteriorly.
Palatal development:
it occurs in between 5th to 12th week. Development occurs from anterior to
posterior.
The primary palate, develops at the end of the 5th week and is fused by 6th
week.
The anterior hard palate is fused by 9 weeks, and the muscular soft palate is
completed by the 12th week.
The fusion of the nasal septum and the palatine processes is done from 9th to
12th week.
Prenatal Sucking and Swallowing development:
The pharyngeal swallow is one of the first motor responses seen in 10th to
14thweek of gestation.
Non-nutritive suckling/sucking and swallowing in most fetuses seen by 15
weeks’ gestation. Suckling is backward and forward movement of the tongue.
Sucking involves more of an up and down movement of the tongue and active
use of the lips.
True suckling begins around the 18th to the 24th week.
By the 34th week, most healthy fetuses, can suckle and swallow.
450 ml to 850 ml of amniotic fluid produced daily is swallowed in utero.
Taste buds are evident at 7 weeks’ gestation, with distinctively mature
receptors noted at 12 weeks.
b) Anatomical structures of swallowing- upper aero digestive system,
anatomic difference between adults and children
The upper aerodigestive tract consists of the nose, oral cavity, pharynx, larynx,
and esophagus.
Nose:
• The nose is important for respiration throughout the life.
• The nose also cleans, warms, and humidifies inspired air.
• As the nasal passage continues posteriorly, it opens into the
nasopharynx, which is an important anatomic chamber that serves as a
resonator for speech production.
• The elevation and retraction of soft palate seal off the nasal cavity from
the oropharynx and the oral cavity.
Oral Cavity:
• The oral cavity is involved in ingestion of food, vocalization, and oral
respiration.
• Structures include lips, mandible, maxilla, floor of the mouth, cheeks,
tongue, hard palate, soft palate, and anterior surfaces of the anterior
tonsillar pillars.
• The structures in the mouth are important for bolus formation and oral
transit (described in detail in the following text).
• Muscles involved in bolus formation and oral transit include the
digastric, palatoglossus, genioglossus, styloglossus, geniohyoid,
mylohyoid, buccinators, and those muscles intrinsic to the tongue.
• Cranial nerves involved include V, VII, IX, X, XI, and XII.
Pharynx:
• The pharynx consists of three anatomic areas: the nasopharynx, the
oropharynx, and the hypopharynx.
• The nasopharynx begins at the nasal choanae and ends at the elevated
soft palate. The eustachian tubes originate in the nasopharynx.
 • The faucial arches form a bridge between the mouth and the
oropharynx. This junction and the tongue base form the anterior
boundary of the oropharynx, which extends inferiorly to the epiglottis.
• The oropharynx includes the epiglottis and the valleculae. The valleculae
are bilateral pockets formed by the base of the tongue and the
epiglottis.
• The hypopharynx (sometimes called the laryngeal pharynx) extends from
the base of the epiglottis to the cricopharyngeal muscles in the upper
esophageal sphincter.
Larynx:
• The larynx is a complex structure that is the superior entrance to the
trachea.
• The larynx consists primarily of cartilages, suspended by muscle and
ligament attachments to the hyoid bone and cervical vertebrae.
• The cartilages include the epiglottis, thyroid, cricoid, and paired
arytenoids, cuneiforms, and corniculates.
• Intrinsic muscles of the larynx form the vocal folds (true and false) that
are integral to respiration and phonation.
• In most humans, the epiglottis plays a role in airway protection.
• Sensory innervation of the supraglottic and glottic areas is provided by
the internal branch of the superior laryngeal nerve (SLN), a branch of the
vagus nerve (CN X). The recurrent laryngeal nerve (RLN) (also from CN X)
provides sensory innervation to the subglottic mucosa.

Oesophagus:
• The oesophagus is a muscular tube lined with mucosa that propels food
from the hypopharynx to the stomach.
• The upper oesophageal sphincter (UES) forms the junction between the
hypopharynx and the oesophagus.
• The lower oesophageal sphincter (LES) forms the junction between the
oesophagus and the stomach.
 • It has three constrictors:
i. At pharyngo-oesopharyngeal junction- 15 cm from the upper
incisors
ii. At crossing of arch of aorta and left main bronchus- 25 cm from
upper incisors
iii. Where it pierces diaphragm- 40 cm from upper incisors
• The wall of the oesophagus has four layers from within outwards they
are:
- Mucosa: innermost and lined with stratified squamous epithelium
- Submucosa: it connects the mucosa and muscular layer
- Muscular layer: it has inner circular fibers and outer longitudinal fibers
- Fibrous layer: it forms the loose covering of the oesophagus
anatomic difference between adults and children
c) Physiology of swallowing- swallow phases, neural control of swallowing,
reflexes related to swallowing, suckling and sucking, airway and swallowing
Physiology of swallowing:
There are three phases:
1. Oral phase: It is divided into two phases:
a. Oral preparatory phase:
- In this phase, the food is broken down in the oral-cavity and is mixed
with saliva to form a bolus.
- This involves repeated transfer of food from oral cavity to oropharyngeal
surface of tongue.
b. Oral phase proper:
- During this phase, the bolus is moved on the back side of the tongue.
- The soft palate covers the nasopharynx to prevent regurgitation.
- The tongue tip and blade elevates towards the hard palate causing
depression in the posterior part which helps in swallowing and sending
the bolus to the pharynx.
2. Pharyngeal Phase:
- During this phase, the soft palate raises to cover nasopharynx.
- As food enters pharynx, trachea is sealed by epiglottis securing the
airway and preventing bolus from entering trachea.
- Contraction of pharyngeal constrictor muscles, propels food downwards
into the oesophagus.
3. Oesophageal phase:
- As the bolus contacts the upper sphincter, it opens and allows the entry
of bolus into the oesophagus.
- A peristaltic wave is initiated at the upper end which helps the bolus to
propel downwards.
- As the bolus reaches the lower sphincter, it opens and allows the entry
of bolus into the stomach.
Neural control of swallowing
Following cranial nerves are involved in swallowing:
• Trigeminal (cranial nerve V)
• Facial (cranial nerve VII)
• Glossopharyngeal (cranial nerve IX)
• Vagus (cranial nerve X)
• Hypoglossal nerve (cranial nerve XII)
• The oral and pharyngeal phases of swallowing would be produced by
muscular contraction, and coordinated by a control center in the
brainstem.
• the cerebral cortex is not essential to the pharyngeal and esophageal
phases although the cerebral cortex appears to facilitate the oral phase
and the initiation of the pharyngeal phase.
• Neural control involves:
• afferent sensory fibers contained in cranial nerves,
• cerebral, midbrain, and cerebellar fibers that synapse with the brain-
stem swallowing centers,
• the paired swallowing centers in the brain stem, and
• efferent motor fibers contained in cranial nerves
- Afferent Pathways:
- Sensory input is stressed as necessary for accurate motor control.
Sensory information is processed during planning, executing, and
evaluating an action. Concepts of sensory feedback and predictions prior
to confirmation seem especially significant for oropharyngeal
swallowing.
- Primary afferents from the receptors in the oropharyngeal mucosa travel
in the trigeminal (V), glossopharyngeal (IX), and vagus nerves (X), and
converge in the solitary tract destined for synaptic contact with second-
order neurons in the nucleus tractus solitarius (NTS). The swallowing
 reflex elicited by primary afferents may be modified by lung/chest wall
receptors such as vagal and intercostals muscle afferents.
- Efferent pathways:
- Central Control Which Includes Central Pattern Generator

Suckling and swallowing:

Suckling:
Suckling, the first pattern to develop, is acquired gradually in the second and
third trimesters and involves definite backward and forward movements of the
tongue.
Liquid is drawn into the mouth through a rhythmic licking (or stripping) type
action of the tongue, combined with opening and closing of the jaw. Lips may
be loosely approximated and flared around a nipple.
The tongue moves forward for half the suckle pattern, but the backward
motion is more pronounced. Tongue protrusion does not extend beyond the
border of the lips.
Sucking:
sucking is the second pattern that develops at about 6 months. The body of the
tongue raises and lowers while the jaw makes a smaller vertical excursion.
Firmer approximation of the lips that must be flared for efficient nipple-
feeding along with the pattern of tongue motion allows for a negative pressure
to build up in the mouth. This combination of movements works to get liquid
and soft food into the mouth. Strength of lip closure is a major factor in the
shift of tongue patterns. The tongue has more space to move in the oral cavity
due to downward and forward growth of oral cavity.

Airway and Swallowing:

• swallowing and breathing are tightly coordinated.
• Swallowing is dominant to respiration in normal individuals.
• Breathing ceases briefly during swallowing, not only because of the
physical closure of the airway by elevation of the soft palate and tilting
of the epiglottis, but also of neural suppression of respiration in the
brainstem.
• When drinking a liquid bolus, swallowing usually starts during the
expiratory phase of breathing. The respiratory pause continues for 0.5 to
1.5 s during swallowing, and respiration usually resumes with expiration.
• This resumption is regarded as one of the mechanisms that prevents
inhalation of food remaining in the pharynx after swallowing.
• When performing sequential swallows while drinking from a cup,
respiration can resume with inspiration. Eating solid food also alters the
respiratory rhythm. The rhythm is perturbed with onset of mastication.
• Respiratory cycle duration decreases during mastication, but with
swallowing.3The “exhale – swallow – exhale” temporal relationship
persists during eating. However, respiratory pauses are longer, often
beginning substantially before swallow onset.
d) Terms involved in dysphagia and development of feeding skills
terms:
1. Swallowing/deglutition: a series of movements that promote bolus
transportation from the mouth to the stomach.
2. Eating/ingestion: the process of taking a bolus into the body by mouth.
3. Eating disorder: a psychological disorder characterized by abnormal or
disturbed eating behaviors.
4. dys-: impaired or abnormal
5. phag-: eating
6. eating problem/dysphagia: eating failure or dysfunction, defined as a
disturbance of the passage of a swallowed bolus from the mouth to the
stomach
7. aspiration: entry of saliva, liquid or food into the airway under the level
of the true vocal folds
8. penetration: entry of swallowed material into the laryngeal vestibule
during swallowing, as above of the level of the true vocal folds
9. retention: presence of a residual swallowed bolus locating in the oral
cavity, vallecula, and/or hypopharynx (pyriform sinus) that is left behind
after the swallow
10.drooling: defined as flowing of food, liquid or saliva outside of the mouth
unintentionally
11.nasal regurgitation: passing out of food from the oral cavity into the
nasal cavity
12.pharyngeal regurgitation: swallowed bolus flows back into the pharynx
through the junction of pharynx and oesophagus passing the
cricopharyngeal sphincter
13.gastroesophageal regurgitation: retrograde movement of the stomach’s
contents back up into the oesophagus
Feeding:
Feeding is the process involving any aspect of eating or drinking, including
gathering and preparing food and liquid for intake, sucking or chewing, and
swallowing.
• Feeding disorders are problems with a range of eating activities that
may or may not include problems with swallowing.
Feeding disorders can be characterized by one or more of the following
behaviors:
• Avoiding or restricting one’s food intake (avoidance/restrictive food
intake disorder [ARFID]; American Psychiatric Association, 2016)
– Refusing age-appropriate or developmentally appropriate foods or
liquids
– Accepting a restricted variety or quantity of foods or liquids
• Displaying disruptive or inappropriate mealtime behaviors for
developmental level
• Failing to master self-feeding skills expected for developmental levels
• Failing to use developmentally appropriate feeding devices and utensils
• Experiencing less than optimal growth (Arvedson, 2008)
 Development of feeding skills:

Age Feeding/Swallowing Development

Birth-2 months • Nipple feeding by breast or bottle
• Hand to mouth movements begin
• Semi-reclined posture during feeding
2-3 months • Interacts with caregiver during feeding through gaze

3-4 months • Begins to put hands on bottle during feeding

5-6 months • Spoon feeding introduced (4-6 months)

• Cup drinking introduced
• Holds bottle with both hands
6-9 months • More upright posture during feeding
• Increases lip closure around spoon
• Accepts spoon feeding of pureed food
• Begins to finger feed solids
• Vertical chewing pattern (munching) begins
• Able to suck liquids from cup
9-12 months • Drinks from cup held by caregiver
• Progresses to thicker, more textured food
• Increased finger feeding of easily dissolvable foods
• Chewing matures to more rotary jaw action
• Deliberately reached for spoon
12-18 months • Grasps spoon with both hands for self-feeding
• Holds cup with both hands
 • Able to hold and tip bottle independently

18-24 months • Primarily self-feeding

• Able to chew a wide range of textures
• Oral movements are more precise
24-36 months • Holds cup with one hand
• Drinks from open cup without spiling
• Uses fingers to put food on spoon
• Uses fork
• Almost completely self-feeds
• Eats a wide range of solid foods
e) Causes of dysphagia in children
Underlying etiologies associated with pediatric feeding and swallowing
disorders include
• Complex medical conditions (e.g., cardiac disease, pulmonary disease,
gastroesophageal reflux disease [GERD], delayed gastric emptying);
• Developmental disability (i.e., Disability with onset before the age of 22
that warrants lifelong or extended medical, therapeutic, and/or
residential supports and is attributable to a mental or physical
impairment or a combination of mental and physical impairments);
• Factors affecting neuromuscular coordination (e.G., Prematurity, low
birth weight, hypotonia, hypertonia);
• Genetic syndromes (e.G., Down syndrome, pierre robin sequence,
prader–willi, rett syndrome, treacher collins syndrome, 22q11 deletion);
• Medication side effects (e.G., Lethargy, decreased appetite);
• Neurological disorders (e.G., Cerebral palsy, meningitis,
encephalopathy, pervasive developmental disorders, traumatic brain
injury, muscle weakness in face and neck);
• Sensory issues as a primary cause or secondary to limited food
availability in early development (e.G., In children adopted from
institutionalized care; beckett et al., 2002, johnson & dole, 1999);
• Structural abnormalities (e.G., Cleft lip and/or palate and other
craniofacial abnormalities, laryngomalacia, tracheoesophageal fistula,
esophageal atresia, choanal atresia);
• Behavioral factors (e.G., Food refusal); and Socio-emotional factors
(e.G., Parent–child interactions at mealtimes).
• Atypical eating and drinking behaviors can develop in association with
dysphagia, aspiration, or a choking event. They may also arise in
association with sensory disturbances (e.G., Hypersensitivity to
textures), stress reactions (e.G., When trying new foods), or undetected
pain (e.G., Teething, tonsillitis).
f) Signs and symptoms of dysphagia in children
Signs and symptoms vary based on the phase(s) affected and the child’s age
and developmental level. They may include the following:
• Breathing difficulties when feeding that might be signaled by
– increased respiratory rate;
– changes in normal heart rate (bradycardia or tachycardia);
– skin color change such as turning blue around the lips, nose and
fingers/toes (cyanosis);
– temporary cessation of breathing (apnea);
– frequent stopping due to uncoordinated suck-swallow-breathe
pattern; and
– desaturation (decreasing oxygen saturation level)
• Coughing and/or choking during or after swallowing.
• Crying during mealtimes.
• Decreased responsiveness during feeding.
• Difficulty chewing foods that are texturally appropriate for age (may spit
out or swallow partially chewed food).
• Difficulty initiating swallowing.
• Difficulty managing secretions (including non-teething-related drooling
of saliva).
• Disengagement/refusal shown by facial grimacing, facial flushing, finger
splaying, or head turning away from food source.
• Frequent congestion, particularly after meals
• Frequent respiratory illnesses.
• Gagging.
• Loss of food/liquid from the mouth when eating.
• Noisy or wet vocal quality during and after eating.
• Taking longer to finish meals or snacks (longer than 30 minutes).
• Refusing foods of certain textures or types.
• Taking only small amounts of food, overpacking the mouth, and/or
pocketing foods.
• Vomiting (more than typical “spit-up” for infants
g) Assessment – inferences from neural developmental assessment, cranial
nerve examination, assessment scales, nutritive and non-nutritive
assessment, instrumental assessment (VFS, cervical auscultation),
gastrointestinal evaluation
Assessment criteria according to ICF:
Consistent with the World Health Organization’s (WHO) International
Classification of Functioning, Disability and Health (ICF) framework,
comprehensive assessment is conducted to identify and describe
• impairments in body structure and function, including the swallowing
phases that are affected;
• co-morbid deficits or conditions, such as developmental disabilities or
syndromes;
• limitations in activity and participation, including the impact on overall
health (including nutrition and hydration) and the child’s ability to
participate in routine activities
• contextual (environmental and personal) factors that serve as barriers
to or facilitators to successful nutritional and the impact of feeding and
swallowing impairments on quality of life of the child and family.
Neural Developmental Assessment:
Abnormalities of the developing brain commonly result in a spectrum of
cognitive, communicative, behavioral, and motor abnormalities that are often
associated with swallowing and feeding disorders.
Clinicians need to assess both the sequence and the quality of developmental
milestones
Observation of the quality or the way in which a child performs various motor
skills is an important part of a neurodevelopmental examination.
Examination of Muscle Tone: Examination of muscle tone and resting posture
is an essential part of a neurologic examination. Check for passive and active
tone.
CNS Evaluation: CNS disorders are usually characterized by abnormalities of
muscle tone in the absence of significant muscle weakness. Children with
neuromuscular disorders will have significant reductions in active muscle tone
(muscle strength) CP is common cause of neurogenic dysphagia.
Characteristic of CNS disorders, particularly CP, is the persistence of strong
primitive reflexes. Evaluation of deep tendon reflexes is helpful in children with
dysphagia and show increased or normal deep tendon reflexes.
Cranial Nerve Examination:
A detailed examination of the cranial nerves involved with swallowing can be
completed in most children.
The trigeminal (CN V), facial (CN VII), glossopharyngeal (CN IX), vagus (CN X),
and hypoglossal (CN XII) cranial nerves control the sensory and motor
components of swallowing
Name Function Activity
trigeminal nerve Chewing a) clinician should apply moderate pressure
sensation of on clients mandible and ask to close the
the face mouth
b) blind fold the client and check for the
sensation of face by touching the skin
surface with a cotton swab.
Facial nerve Taste a) Ask the client to taste the following and
sensation, identify it: Honey, salt.
movement of
b) ask the client to :
facial
expression smile, pucker, blow, raise eyebrow
Glossopharyngeal Secretion of Take a tongue depressor and touch the
nerve saliva, sense of back part of the tongue (gag reflex)
test,
movement of
pharynx
Vagus nerve Movement, Ask the client to take a deep breath and say
secretion /a/. ask to dry swallow
Hypoglossal Movement of Ask the client to make tongue movements:
nerve tongue protrude, retract, lateral, up and down.
Assessment of readiness for oral feeding include:
• physiologic stability—stability of digestive, respiratory, heart rate, and
oxygenation parameters;
• motoric stability—stability of muscle tone, flexion, and midline
movements; and
• behavioral state—including the ability to become alert to a stimulus and
remain alert.
Non-Nutritive Suck (NNS)
NNS is sucking for comfort without fluid release (e.g., with a pacifier, finger, or
recently emptied breast). NNS does not determine readiness to orally feed, but
it is helpful for assessment. NNS patterns can typically be evaluated with
skilled observation and without the use of instrumental assessment.
A non-instrumental assessment of NNS includes an evaluation of the following:

• The infant’s oral structures and functions, including palatal integrity, jaw
movement, and tongue movements for cupping and compression.
(Note: Lip closure is not required for infant feeding because the tongue
typically seals the anterior opening of the oral cavity.)
• The infant’s ability to turn the head and open the mouth (rooting) when
stimulated on the lips or cheeks and to accept a pacifier into the mouth.
• The infant’s ability to use both compression (positive pressure of the jaw
and tongue on the pacifier) and suction (negative pressure created with
tongue cupping and jaw movement).
• The infant’s compression and suction strength.
• The infant’s ability to maintain a stable physiological state (e.g., oxygen
saturation, heart rate, respiratory rate) during NNS.

Nutritive Sucking (NS)

Any loss of stability in physiologic, motoric, or behavioral state from baseline

should be taken into consideration at the time of the assessment.

NS skills are assessed during breastfeeding and bottle-feeding if both modes

are going to be used
Assessment of NS includes an evaluation of the following:

• sucking/swallowing/breathing pattern—ability to coordinate a

suck/swallow/breathe pattern
• efficiency—volume of intake per minute
• endurance—ability to remain engaged in the feeding to finish the
required volumes while sustaining appropriate feeding patterns
• the feeding relationship—interaction between the infant and the feeder

These cues can communicate the infant’s ability to tolerate bolus size, the
need for more postural support, and if swallowing and breathing are no longer
synchronized.
Breastfeeding: In addition to the clinical evaluation of infants noted above,
breastfeeding assessment typically includes an evaluation of the
• infant’s general health and medical comorbidities;
• infant’s current state, including respiratory rate and heart rate;
• infant’s behavior ex. positive rooting, willingness to suckle at breast
• infant’s position (e.g., well supported, tucked against the mother’s
body);
• efficiency and coordination of the infant’s suck/swallow/breathe
pattern;
• mother’s behavior (e.g., comfort with breastfeeding, confidence in
handling the infant, awareness of the infant’s cues during feeding).
Bottle-Feeding: The assessment of bottle-feeding includes an evaluation of the

• infant’s general health and medical comorbidities;

• infant’s current state, including the respiratory rate and heart rate;
• infant’s behavior
• caregiver’s behavior while feeding the infant;
• efficiency and coordination of the infant’s suck/swallow/breathe
pattern;
• nipple type and form of nutrition (breast milk or formula);
• infant’s position and quantity of intake;
• length of time the infant takes for one feeding; and
• infant’s response to attempted interventions, such as
o a different nipple for flow control,
o external pacing,
 o a different bottle to control air intake, and
o different positions (e.g., side feeding).

Spoon-Feeding: The assessment of spoon-feeding includes an evaluation of

the optimal spoon type and the infant’s ability to

• move their head toward the spoon and then open their mouth,
• turn their head away from the spoon to show that they have had
enough,
• close their lips around the spoon,
• clear food from the spoon with their top lip,
• move food from the spoon to the back of their mouth, and
• attempt to spoon-feed independently.

The clinical evaluation for infants: from birth to 1 year of age—including those
in the NICU—includes an evaluation of pre-feeding skills, an assessment of
readiness for oral feeding, an evaluation of breastfeeding and bottle-feeding
ability, and observations of caregivers feeding the child.
The clinical evaluation of infants typically involves
• a case history, which includes
o gestational and birth history and
o pertinent medical history;
• a physical examination, which includes
o a developmental assessment,
o a respiratory status assessment, and
o an assessment of sucking/swallowing problems and a
determination of abnormal anatomy and/or physiology that might
be associated with these findings (
• a determination of oral feeding readiness;
• an assessment of the infant’s ability to engage in non-nutritive sucking
(NNS);
• developmentally appropriate clinical assessments of feeding and
swallowing behavior (nutritive sucking [NS]), as appropriate;
 • an identification of additional disorders that may have an impact on
feeding and swallowing;
• a determination of the optimal feeding method;
• an assessment of issues related to fatigue and volume limitations;
• an assessment of the effectiveness of parent/caregiver and infant
interactions for feeding and communication; and
• consideration of the infant’s ability to obtain sufficient
nutrition/hydration across settings (e.g., hospital, home, day care
setting).

Clinical Evaluation: Toddlers and Preschool/School-Age Children

In addition to the areas of assessment noted above, the evaluation for toddlers
(ages 1–3 years) and preschool/school-age children (ages 3–21 years) may
include

• a review of any past diagnostic test results,

• a review of current programs and treatments,
• an assessment of current skills and limitations at home and in other day
settings,
• screening of willingness to accept liquids and a variety of foods in
multiple food groups to determine risk factors for avoidant/restrictive
food intake disorder,
• an evaluation of dependence on nutritional supplements to meet dietary
needs,
• an evaluation of independence and the need for supervision and
assistance, and
• the use of intervention probes to identify strategies that might improve
function.
Instrumental evaluation
Instrumental evaluation is conducted following a clinical evaluation when
further information is needed to determine the nature of the swallowing
disorder.
Instrumental evaluation can also help to determine if swallow safety can be
improved by modifying food textures, liquid consistencies, or positioning.
Videofluoroscopic Swallow Study (VFSS)
VFSS, also known as modified barium swallow, is a radiographic procedure that
provides a direct, dynamic view of oral, pharyngeal, and upper esophageal
function during swallowing.
VFSS shows the characteristics of the swallow and the patterns of bolus
movement including, initiation of the swallow, nasopharyngeal reflux,
pharyngeal clearance, and laryngeal penetration and aspiration.
During this procedure, the SLP presents food and liquid mixed with barium.
The barium is necessary to view structures via videofluoroscopy during the
swallow.
A VFSS is indicated when there is
• a need to observe oral preparatory, oral transit, pharyngeal, and/or
esophageal phases of swallowing;
• a diagnosed or suspected presence of abnormalities in the anatomy of
nasal, oral, pharyngeal, or upper esophageal structures
• an aversion to having an endoscope inserted;
• the presence of a persistent feeding refusal problem for which a
swallowing disorder might be a contributing cause; or
• the need to determine treatment or management strategies to minimize
the risk of aspiration and increase swallow efficiency
Procedures for the VFSS:
The SLP may prepare the patient for a VFSS:
• Educate the patient and/or caregiver regarding VFSS procedures
• Position the patient upright, if possible, use postural supports
 • Consider having the patient fed by a familiar family member or
caregiver. Make every effort to maintain the patient in a calm, alert state
during testing.
The common procedure is to start with the thinnest liquid barium contrast first
with a controlled small volume, then to consecutive swallows by nipple, cup, or
straw.
The SLP and radiologist make observations relating to: timing of the swallow,
coordination in oral and pharyngeal phases of the swallow, pharyngeal
motility, presence or absence of material in the pharyngeal recesses before a
swallow or residue in the pharyngeal recesses after the swallow, and
esophageal transit time.
Occurrence of aspiration before, during, and/or after swallows of varied
textures is documented. It is also important to document whether a child
responds to the aspiration with a cough or some other observable action,
attempts to clear with a cough, or makes no response (silent aspiration).
Once the VFSS begins, the SLP may

• identify relevant anatomical structures;

• evaluate the oral and pharyngeal phases of swallowing;
• identify the effectiveness of swallow function and probe sensory
awareness;
• assess the effectiveness of altering bolus delivery or bolus consistency;
• consider alternative methods of presentation (e.g., modified cups,
spoons, alternative nipple to modify flow rate);
• assess the presence and effectiveness of the patient’s response to
laryngeal penetration, residue, and/or aspiration.

A complete VFSS requires a sufficient number of swallowing attempts to

determine the need for additional assessments and interventions
Cervical Ausculation: It is the use of a listening device, typically a stethoscope
in clinical practice, to assess swallow sounds. Listeners interpret the sounds
and suggest what might be happening with the swallow or causing impairment.
Fiberoptic Endoscopic Evaluation of Swallowing: Without Sensory Testing
(FEES) or With Sensory Testing (FEESST)
Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is a procedure in which
a fiber optic endoscope is inserted through the nose and into the throat to
obtain a direct visualization of structures, a dynamic view of the oral–
pharyngeal transfer, and indirect evidence of the pharyngeal–esophageal
transfer during swallows.
Saliva swallowing can be evaluated, and the anatomy and physiology of saliva
swallow can be viewed in the absence of acceptance of food and/or liquids.
The swallow is then assessed with presentation of food and liquid.
Fiberoptic Endoscopic Evaluation of Swallowing With Sensory Testing
(FEESST) is a modification of FEES, is a test of the Laryngeal Adductor Response
(LAR), a reflexive vocal fold adduction in response to a pressure- and duration-
calibrated air puff delivered anterior to the arytenoids along the aryepiglottic
folds. The test measures the intensity level at which the LAR is elicited.
Procedure for FEES
• educate the patient and/or caregiver regarding FEES procedures and
rationale for the examination;
• position the patient consistent with the patient’s typical eating posture
(e.g., upright, reclined);
• provide a topical anaesthetic if appropriate (see below for further
information regarding anaesthetic);
• select the appropriate endoscope type and size;
• insert the scope;
• identify anatomical landmarks and any abnormalities
• administer flexible endoscopic evaluation of swallowing with sensory
testing (FEESST), if indicated, to determine laryngeal adductor reflex
(LAR) sensitivity and vocal fold dynamics; and assess basic movement
abilities of anatomical structures through specific maneuvers
Gastrointestinal evaluation:
The gastrointestinal (GI) tract is an organ system responsible for nutrient
absorption, waste excretion, and immunity.
It is composed of the upper GI tract (oral cavity, esophagus, and duodenum),
lower GI tract (small intestine, cecum, colon, rectum, and anus), and
associated glandular organs (gallbladder, pancreas, and liver)
An abdominal examination is an essential part of the GI workup and classically
includes inspection, auscultation, percussion, and palpation in this order.
Laboratory and microbiologic tests may be used to assess organ function, to
screen for certain GI disorders, and to evaluate the effectiveness of therapy
Ultrasonography:
it provides images of deeper structures such as the gallbladder, liver, and
kidneys and can also be useful in helping define vascular abnormalities in the
intra-abdominal cavity
Computed Tomography:
Advances in CT or computed axial tomography (CAT) scanning have resulted in
a paradigm shift for chest and abdominal-pelvic imaging, providing improved
resolution and faster acquisition of radiographic information
Magnetic Resonance Imaging:
MRI allows for a comprehensive evaluation of intra-abdominal solid organs
including, the liver, pancreas, and spleen, without the use of ionizing radiation

ASSESSMENT SCALES:
• Mealtime Behavior Questionnaire (MBQ):
• Oral Motor Assessment Scale (OMAS):
• Pre-Speech Assessment Scale (PSAS):
• Pediatric Assessment Scale for Severe Feeding Problems (PASSFP)
• Schedule of Oral Motor Assessment (SOMA)
• Screening Tool of Feeding Problems, modified for children (STEP-Child).
1.Mealtime Behavior Questionnaire (MBQ):
• age: 2 to 6 yrs
• specific population: feeding problems
• measures: meal time behaviors
• administered by: caregiver
• format: observation
2.Oral Motor Assessment Scale (OMAS):
• age: 3 to 13 yrs
• specific population: cerebral palsy
• measures: Oral Motor Skills
• administered by: clinician
• format: observation and history
h) Management: positioning, oral- motor treatment, team approach, non-
oral feeding, transitional feeding, modifications in feeding

Postural and Positioning Techniques

Postural and positioning techniques involve adjusting the child’s posture or
position to establish central alignment and stability for safe feeding. These
techniques serve to protect the airway and offer safer transit of food and
liquid. No single posture will provide improvement to all individuals. Postural
changes differ between infants and older children.
Techniques include
• chin down—tucking the chin down toward the neck;
• chin up—slightly tilting the head up;
• head rotation—turning the head to the weak side to protect the airway;
• upright positioning—90° angle at hips and knees, feet on the floor, with
supports as needed;
• head stabilization—supported so as to present in a chin-neutral position;
• cheek and jaw assist;
• reclining position—using pillow support or a reclined infant seat with
trunk and head support; and
• side-lying positioning (for infants).
• Latching
• The mother may feed the infant in cradle hold, upright facing the feeder,
in right or left side lying position, or facing away from the feeder.
• some authors recommend a single posture for optimum swallowing,
generally with the head tilted forward at a 450 angle

Maneuvers are strategies used to change the timing or strength of movements

of swallowing (Logemann, 2000). Some maneuvers require following multistep
directions and may not be appropriate for young children and/or older children
with cognitive impairments. Examples of maneuvers include the following:
 • Effortful swallow—posterior tongue base movement is increased to
facilitate bolus clearance.
• Masako, or tongue hold—tongue is held forward between the teeth
while swallowing; this is performed without food or liquid in the mouth
to prevent coughing or choking.
• Mendelsohn maneuver—elevation of the larynx is voluntarily prolonged
at the peak of the swallow to help the bolus pass more efficiently
through the pharynx and to prevent food/liquid from falling into the
airway.
• Supraglottic swallow—vocal folds are usually closed by voluntarily
holding breath before and during swallow in order to protect the airway.
• Super-supraglottic swallow—effortful breath hold tilts the arytenoid
forward, which closes the airway entrance before and during the
swallow.

Oral-motor treatment:
• Oral–motor treatments include stimulation to—or actions of—the lips,
jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles.
• Oral–motor treatments range from passive (e.g., tapping, stroking, and
vibration) to active (e.g., range-of-motion activities, resistance exercises,
or chewing and swallowing exercises).
• Oral–motor treatments are intended to influence the physiologic
underpinnings of the oropharyngeal mechanism in order to improve its
functions. Some of these interventions can also incorporate sensory
stimulation
• Beckmann oral motor approach
- provide assisted movements to activate muscle contraction and to
provide movement against resistance to build strength.
- to increase functional response to pressure and movement, range,
strength and variety and control of movement for the lips, cheeks, jaw
and tongue using assisted movement and stretch reflexes.
 - Development of oral motor skills enhances the progression from breast
milk or formula, then to pureed food and to table foods as well as the
skills needed to progress from sucking a nipple to using a wide variety of
utensils i.e. straws, cups, spoons and forks.

Non-oral Feeding:
NNS involves allowing an infant to suck without taking milk, either at the
breast (after milk has been expressed) or with the use of a pacifier. It is used as
a treatment option to encourage eventual oral intake.
Steps involved are:
• Place a gloved finger or a pacifier in the infant’s mouth
• Press firmly 4-6 times (1-2 times per second) on the middle of the
tongue
• Pause to see if the infant continues unassisted sucking
• Repeat as tolerated.

Transitional Feeding:
NNS and Oral Feeding Readiness:
Rule of Thumb:
If the infant can produce non-nutritive suck, he/she may be able to produce a
nutritive suck.
If the infant cannot produce non-nutritive suck, he/she may be able to produce
a non-nutritive suck and is not ready for oral feed.
Repeated trials at oral feeding prior to infant readiness may actually delay
development of oral feeding skills.
Readiness for oral feeding—Toddlers and older children who are beginning to
eat orally for the first time or after an extended period of non-oral feeding will
need time to become comfortable in the presence of food
tube feeding:
Tube feeding includes alternative avenues of intake such as
• nasogastric [NG] tube,
• transpyloric tube (placed in the duodenum or jejunum),
• gastrostomy (G-tube placed in the stomach or GJ-tube placed in the
jejunum).
• These approaches may be considered if the child’s swallowing safety and
efficiency cannot reach a level of adequate function or does not
adequately support nutrition and hydration.
• Physiologically stable preterm infants, are generally transitioned from
tube feeding to oral feeding at 32–34 weeks gestational age. This
transition may take days to weeks
• Success in this transition, defined as adequate intake for growth and
maintenance of physiologic stability, depends on several factors:
• (a) the infant's neurological and physiological maturity, namely, the
infant's ability to remain engaged in feeding, organize oral-motor
functioning, co-ordinate swallowing with breathing, and maintain
physiologic stability

Sensory Stimulation Techniques

• Sensory stimulation techniques vary and may include thermal–tactile
stimulation (e.g., using an iced lemon glycerin swab) or tactile
stimulation (e.g., using a NUK brush) applied to the tongue or around
the mouth.
• Children who demonstrate aversive responses to stimulation may need
approaches that reduce the level of sensory input initially, with
incremental increases as the child demonstrates tolerance.
• Sensory stimulation may be needed for children with reduced responses,
overactive responses, or limited opportunities for sensory experiences
• Oral stimulation program:
- This program involves stimulating the face and oral cavity with different
textures, touch pressures, and temperatures
 - Provide the infant/child with opportunities to orally explore a variety of
toys
- Encourage the infant to suck on fingers and/or a pacifier during tube
feedings
- Rub the child’s face with various textures (soft/smooth-stiff/rough).
- Use a finger to apply firm pressure to the gums, tongue, and teeth (if
applicable). Start at midline and work your way back. Repeat 3-4 times
- Provide the infant with a toothette, small toothbrush, or gloved finger
dipped in water, formula, or breast milk. Apply pressure downward, and
then apply a finger stroke.
Developing chewing skills:
• This involves assisting the child learning to masticate and manipulate
new food textures without choking. This is aimed at expanding the
child’s food repertoire and developing normal feeding skills.
• Start by placing new soft solid textures . i.e. food strips of fruit, inside
gauze that is tied tightly together with dental floss so you can pull it out
if needed (sham bolus).
• Place food anteriorly on the tongue tip so the child can identify the
food.
• Next, move the food laterally (on molars) to encorage tongue
lateralization.
• Use external jaw support to assist with lip closure and graded jaw
movements.
• Experiment with different food flavors (spicy, sweet, sour) and
temperatures (very cold to warm) to increase sensory input
• Stroke up/down inside the cheek to promote chewing behaviours.
• Once the child is accepting and lateralizing food in gauze from midline of
tongue to molars, introduce soft, soluble solids. Go slowly modified.
Modifications in feeding:
• The combined goals of the feeding specialists and parents for
management and treatment usually include
• 1) improving the infant’s overall stability with integrated developmental
care
• 2) proper positioning in an incubator or crib, proper positioning during
feeding
• 3) use of appropriate latching skills and positioning for breastfeeding
• 4) use of appropriate bottles and nipples.
• Present the infant opportunities to suck on fingers and thumbs before
bottle is presented.
• Avoid distracting movements by the feeder. Try not to stimulate the
infant by giving chin support or touching the face unless necessary.
• Feed the infant in a side lying position.
• If the infant is supported well, a face to face hold will help the feeder
monitor the infant’s response. If the infant is disorganized, a cradle hold
will provide more support and organization
• Utensils for feeding:
- Pacifiers: used in preterm babies to assist in non-nutritive suck. They
should match infants oral cavity, sensitivity and sucking needs
- Nipples: they are characterized by material of composition that
determines the shape, size and flow rate. Silicone nipples are clear, firm
and likely to collapse. Plastic nipples may be tan colored and will
collapse easily. Straight nipple requires more tongue cupping, more
consistent flow rate, more pressure before it collapses. Orthodontic
nipples is useful when infant has flatter and larger tongue as it requires
less pressure to collapse, a less predictable flow rate. Different variety of
nipples:
i. Stiffness: soft nipple may collapse easily and make it hard for
child to draw fluid (for child with weak suck). Too hard nipples
may tire infant easily (for children with hypotonic tongue)
 ii. Size: too large or long can gag the child, too small may frustrate
the child
iii. Shape: standard nipples are oblong and work well for child who
can form a central grove. Long, thin nipples work when the
tongue Is retracted to bring it forward.
iv. Flow rates: depends on sucking strength and viscosity of fluids.
Nipples have 12 (slow flow) to 4 (fast flow) holes. Slow flow
rates are helpful for those with respiratory compromise, weak
suck and poor endurance. Fast flow rates for those with intact
pharyngeal swallow but early fatigue.
- Bottles: soft plastic bottles are flexible and can be squeezed to assist
rate of flow. Angle neck bottles allow infant to eat in upright position,
also good for side lying or prone positions.
- Cup: sipper cups with a spout to support jaw and lip closure but doesnot
cause the child to tilt the head. Shouldn’t use cups that will break, crack
or shatter if the child bites down on edge.
- Spoon: the bowl of the spoon should be relatively flat so that the child
can remove food using the upper lip. Do not let the child scape food with
upper teeth. Spoon should be hard and the bowl should fit the child’s
mouth. Handle should be of appropriate to the size of the child’s hand.
-
i) Role of speech-language pathologist in neonatal intensive care with
reference to feeding and swallowing

educating families of children at risk for pediatric feeding and swallowing

disorders;
educating other professionals on the needs of children with feeding and
swallowing disorders and the role of SLPs in diagnosis and management;
conducting a comprehensive assessment, including clinical and instrumental
evaluations as appropriate;
considering culture as it pertains to food choices/habits, perception of
disabilities, and beliefs about intervention (Davis-McFarland, 2008);
diagnosing pediatric oral and pharyngeal swallowing disorders (dysphagia);
recognizing signs of avoidant/restrictive food intake disorder (ARFID) and
making appropriate referrals with collaborative treatment as needed;
referring the patient to other professionals as needed to rule out other
conditions, determine etiology, and facilitate patient access to comprehensive
services;
recommending a safe swallowing and feeding plan for the individualized family
service plan (IFSP), individualized education program (IEP), or 504 plan;
educating children and their families to prevent complications related to
feeding and swallowing disorders;
serving as an integral member of an interdisciplinary feeding and swallowing
team;
consulting and collaborating with other professionals, family members,
caregivers, and others to facilitate program development and to provide
supervision, evaluation, and/or expert testimony, as appropriate (see ASHA’s
resources on interprofessional education/interprofessional practice [IPE/IPP]
and person- and family-centered care);
remaining informed of research in the area of pediatric feeding and swallowing
disorders while helping to advance the knowledge base related to the nature
and treatment of these disorders; and
advocating for families and individuals with feeding and swallowing disorders
at the local, state, and national levels.
• SLP will consult the nursery staff, caregivers and other members of the
medical team to gain insight to determine the infant’s readiness to feed
orally.
• SLP performs a battery of assessment tools available to assess breast
feeding, bottle feeding, and sucking skills.
• SLP also assess respiratory rate, heart rate, suck-swallow-breathe
coordination, quantity of intake, and infant positioning
• SLPs must develop intervention strategies that are appropriate for the
infant’s medical condition, behavioral status, swallowing competencies
and most importantly, their overall safety.
• SLPs often use a combination of intervention techniques to enhance oral
motor skills and to improve the coordination of suck-swallow-breathe
• To conclude, the role of swallowing therapist is to
• identify safe swallowing strategies
• including optimal diet
• to teach is to caregiver
• to monitor caregiver on the same
• to improve or compensate for patients abnormal neuromuscular for
swallowing.