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Feeding, Speech, and Mouth Function in Pediatrics
Some Workshop Thoughts
Welcome to the course and THANK YOU for attending
Turn cell phones to “off” or “vibrate”
Use restrooms as needed, and make yourselves comfortable
throughout the presentation
Limit side-talking during the presentation
Questions, thoughts, ideas are welcome at designated times
 Write these down for yourself
 If we don’t address your questions during the workshop,
please feel free to contact me
Chewy Tubes for this workshop donated by Mary Shiavoni
and John Cushing of Chewy Tubes (www.chewytubes.com)
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Treatment of Feeding, Speech,
and Mouth Function in Pediatrics
Diane Bahr, MS, CCC-SLP, CIMI
[email protected]
www.agesandstages.net
702-875-2888
2
Speaker Disclosure

Financial: Diane Bahr is
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The author of the two books Oral Motor Assessment and
Treatment: Ages and Stages and Nobody Ever Told Me (Or
My Mother) That! Everything From Bottles and Breathing To
Healthy Speech Development for which she receives royalty
payments and
The co-owner of Ages and Stages®, LLC for which she is
paid.
Nonfinancial: Diane Bahr is a volunteer board member for the
Oral Motor Institute Study Group, a volunteer consultant for
Future Horizons, Inc., and a member of ASHA, IAIM, & AAMS.
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[email protected]
1
Who is Diane Bahr?
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Public school SLP
School for the Blind
SLP
Brain injury SLP
University SLP
Private practice SLP
Author/Instructor
Sibling
4
Who Are You?
Who Do You Work With?
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Therapists-OT, PT, SLP?
Educators?
Early Interventionists?
Nurses/Doctors/LCs?
Psychologists/Social
Workers/Behavioral
Therapists?
Dental Professionals?
Others?
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Infants and
Toddlers?
Preschool-Age?
School-Age?
Adolescents?
Adults?
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Part 1: Beginning to Solve the Feeding,
Speech, and Mouth Function Puzzle
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Key assessment
concepts
Problems we treat
Useful anatomy and
physiology
Typical face and
mouth development
Health problems our
clients encounter
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[email protected]
2
Nobody Ever Told Me (or my Mother) That!
Everything from Bottles and Breathing to
Healthy Speech Development
Creative Child
Magazine
2010
Top Choice
Award
Sensory World, 2010
7
Key Oral Sensory-Motor
Assessment Concepts
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Case history and
assessment for:
Body and mouth
Eating and drinking
Oral motor tasks
Speech production
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Oral Sensory-Motor
Problems We Treat
http://www.wallstreetotc.com/picky-eating/219870/
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Oral Defensiveness
Long-Term Pacifier
Use/Thumb Sucking
Excessive Mouthing
Tooth Grinding
Drooling
Feeding Delays and
Differences
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Picky Eating
Nutrition Concerns
Speech Delays and
Differences
Tongue/Lip/Buccal
Ties
Cleft Lip/Palate
Others
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[email protected]
3
Populations We Treat
Chap. 10 (See charts and lists)
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Children born prematurely, pp. 322-326
Children with
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Down syndrome, pp. 326-332
videos
Autism, pp. 332-340
Cerebral palsy, p. 340
Hearing loss, p. 341
Other developmental delays, pp. 341-348
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www.pinterest.com
USEFUL ANATOMY AND
PHYSIOLOGY
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Mandibular Depressors
12
[email protected]
4
Mandibular Elevators
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Intrinsic Tongue Muscles
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Extrinsic Tongue Muscles
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[email protected]
5
Don’t Forget the Buccinator,
Orbicularis Oris, & Mentalis
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Which Child Likely Has Better Orbicularis
Oris & Buccinator Musculature?
www.today.com
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Movement is Developmental
and Rhythmic
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Straight planes
(anterior- posterior)
Lateral planes
Diagonal planes
Rotation
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[email protected]
6
Underlying Processes in
Sensory-Motor Function
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Sensory processing
for feeding, speech,
and mouth function
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Vestibular system
Tactile and
proprioceptive systems
Olfactory and
gustatory systems
(feeding)
Auditory and visual
systems
http://en.calameo.com/books/
00409901094ea315ee9b3
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Muscle function and
motor planning
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Adequate muscle tone
and strength
Dissociation and grading
of movement
Dynamic stability
Direction, timing, and
coordination of
movement
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Taste and Smell Work Together
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Motor Control and Sensory Processing
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[email protected]
7
Senses, Integration, & End Products
22
Typical Oral Development
(Chaps. 1 & 8)
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Newborn baby vs. adult mouth and
throat (pp. 3-11)
Infant mouth reflexes (pp. 11-17)
Typical face and mouth structure
(pp. 277-282)
Mouth development problems
(pp. 282-289)
Face, mouth, and vocal development
through adolescence (pp. 289-307)
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Newborn Baby vs. Adult
Mouth and Throat, p. 4
Drawings developed by Artist Betsy True for Suzanne Evans Morris who
granted permission for their use.
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[email protected]
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The Newborn Baby’s Structure
& Function, pp. 5-11
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Small open space
within mouth
Small, slightly retruded
lower jaw
Hard palate wide “U”
shape
Hard palate still
flexible/moveable
Tongue fills mouth at
rest
Tongue deeply cupped
when suckling
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Gums enlarge to assist
with latch
Sucking pads in cheeks
Nose breathing
Mouth and throat
structures close
together
Eustachian tube
horizontal
Larynx high in the neck
area
Drawing
developed
by Artist
Betsy True
for Suzanne
Evans
Morris who
granted
permission
for its use.
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Infant Mouth Reflexes
pp. 12-17
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Rooting
Suckling
Tongue
Swallowing
Bite
Transverse tongue
Gag
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Compare Anthony’s Structure as a
Newborn (p. 3) to Kate and Shani
Video: Kate and Shani at 1 month
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[email protected]
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Mouth and Facial Features
Changing Significantly, p. 276
Anthony at birth
Anthony at 4 months
Anthony at 6 months
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Appearance from Front and Side
(By Age 6 Years), pp. 278-279
Artist: Anthony Fotia, Sr.
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Front and Side Views
pp. 277-281
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Front
Eye area width: Approx.
1 eye x 5
Center eye corners line
up with widest part of
nose
Face has appearance of
equal thirds
Top and bottom jaws
align
Straight lip line
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Side
Bridge of nose in line with
philtrum and chin
Angle of nose and
philtrum 90-110 degrees
Top teeth slightly in front
of bottom teeth
Goniometer
[email protected]
30
10
Face, Mouth, and Vocal Development
Birth – Adolescence, pp. 289-307
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Birth to 2 years: Most significant period of
face and mouth development
3 to 7 years: Gradual growth of mouth, face,
and head continues (adultlike vocal tract by
age 4)
7 to 10 years: Growth spurt in lower face
10 to 18 years: Jaw, tongue, and lips
continue to grow (gender specific)
http://www.istockphoto.com
/photos/adolescent
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Jaw and Tooth Development
Go Together, p. 302
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5 to 6 months: First
teeth
By 24 to 30 months:
All primary teeth
6 to 14 years: All
permanent teeth
except wisdom teeth
17 to 25 years:
Third molars
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What You Want to See in
Tooth and Jaw Development
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Significant jaw growth in the first two
years, particularly the first year
Teeth emerging as part of jaw
development
 On time
 In a regular sequence
 Fully formed
Lip and tongue
http://www.vdh.state.va.us
development/movement following jaw
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development/movement
[email protected]
11
There is Something to be Said
about Heredity
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Anatomic Problems Impacting
Mouth Development
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Tongue tie (pp. 22-23)
can inhibit:
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Breastfeeding
Placement and
collection of bolus
Oral hygiene
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Brian Palmer, DDS
Lip and Buccal
restrictions can also
inhibit feeding
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Terms: Restricted
Frenum, Frenulum,
Tethered Oral Tissue
(TOT)
Clefting (p. 348),
need to address:
 Scar tissue
 Lips
 Palate
 Intraoral
pressure
problems
and/or fistula
Mayo Clinic
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Mouth Development Problems
pp. 282-289
Problem
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High, narrow palate
Underbite, cross-bite,
closed bite, trismus, high
jaw position
Overbite, overjet, anterior
or lateral open bite
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Possible Cause
Low tongue resting posture
Jaw weakness or imbalance
Some form of tongue
thrust swallow
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https://elements
ofmorphology.nih
.gov
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Immature/Unsophisticated
swallow
Exaggerated tongue
protrusion
Reverse swallow
[email protected]
36
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Oral-Facial Illustrations and
Reference Guide (Boshart, 1999)
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Let’s Compare These Faces
and Oral Movements
Greta and
Gordie Video
Brian Williams
Campbell Brown
Ryan Seacrest
Al Roker
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What is Going On in the Jaws of
Marlon, Jay, Greta, & George?
39
[email protected]
13
Typical Tongue Resting
Posture, p. 289
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Are your lips together
at rest?
Does the front of your
tongue rest against the
ridge behind your top
front teeth?
Is your tongue lightly
suctioned against your
palate?
OMT Materials, 1994
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Normal Swallow Sequence
OMT Materials, 1994
Products of
William E.
and Julie
Zickefoose:
http://www.
oralmyofunct
ional.com/
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Typical Oral Phase
Swallow p. 286
http://www.slideshare.net/shilpa_prajapati/training-for-feeding
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Does your tongue gather food or liquid into the
center?
Is your tongue cupped with the sides of your
tongue sealing against the sides of your hard
palate?
Does your tongue tip contact the ridge behind
your top front teeth to start the swallow?
Does the rest of your tongue move in a front-toback wavelike motion to carry the food or liquid
to the back of the mouth for the swallow?
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[email protected]
14
Symptoms of Tongue Thrust
Swallow, pp. 282-289
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Low tongue resting
position
Overfilling mouth
Dipping and sauce use
Cracker test failure
Excess lip tension
Poor jaw muscle
movement (masseter
& mylohyoid muscles)
Problems saying “r, l,
s, z, sh, ch, and/or j”
Detrimental oral habits
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We May Look for Tongue Thrust in
Brokaw and Walters Based on
Articulation, but What is the Difference?
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Detrimental Oral Habits
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Chronic chewing or
sucking on fingers,
fingernails, straws,
pens/pencils, tongue,
other items
Consider systematic jaw
work to replace
detrimental oral habits
Give hands something to
do (e.g., stress ball, fidget)
Apply consistent and
appropriate behavioral
techniques
StopBitingNails.com
45
[email protected]
15
How to Promote Good Mouth
Development from Birth
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Nose Breathing and Belly Time
Attention to Respiratory and
Gastrointestinal Problems
Appropriate Mouth Experiences
Appropriate Feeding Experiences
Appropriate Vocal Interactions
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Nose Breathing, pp. 54-56
Important for All Ages
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Supports:
 Mouth/nasal shape
 Oxygen absorption in
body and brain
 Immune system
function
 Metabolism
 Body movement
Reduces stress response
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Belly Time & Other Positions
when Awake pp. 56-59
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video
Helps develop muscles
of neck, back, chest,
abdomen, shoulders,
etc.
Provides sensory
experiences
Needed for development
of respiration and body
movement
48
[email protected]
16
http://www.telegraph.co.uk/news/health/news/1
1005559/Fear-that-reflux-treatment-for-babieswill-be-denied-under-new-Nice-guidance.html
Relationship to Structure, Sensitivities, and Reflux
COMMON HEALTH PROBLEMS
POSSIBLE TREATMENTS
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Possible Allergy-Related
Issues, pp. 60-65
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Excessive spit-up/reflux
Excessive diarrhea
Excessive constipation
Food sensitivity or allergy
http://www.lifemartini.com/preventions-forRashes or eczema
skin-rashes-in-infants/
Hay fever and other environmental
allergies or sensitivities
Feeding problems
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Tracking Allergies and Sensitivities,
pp. 63-65
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Food diary
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Date
Symptom seen
What baby/child
ate/drank
What mother
ate/drank if
breastfeeding
What change made
http://www.gettyimages.com
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Log sheet to track possible
allergens/sensitivities
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Date
Symptom seen
Change made
Improvement noted or
not
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[email protected]
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Possible Resulting Respiratory
Problems, pp. 66-71
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Upper
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Stuffy or runny
nose
Sinus concerns
Snoring
Frequent colds
Mouth breathing
Middle ear
problems
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Lower
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Wheezing or
asthma
Hoarse or wetsounding voice
Persistent croupysounding cough
Frequent
pneumonia
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Log Sheets to Track Health
Issues, pp. 70-71, p. 197,198
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Tracking health problems
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Date
Change made
Did it work?
Food/Fluid record,
eating/drinking patterns
Bowel Record Chart
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http://www.childhoodconstipation.com
/Documents/Extra_Documents/BowelC
hart.pdf
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Allergies and Sensitivities
pp. 71-79
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Symptoms in utero (p. 71)
Infant symptoms (p. 72)
Toddler symptoms (p. 74)
Most common food allergies
and sensitivities (pp. 77-79)
Most allergenic and sensitizing foods
Least allergenic and sensitizing foods
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[email protected]
18
Reflux, SIDS, Back-to-Sleep
pp. 79-82
Sudden Infant Death Syndrome
(SIDS)
 Potential connection to reflux
and growth in vocal tract
 Most common birth to 1 year
http://www.healthybabiesjacksonville.org/fear-ofaspiration/
 Peak at 2 to 4 months of age
Back-to-sleep
 Moro/Startle response
 Babies do not sleep as deeply
Pacifier use for reflux & to avoid SIDS
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Reflux (Excessive Spit-Up)
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Possible causes of reflux
 Weakness or laxity in lower
esophageal sphincter (LES) –
Belly time when awake is
crucial
 Overfeeding (even slightly)
Health problems related to reflux
 Torticollis (wry neck)
 Ear and sinus infections
 Asthma
 Voice disorders
http://www.infantfeeding.info/reflux.htm
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Apparent Increase in Allergies,
Sensitivities, & Reflux?
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Dr. Stephen Edelson (2003) said:
 Children “absorb pollutants more readily than
adults, and retain them in the body for
longer periods of time.”
 “Toxic chemicals can easily disrupt the
developmental processes.”
 Sensitivities/Allergies result in abnormal
immune system reactivity to food, chemicals,
bacteria, or inhalants.
Food supply and environment contain more
toxins and chemicals than in past generations
57
[email protected]
19
What about Vaccines?
pp. 82-83
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We need vaccines, so we don’t have epidemics.
However, some doctors question and consider:
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Could a vaccine overload an already stressed immune
system?
More vaccines are routinely given than in the past
beginning with hepatitis B (at birth)
Some vaccines are grown on skin cells of baby chickens
(MMR, flu)
Could a different schedule of childhood vaccinations make
a difference?
Can vaccines be individualized using blood titers?
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Part 2: Adding Pieces to Solve the Feeding,
Speech, and Mouth Function Puzzle
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The hand-mouth
connection
Detrimental oral habits
Teething and drooling
Appropriate oral massage
Appropriate jaw, lip, and
tongue activities
Appropriate respiratory
activities
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THE HAND-MOUTH
CONNECTION
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[email protected]
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Early Hand-Mouth Connection
pp. 86-91
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Hand-Mouth
reflexes from birth
(pp. 86-88)
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Palmomental
Babkins
Grasp
Hands at midline
during feeding
(pp. 89-91)
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The Importance of Good Mouthing
Experiences, pp. 91-108
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Generalized mouthing
(birth to 4-5 months),
pp. 93-97
Discriminative mouthing
(begins 5 to 6 months),
pp. 99-101
True mouth play (9 to 24+
months), pp. 101-108
videos
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What is the Problem with Most of
These Infant Mouth Toys?
Too large for chewing at the back molar area and oral discrimination
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[email protected]
21
More Appropriate Items for
Mouthing and Chewing
Baby
Grabber
ARK
Tri-Chews (Beckman)
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Anthony is Using his Chewy Tube
with Supervision at 6 months
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Which Toys Encourage More
Sophisticated Oral Movement?
Anthony – 12 Months
66
[email protected]
22
Oral Stereognosis Test for
Older Children and Adults
Oral Stereognosis is the ability to recognize and discriminate forms within the mouth.
Oral Discrimination is needed for eating, drinking, speaking, and oral hygiene.
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PACIFIER, THUMB, OR FINGER
SUCKING; AND EXCESSIVE
MOUTHING, PP. 108-115
68
Pacifier Types
www.new-vis.com
www.amazon.com
69
[email protected]
23
Pacifier Use and Weaning
p. 111 (Chart)
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Pacifier needs to fit mouth
Birth to 5 or 6 months: As
needed to calm
6 to 10 months: Just
before sleep, replace with
appropriate mouth
activities
Discontinue after 10
months to avoid middle
ear problems
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Breaking Pacifier and Thumb
Sucking Habits, pp. 111-115
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Begin early (at 5 to 6 months)
Help child replace sucking with appropriate mouthing and
chewing activities/toys (Weaning Summary, p. 113)
Older child (Carefully modify pacifier, use reason/plan)
Use consistent behavioral techniques:
 Ignore the problem behavior when possible
 Positively reinforce the desired behavior
consistently/constantly at first
 Positively reinforce the desired behavior intermittently as
it becomes more consistent
 Avoid punishment when possible
71
Excessive Mouthing and Tooth
Grinding, pp. 148-149
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Use consistent behavioral
techniques to develop new
habits
Oral massage may help
Systematically replace habit with
appropriate hand-mouth activity
 Sips from cup, straw, water
bottle
 Systematic jaw work with
exercisers/gum/food, etc.
 Blowing bubbles/horns
72
[email protected]
24
Start by Looking at How the Child
Uses the Mouth during Mouthing
• Is the child chewing at the back molar area?
• Is the child using generalized or discriminative mouthing?
73
Teething & Drooling
pp. 115-121
imother.wordpress.com
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Birth to 24 months: Drooling observed with
teething, as well as, gross motor and fine
motor development
Profuse drooling is never typical/normal
Teeth begin to erupt at 5 to 6 months of age
Most primary teeth have emerged by 24
months
74
Drooling Management is a
4-Part Process, pp. 120-121
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Upper airway concerns
Oral sensory concerns
Jaw concerns
Swallowing every 30
seconds
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ENT/Dental management
Oral massage/experiences
Jaw strengthening,
stability, and grading
Time and encourage
swallowing (thermal
gustatory stimulation, sips
of liquid, etc.)
75
[email protected]
25
Systematically Applied Oral Massage
Can: (pp. 125-136)
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Decrease defensiveness
Increase awareness
Reduce gagging and
tonic bite
Help satisfy oralseeking behaviors
Be part of a toothbrushing routine
videos
76
General Oral Massage Concepts
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Make environment conducive
(e.g., routine song,
appropriate lighting)
Approach carefully and
systematically
Consider use of vibration if
child is defensive
Use intuition, and sense mood
Make child and parent part of
the process
77
Just a Few Possible Oral and Facial Massage
Tools (Must be Safe for Oral and Facial Use)
ARK
This image cannot currently be display ed.
78
[email protected]
26
Why Has Exercise Historically
Been Part of Our Treatment?
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Oral/Respiratory/Vocal
To whom would you
exercise works on:
rather teach the complex
 Dissociation of movement
movements of tennis?
 Grading of movement
Someone who is “in
shape” or someone who  Direction of movement
is not?
 Strength is only part of the
Why would the complex
picture
movements of the mouth  Exercise does not
be any different?
automatically improve
Oral exercise gets the
eating, drinking, or
mouth “in shape” if it is
speaking (different motor
out of shape.
plans)
79
Systematic Jaws-ercise
pp. 136-147
www.new-vis.com
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Works on:
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Graded jaw elevation
and depression
Jaw alignment
Tongue retraction
Tongue lateralization
(if work from front to
back teeth)

Can help resolve:

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Excessive mouthing
Tooth-grinding
Long-term pacifier
use or thumb
sucking
Other detrimental
oral habits
Open mouth posture
80
Jaw Exercise at Back
Molar Area, pp. 142-147
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Place jaw exerciser at back
molar area from the side
Look for jaw alignment
Work toward 12-15 solid
and graded chews on each
molar surface
Work toward 3 sets
alternating sides
Be sure chewing item does
not hyperextend jaw
[email protected]
videos
81
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Jaw Support
pp. 159-160
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Jaw support is a
partner dance
Appropriate jaw
movements lead to
appropriate lip and
tongue movements
Never force the child’s
jaw in any direction

From front, use
nondominant hand


Index finger under
chin bone, thumb
on chin bone
Thumb and index
finger along
jawbone
82
Tools Developed Specifically
for Jaw Work
ARK Therapeutic Services, Inc.
83
A Few Other Possible Jaw Exercise
Tools (Need to be Safe for Oral Use)
Chewing Gum & Dried
Fruit
Stretchy Tubing
(Super Duper)
Use bite-sized pieces of food or appropriately-sized tool for person’s jaw
[email protected]
84
28
Working with Jaw Sliding and
Trismus



Position tool into
the front of the
mouth
Work for aligned
jaw elevation and
depression
Work for
appropriate range
of motion
Talk Tools Jaw Exerciser
TheraBite System
85
Jaw Programs

Jaw Program Complete: Sara Rosenfeld-Johnson,
TalkTools

Jaw Rehabilitation Program: Mary Schiavoni, Chewy
Tubes
86
Myomunchee to Facilitate Jaw and
Tooth Alignment (prescribed by
orthodontists and dentists)



Can decrease bruxism,
clenching, TMJ problems
Can be used with
children ages 2 to 5
years and as an
alternative to braces
Promotes nose breathing
and typical swallow
http://www.teethperfect.com/
87
[email protected]
29
Palatal Expansion Used with Children
and Adults to Improve the Airway




Orthotropics – Dr. John
Mew
Rapid Palatal Expansion
(RPE) still in use
Daytime-Nighttime
Appliance System (DNA) –
Dr. Dave Singh
ALF (Advanced Lightwire
Functionals) – Dr. Darick
Nordstrom
www.blodgettdentalcare.com
88
Working the Lips and Buccinators
in Protraction and Retraction


Alternate
between the
speech sounds
“oo” and “ee”
The Pediatric
Facial Flex (can
be difficult for
some children)
89
Iowa Oral Performance Instrument
(IOPI Medical)




Lip compression
Tongue elevation
and lateralization
Hand strength
Has been used in
research related to
swallowing and
speech intelligibility
Developed by: Erich Luschei and
Don Robin
[email protected]
90
30
Tools to Facilitate
Tongue Movement
by Luz Arias
www.arktherapeutic.com
Tongue Tip Lateralization & Elevation
Tools – Talk Tools
OroNavigator - ARK
91
Ora-Light Tools to Facilitate
Tongue Placement (Kapitex)
92
Other Items to Encourage Appropriate
Tongue Movement





Cake Icing in a Tube (Sweet
and/or Tart)
Cake Decos/Confetti
Sweet Taste on Chewy Tube
(Working from Front Teeth to
Back Molar Area)
Frozen Yogurt in Half Straw
(Rosenfeld-Johnson,
Overland)
Speech Sounds (e.g., “t,” “d,”
“n,” “k,” “g,” “ng”)
93
[email protected]
31
http://www.iaom.com/index.html
http://www.aamsinfo.org/
To correct resting tongue position/posture and any form of tongue
thrust, immature, or unsophisticated oral phase swallow
OROFACIAL MYOFUNCTIONAL
TREATMENT
94
Orofacial Myofunctional Programs


Smile Program by Robyn
Merkel-Walsh (ages 7-12),
TalkTools
Swallow Right (Roberta Pierce)
Adult & Child Programs
 Stage 1: Muscle Training
 Stage 2: Swallow Training
 Stage 3: Habituation
 Recheck period
95
Compare Daniel to the Young
Woman Locating “The Spot”
Orthodontic Elastics
96
[email protected]
32
Franklin Susanibar
& Cynthia Dacillo
Evaluates structure
and function of
• Body
• Face
• Mouth
• Breathing
• Voice
AIRWAY AND
RESPIRATORY WORK
97
What Happens When You Blow
Horns/Bubbles?, pp. 149-150





Pretend you are blowing a bubble or
horn
Place your hand on your abdomen and
diaphragm (what do you feel?)
Where is your jaw?
Where is your tongue?
What are your lips and cheeks doing?
98
Systematic Horn Play
pp. 151-152

Horn



Blow easy horns
together for longer and
longer (horn races)
Work toward 12-15
toots/blows
Take turns with
imitation (2 toots, 3
toots, etc.)
Anthony, 12 months
[email protected]
99
33
Systematic Bubble Play
pp. 152-153

Bubbles
Blow bubble and catch on
wand
Bring bubble to child’s lips
Help child move or blow
bubble (“h” sound, lip
rounding)
Work toward 12-15
repetitions
Blow bubbles at targets





100
M.O.R.E.
(Oetter, Richter, & Frick)



Suck/Swallow/Breathe
Synchrony
Treatment Principles and
Activities
Therapeutic Toys and
Activities






Whistles
Kazoos/Music Makers
MORE Exercisers
Bubbles
Blowers
Infant/Toddler Toys
Schylling
Ambi
Trumpet
Stretchy Tubing
Super Duper
Straw and
Cotton Balls
www.littlekidsinc.com
101
Horn Blowing Hierarchy
(Sara Rosenfeld-Johnson, Talk Tools)
Oral Placement Therapy for
Speech Clarity and Feeding
102
[email protected]
34
Other Tools for Working on
Graded Air Flow
Nasal Mirror
Nose Clip
www.scielo.br
See Scape
The Breather
sig16perspectives.pubs.asha.org
Incentive Spirometer
103
Connection between Oral
Sensory Input and Attention



Sucking: Pacifier,
bottle, breast, straw,
sips from cup
Chewing: Food,
mouth toys, Chewy
Tubes, Grabbers, YChews, gum
Blowing: Bubbles,
horns
104
Part 3: Putting the Feeding,
Speech, and Mouth Function
Puzzle Together


Treatment session
Feeding






Breast/Bottle feeding
Spoon feeding
Cup and straw drinking
Food and liquid
progression
Picky eating/drinking
Typical feeding
development




Speech and
communication
development
Components of intelligible
speech
Speech treatment
If time allows



Auditory processing
Teamwork
Resources
[email protected]
105
35
Possible Components of a
Treatment Session
Gross motor activity (brief)
Oral massage/facilitation
(1 minute)
 Specific oral sensory-motor
activities/exercises (1 minute,
well chosen, as breaks, keeps
mouth engaged)
 Feeding activities (focus of
session)
 Specific speech and
language/cognitive activities
(focus of session)
(Bahr, Allyn & Bacon, 2001, p. 98)


106
Gross Motor/Sensory Room
(Loyola College in MD)
Nicole – Age 5 Yrs.
107
Session
Suggestions
www.autismbd.com









Predictable, yet flexible (e.g., PECS, schedule board, etc.)
Small changes in routine over time
Use of choices (appropriately limited) as much as possible
Combination of alerting and calming activities
Make visual/auditory environment conducive (e.g., routine song,
appropriate lighting)
Approach client carefully and systematically
Use vibration judiciously
Use intuition and sense mood
Keep child’s hands engaged in process when possible (hand-mouth
connection)
108
[email protected]
36
Session Modifications







Counting seconds (one one-thousand,
two one-thousand, etc.)
Metronome (set at 60 beats per
minute to count seconds)
Visual timer
Add speech sound production for
interest (if child can handle it)
Token economy
Social stories (children with ASD and
others)
Videos as a teaching tool
109
More Session Modifications





Keep it simple but
interesting
Find child’s best pace
Systematically vary
stimulation (picture, word,
pacing board, beat on
drum, stomp feet)
On-Task sheets
Brief sensory/movement
breaks (e.g., carefully
chosen mouth activities)
On-Task Sheet
Name:
Date:
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
5
6
6
6
6
6
6
6
6
6
6
7
7
7
7
7
7
7
7
7
7
8
8
8
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
9
9
10
10
10
10
10
10
10
10
10
10
110
Creating an Appropriate
Visual Environment




Appropriate lighting
Appropriate room color
(neutral)
Use of color and contrast in
learning activities (“Children
tend to prefer intense primary
colors,”SenseAbilities, p. 25)
Eliminate visual clutter
Visual Clutter
111
[email protected]
37
Use of Music to Create an Appropriate
Auditory Environment (new-vis.com)




Quiet, Centering Music
Superlearning/Folk
Music
Metamusic
Some Rock Music

Marvelous Mouth Music
Time to Sing
Silly Songs

Some Drum Music


112
Important Mouth Characteristics Infant Feeding, pp. 24-25 (Chart)
http://themilkmeg.com







Small jaw movement once latched
Tongue cupping/grooving
Even, front-to-back wavelike
tongue movement
Tongue is “just” over lower gum
A good latch
Draws liquid easily from breast or
bottle
Good feeding rhythm
http://breastfeeding.support
Laid-Back Position
113
Best Positioning for Feeding,
pp. 28-29 (Chart)



Head, neck, and body
aligned
Ear at least slightly
above mouth during
bottle-feeding (body at
45 degree angle +)
Body in a correct laidback, cradle, crosscradle, side-lying, or
football hold during
nursing
[email protected]
video
114
38
Just a Few Advantages of
Breast-Feeding, pp. 29-31
www.telegraph.co.uk




Breast drawn deeply into mouth to help
maintain palate shape
Alternating breasts stimulates/
exercises both sides of face, head,
and body
Better face, jaw, palate, tooth, and
speech development (balanced
intraoral pressure)
Supports suck-swallow-breathe
synchronization, fewer respiratory
problems
Cradle hold
Video
What problems do
you see in this
video?
115
Choosing the “Right” Bottle
Nipple, p. 34 (Chart)

Problem




Baby’s tongue does
not cup around the
bottle nipple
Bottle nipple moves
in & out of the
baby’s mouth
Bottle nipple moves
in & out of mouth
with cheek support
Things to try



Choose a
rounded nipple
Carefully apply
cheek support
Nuk Orthodontic
Playtex Nurser
Try a shorter or
different nipple
Mam
Latching Problems
p. 36 (Chart)

Lips not latched on
flared part of bottle
nipple


Carefully apply cheek
support
Check nipple length

116
Check for tethered oral
tissues (tongue, lip,
buccal ties)
Baby not properly
latched onto breast


Try “Dancer” hold
Try modified
“Dancer” hold if
using cradle/crosscradle or side-lying
www.lllc.ca
[email protected]
117
39
Flow Problems
pp. 38-39 (Chart)

Milk let-down too
fast during breastfeeding



Feed in more upright
position
Work with lactation
consultant (IBCLC)
Low milk supply





Work with a lactation
consultant (IBCLC)
High-pitched,
gulping sounds
during bottle
feeding
casa.colorado.edu
video
Slow flow or
variable flow nipple
Paced bottle feeding
Bottle flow too slow

Faster flow or
variable flow nipple
118
Paced Bottle Feeding,
p. 26
https://www.lactationtraining.com/






Stroke baby’s lips with bottle nipple
Roll the bottle nipple into baby’s mouth when
open and baby ready to feed
Break after 4 to 5 sucks/suckles by … tipping
bottle (Newborn)
Use a slow-flow nipple
Keep baby upright and bottle more horizontal
Follow baby’s hunger cues to avoid overfeeding
119
There are So Many Bottles
Typical
Special Needs
Medela
Bionix
Playtex
Dr. Brown
Tommie Tippee First Years
[email protected]
Born Free
Nuk
120
40
Nutrition and Hydration (Satter,
Morris, Klein), pp. 41-45

Baby body
language, pp. 43-44




Ready to eat, take a
break, full
Bottle-feeding
amounts, p. 44
Dehydration
symptoms, p. 45

Infants require 1 ½
ounces of fluid per
pound of body
weight per day
Children should
drink 2/3 of body
weight in ounces
each day
121
Birth to 6-Month Feeding
Highlights, pp. 46-51
everydaylife.globalpost.com




6-month-old
1 month: Uses both suck and suckle
2 to 3 months: Longer suckling/sucking
3 to 4 months: Three dimensional suck
developing, sucking pads shrinking
4 to 6 months: Mouth and digestive
system getting ready for cereals, pureed
foods, soft baby cookies, etc.
122
Appropriate Feeding Experiences
(from birth), Chaps. 2 & 6



Only bottle (ear above mouth) and/or breast
feeding (birth until 4-6 months)
Spoon, open cup, and straw introduction
(around 6 months)
Soft baby cookie and food texture increase
Anthony at
(beginning around 6 months)
6 months
123
[email protected]
41
Positioning for Higher-Level
Feeding Activities, p. 159 (Chart)




Prior to 6 months or
“sitting up:” Stable
infant seat at 45 to
90 degree angle
Stable high chair or
Tripp Trapp type
chair with footrest
Eye level feeding
Jaw support
124
Some Chairs to Encourage Appropriate
Postural Stability and Control
Tripp Trapp
Rifton
Keekaroo
Svan Signet
125
Children Often Have Postural Issues that
Require More Than a Good Chair




Semi-Reclined (chair,
bean bag chair, or
hammock swing)
Bench or telephone
books wrapped in
duct tape
Wedge or other chair
insert
Therapy ball, peanut,
bolster
Bench
Movin’ Sit
126
[email protected]
42
Spoon-Feeding,
pp. 160-166

Natural method






Spoon with small, flat bowl
fitting lips
Reasonable amount of food
on spoon
Closes lips on spoon
Spoon removed in level
manner
Good feeding rhythm
Watches parent eating
from spoon
videos
127
Side-to-Side Spoon Feeding,
Other Spoon Feeding Methods
Michael – 9 Months
128
There are Many Spoons
NumNum Dipper Spoons
Z-Vibe Spoons
E-Z Spoons
Lip Closure Spoons
Textured Spoons
129
[email protected]
43
Spoons for Self-Feeding
Weighted
RoscheOuten
Easie
Eaters
Less Mess
Lightweight Foam
Handles
130
Anthony Taking Turns/Self-Feeding
with Spoons at 12 months
131
What Does Carmen’s Pattern with
the Spork Demonstrate?
132
[email protected]
44
Open Cup-Drinking
pp. 166-171




Open cup fitting mouth
Open cup rim placed on
bottom lip (not tongue)
One sip at a time,
moving from thickened
to thin liquid (unless
want to begin with thin
liquid)
Consecutive swallows
Anthony –
6 Months
Michael –
9 Months
133
Natural Thickeners





Stage one baby food,
thinned with water
Baby cereal in formula or
milk-like products
Instant mashed
potatoes/bread crumbs to
thicken soup
Applesauce in juice or nectar
Smooth yogurt in milk/soy
product, yogurt drink (check
with pediatrician)
134
Thickeners and
Thickened Liquids
Work with the child’s pediatrician and dietician.
Read the guidelines for each product to check age-appropriate use.
[email protected]
135
45
Getting Past the Cup Drought:
Should See Up-Down Jaw Movement
Flexi Cups
Infa Trainer
Independence
Drinkware
Doidy Cup
Reflo Cup
OXO
Playtex
Coolster
136
Possible Transition Cups:
Carefully Observe Jaw Movements with Spouted Cups –
Often See Front-Back Jaw Movement as with a Bottle
Nuby Super Spout
No Tip Cup
Flo-Trol Cup
Independence Drinkware
Q-Cup fit most
standard bottle
nipples – no
longer available,
was a good idea
137
Drinking From a Cup with a
Recessed Lid
Anthony (12 months) drinks from a
cup with a recessed lid and handles
Carmen (21 months) receiving a
little support with an Infa Trainer
138
[email protected]
46
Straw-Drinking
pp. 171-176
Anthony, 6 months




Initially learns to drink
from a straw bottle
Drinks from a straw
placed just on lips in
the center
Initially takes one sip
at a time
Drinks swallow after
swallow when
develops the skill
Anthony, 12 months
139
Straw Drinking with
Squeeze Bottle
Sauce or Other
Bottles Meant to
Hold Food or
Drink
Cut straw
to fit “just”
on the lips
as soon as
possible or
use a lip
bumper
Honey Bear (Talk Tools)
Cip-Kup (ARK)
140
What Does Carmen’s Pattern
with the Straw Tell Us?
141
[email protected]
47
Straw Drinking Hierarchy
(Sara-Rosenfeld Johnson, Talk Tools)
Oral Placement Therapy
for Speech Clarity and
Feeding
142
Some Straw Drinking Options
One Way
Munchkin
Straw Cup
OXO
Gravity Assisted
Sip Tip
143
More Straw Options
Lip Bumpers
Straw Holder
ARK
Talk
Tools
Bubble Tea
Straw
Clip
ARK
Spoon
Dixie Stir 5½"
7 ¾ x ¼"
8 x ½"
10 ¼"
10" Fat Black Artistic 7.5-13.5"
[email protected]
144
48
Taking Bites and Chewing
Foods, pp. 177-181



Baby bite-sized food
pieces in safe feeder or
cheesecloth
Move from front of
mouth to back molar
area as baby bites
12 to 15 chews on one
side then the other at
back molar area
Hansen
Kids
Feeder
Munchkin
Feeder
Baby
Safe
Feeder
145
Appropriate Foods and
Liquids???????????????
Can you believe these were actual ads?
146
Appropriate Foods and Liquids
pp. 181-182

Birth to 4-6 month



Breast milk
Formula
4-6 months



Nonwheat baby
cereal
Pureed fruits and
vegetables
Soft nonwheat baby
cookies
147
[email protected]
49
Who Has the Soft Cookie?
Anthony – 6 months
Michael – 9 months
148
Liquids pp. 182-183

6-8 months




OXO Tot
Baby Food
Mill


Milled/blended/wellmashed foods
Wheat-free soft
cookies/crackers
Cooked sticky rice
Sips of water and very
diluted fruit juice from
open cup, straw cup,
recessed lid cup
Formula, breast milk
7-10 months






www.nurturebaby.com
Chopped cooked
fruits/vegetables
Mashed foods
Soft cheese
Wheat and corn
products
Water, very diluted
fruit or vegetable juice
(open cup, straw cup,
recessed lid cup)
149
Liquids pp. 183-184

9-12 months








Soft, cut-up cooked and raw
foods
Soft, chopped meats
Casseroles
Bread, toast, crackers
Egg yolk (9 months), egg white
(1 year)
Cottage cheese, baby yogurt
Water, diluted juice (open cup,
straw cup, recessed lid cup)

12-18 months






www.mommygaga.com
Chopped table food
Soft meats including
fish (without bones)
Cookie, crackers
Milk, water, diluted
juice from open cup,
straw cup, recessed lid
cup
Bottle weaning
Breast feeding may
continue
150
[email protected]
50
Liquids pp. 184-185
www.trufflehead.com

18-21 months




Chopped table food
including many meats
and raw vegetables
Can bite through a
hard cookie or cracker
Water, milk, diluted
juices from open cup,
straw cup, recessed lid
cup
24 months





Bites through hard cookie
with ease
Can chew with closed lips
Mature biting and chewing
patterns
Actively uses lips on open
cup
Can hold open cup with
one hand without spilling
151
How Much Should a Child Eat?
pp. 186-188 (Satter, Morris, Klein)




http://portionsizematters.blogspot.com

Serving size = 1 tablespoon per
year of age
6 servings of rice, cereal, or
pasta per day
5 servings of fruits, vegetables
2 servings of meat, poultry,
fish, eggs, cooked beans
2 to 3 servings of milk, yogurt,
cheese
152
Weaning from Bottle and
Breast, p. 191 (Chart)

4-6 months

Introduce open cup




Anthony at
6 months

Formula/breast milk
Can thicken with
baby cereal if
pediatrician says OK
Stage-one baby foods
thinned with water
when pediatrician
says OK
Other appropriate
mouth activities
6-9 months



Continue open cup
experiences
Begin teaching straw
drinking with straw
cup and thickened
liquid
Provide other
appropriate mouth
activities
[email protected]
153
51
Weaning from Bottle and
Breast, p. 192 (Chart)

9-12 months




Formula, breast milk,
very diluted fruit or
vegetable juice,
water
Open cup, recessed
lid cup, straw
Provide other
appropriate mouth
activities
Anthony at
12 months
12-15 months




Bottle only at
nighttime before
bed, while sitting up
Can dilute milk in
bottle with water if
OK with pediatrician
Provide liquid
throughout the day
from straw or cup
Other appropriate
mouth activities
154
Feeding Delays/
Differences





videos
Lack of experience (Chaps. 2 & 6)
 Parent/Care Provider lacks information
 Child has significant sensory-motor delays
(important to keep “at risk” children “on track” as
much as possible)
Child does not eat enough, p. 194
Child wants to eat all the time, p. 194
Child is a “picky eater,” p. 195
Child has a tongue thrust swallow (Chap. 8)
155
This is How Some Foods May Seem
to Children with Sensory Concerns
156
[email protected]
52
The Curious Incident of the Dog in
the Night-Time (Mark Haddon, 2003)
These are Behavioral Problems stated by the fictitious
adolescent with ASD in this book:





Not eating or drinking anything for a long time
Not liking being touched
Not liking yellow things or brown things and
refusing to touch yellow things or brown things
Refusing to use my toothbrush if anyone else
has touched it
Not eating food if different sorts of food are
touching each other (p. 46)
157
Picky Eating, pp. 193-202
Consider:






Food tastes/textures introduced on schedule
Sensory preferences (taste, texture,
temperature, smell, color, shape, etc.), p. 198
Motor ability (mouth and body)
Reflux/GI/Nasal/Sinus problems
Food allergies/overexposure
Behavioral concerns
www.suggestkeyword.com
158
Systematic Approach
(Bahr, 2001, pp. 134-137; Bahr, 2010, p. 198)
159
[email protected]
53
Resolving Picky Eating,
pp. 193-202
www.epicurious.com








Three-day food record (minimum), p. 197
Look at child’s behavior and family eating patterns
Involve child in food shopping, selection, discussion,
and preparation
Resolve oral defensiveness (oral massage and oral
experiences, Chaps. 4 & 5)
Make small, systematic changes over time
Provide 10-15 opportunities for new foods and liquids
(also on pp. 185-186)
Do not force feed or use punishment
Use consistent behavior management
160
Let’s Get Kids
Shopping and Cooking
healthykidstoday.org
161
Helpful Books and Materials
for Parents
Tania Stegen-Hanson
& Lori Ernsperger
Katja Rowell &
Jenny McGlothlin
Nimali Fernando
& Melanie Potock
Ellyn
Satter
Melanie Potock
162
[email protected]
54
Feeding Development
from 5 to 24 Months
pp. 202-214
(Spoon-Feeding Highlights)






http://numnumbaby.us/
6-7 months: Holds mouth still for spoon; lips move
inward slightly when food on them
8 months: Upper lip removes food from spoon
9-10 months: Holds and/or bangs spoon, imitates
stirring
12-14 months: Begins to self-feed with spoon
15-18 months: Scoops food with a spoon
24 months: Has palm up when bringing spoon to
mouth
163
Feeding Development
from 5 to 24 Months
pp. 202-214
(Drinking Highlights)
https://www.youtube.com/watch?v=tcQWGSj7gpU





6-8 months: Can take single sips from an open cup
held by adult
6-12 months: Consecutive sucks from open cup,
recessed lid cup, or straw
12 months: Holds open or handled cup, and drinks
with some spillage
15-18 months: May bite on cup rim for stability
24 months: Can drink from an open cup without
spillage, no longer bites on cup rim
164
Feeding Development
from 5 to 24 Months
pp. 202-214 (Finger
Feeding Highlights)
tribecanutrition.com




6-8 months: Picks up food pieces with fist and can
hold a soft baby cookie
8-9 months: Can pass food from one hand to the
other
9-12 months: Begins to pick up food with thumb
and fingers
12-15 months: Can pick up food with thumb and
index finger
165
[email protected]
55
Feeding Development
from 5 to 24 Months
pp. 202-207 (Oral
Management Highlights)
www.casualclaire.com

6-9 months




Jaw movements begin
matching shape and size
of food
Lips and cheeks help
keep food in place
Tongue moves toward
food placed on side
gums
9-12 months




Diagonal rotary
chewing increases
Soft cookie stabilized
and broken off
Lips increasingly active
Food moved from
center of tongue to side
166
Feeding Development
from 5 to 24 Months
pp. 207-211 (Oral
doctorspiller.com

12-15 months




Can bite through a soft
cookie
Lip corners and cheeks
control food placement by
15 months
Tongue tip elevation to
alveolar ridge to initiate
swallow (intermittent at
first)
15-18 months



Coordinated diagonal
rotary chewing
Top front teeth remove
food from bottom lip as
lip moves inward
Tongue lateralization
increasingly
sophisticated
167
Feeding Development
from 5 to 24 Months
pp. 211-214 (Oral
Two-year-old children

18-21 months



Can bite through a
hard cookie with
difficulty
Can chew with lips
closed
Has good control of
swallowing

21-24 months



rainbowchildrens.com
Can bite through a hard
cookie with ease
Can chew with closed lips
using both diagonal rotary
and circular rotary chewing
Can easily move tongue tip
to place and collect food for
chewing and swallowing
168
[email protected]
56
Encouraging Vocal Development
from Birth, pp. 216-218





Vocalize with child
beginning at birth
Imitate baby’s
vocalizations
Use pacifier only for
calming, so child can
vocalize
Take vocal turns; wait
for baby to vocalize;
have pretend
conversations
Look at pictures & read
169
Speech Development
pp. 218-219



1 month: Vowel-like sounds
short “a” and long “e”
2-3 months: Up to 5 different
vowel-like sounds; consonantlike sounds “h,” “k,” and “g”
3-4 months: Babbling may
include “bababa,” “dadada,”
and “mamama”
1-month-old
www.newkidscenter.com
Anthony at 4 months
170
Speech Development
pp. 219-220



4-6 months: VC and CV syllables
developing; most vowel sounds
heard
6-7 months: Begins to imitate
two-syllable babbling; consonants
“p,” “b,” “w,” “t,” “d,” “m,” “n,”
“k,” “g,” “y” heard
7-9 months: Begins to string
vowels together in a sentence-like
manner
[email protected]
6-month-old
www.gettyimages.com
9-month-old
www.jenlavazza.com
171
57
Speech Development
pp. 221-223




9-12 months: Says first meaningful
words
12-15 months: Uses 5+ meaningful
words; imitates words has not said
15-18 months: Says 15-20
meaningful words; names 5-7
objects
18-21 months: Two-word stage
begins, but primarily speaks in
single words
12-month-old
www.babygaga.com
18-month-old
www.heidihope.com
172
Speech Development
pp. 223-225

21-24 months:




2-year old
parenting.blogs.nytimes.com
Uses 20+ words clearly and appropriately
Can say between 50 and 270 words
Uses full range of vowel, diphthong, and
consonant sounds in speech
2-3 years: Speech is clear and
understandable; speaks in 2 and 3 word
sentences
173
Speech
Development
pp. 225-226

3-4 years:



5-year-old
www.care2.com
5 years:


Speech more precise; simple sentences
Significant vocabulary increase
Uses adultlike language
6-8 years:


Speech sound production matures
Vocabulary continues to increase
174
[email protected]
58
Communication Development
Birth to Age 3, pp. 234-268



Babies communicate
from birth
Parents need to know
what to look for, so
they can recognize
and facilitate it
Therapists, educators,
pediatricians, and
others can help
parents do this
175
Essentials for Intelligible
Speech, pp. 227-234
Vowel sound production, pp. 227-228
Speech breathing, pp. 228-231
Intraoral pressure for speech, p. 231
Tongue retraction during speech, p. 232
Dynamic stability, dissociation, grading,
and direction of movement for speech,
pp. 232-233, p. 261
The hand-mouth connection for speech,
pp. 233-234






video
Dynamic bilateral
tongue retraction to
the top back molar
area during
co-articulated speech
– Sara RosenfeldJohnson
176
Vowels Require Significant
Jaw Grading


Front Vowels
 ē as in “eat”
 ĭ as in “it”
 ā as in “ate”
 ĕ as in “Ed”
 ă as in “at”
Mid Vowel
 Ә as in “up”

This person’s jaw
is NOT graded
Back Vowels
 ū as in “food”
 ŭ as in “put”
 ō as in “go”
 ough as in
“bought”
 ŏ as in “pot”
177
[email protected]
59
Jaw Grading Bite Blocks
(Sara Rosenfeld-Johnson, Talk Tools)
Great for Front Vowels and
Spread Lip Consonants
178
Jaw Positions for Speech
Production (Rosenfeld-Johnson)
179
Daniel and Beth Work with
Jaw Grading Bite Blocks
What does Daniel need to
change?
Beth’s jaw works better away from
gravity.
[email protected]
180
60
Progressive Jaw Closure Kit (Talk Tools)
Prep. for Straw, Bubbles, Back Vowels, Round-Lip Consonants
181
Palatograms – Pam Marshalla
182
Palatometry, Complete Speech
183
[email protected]
61
Speech Buddies (www.speechbuddy.com)
Developed by
Articulate Technologies, Inc.
Alexey Salamini
& Gordy Rogers
184
Affordable Computerized Programs and Apps Can
“Make Speech Visual and Auditorily Consistent”
Synapse
Speech Prism
Speech
Tutor
Bungalow
Software
Look for Speech
Spectrum and
Voice Analyzer
Apps as well
Speak in
Motion
(video
modeling)
TheraVox,
Talking
Ben and
Tom
lingWAVES, visual
voice and speech
feedback software
185
Dr. Speech (Makes It Visual)
Real Analysis
Speech Therapy
Speech Training
[email protected]
Nasal/View
186
62
Kay Pentax (Makes It Visual)
Phonatory Aerodynamic System
Visi-Pitch
Sona-Speech
Nasometer
187
What To Do about Speech
Delays/Differences, pp. 268-274

www.jaist.ac.jp
Work with a speech-language
pathologist to determine the
components of the problem:
 Muscle function concerns
 Motor planning concerns
 Verbal Dyspraxia
 Childhood Apraxia of Speech
(CAS)
 Auditory concerns
 Behavioral concerns (e.g.,
selective mutism)
188
ptbraintrust.wordpress.com
Some Characteristics
of CAS (Bahr, 2001,
p. 153)



Limited sound play as
infant
Multiple speech sound
errors with omissions
most prominent
Consistent speech
errors in spontaneous
speech; problem with
imitative speech





Substitutes voiced for
unvoiced speech
sounds
Groping, struggle, trial
and error
Telegraphic speech
Words “out of the
blue”
Frequent oral/limb
dyspraxia
[email protected]
189
63
Specific Treatment Ideas to
Facilitate Speech, pp. 270-274



Hands-On Speech
Facilitation
(Motokinesthetics,
PROMPT)
Cues at the Place of
Articulation/Mouth
(e.g., Jelm cues)
Pacing/Signing/PECS
Merry Meek, Clinician’s View
190
Specific Treatment Ideas to
Facilitate Speech, pp. 270-274



Bottom-Up Approach
(V, CV, VC, etc.)
Hierarchical Approach
(expanding speech
from sounds child
makes)
Practice (from unison
to function)
videos
191
Cues from Rosenbek
& Associates
www.speechbuddy.com








Say word/phrase/sentence in unison
Model utterance/silently mouth utterance together
Model utterance/client repeats
Model utterance/client repeats several times
Client reads/says utterance from card/picture
Client silently reads/says utterance when card
removed
Client answers question with target utterance
Client uses target utterance in role-play
[email protected]
192
64
Improving Speech
Intelligibility, pp. 270-274






Focus on vowels as well as consonants
Slow speech down by prolonging vowels
(e.g., pacing, slower speech model)
Pacing
Increase intra oral pressure by exaggerating speech
Boards
movements
Work on speech stress, inflection, and emotion
Work on speech breathing
Work on dynamic stability, dissociation, grading, and
direction of speech movements (e.g., PROMPT,
Motokinesthetics, bite blocks/jaw closure tubes with speech
sounds)
193
Some of Diane’s Favorite
Materials
Kaufman
Speech
Praxis
Treatment
Kits for
Children
Stevenson
Language Skills
Program (phonicsbased reading,
writing, spelling
program)
Noisy Stories
194
Encouraging Vocal Output/Providing
Auditory Feedback



Items that allow reverberation
(e.g., Echo Mic, Talking Can)
Items that provide more direct
auditory input (e.g., PVC elbow,
HearFones)
Auditory trainer (used carefully
and systematically)
The Attender
(Audio
Enhancement)
HearFones
[email protected]
195
65
Auditory Processing Program with
Picture Stimuli (Age 3 and up)
Super Duper
196
Working with Appropriate
Professionals, Chap. 9, p. 310








Pediatrician, GI Doctor, ENT Doctor, Dentist
Dietician
Lactation Consultant
Feeding Therapist
Occupational Therapist
Speech-Language Pathologist
getmespark.com
Psychologist, Behavior Specialist
Teams and Others as Appropriate
197
Suggestions to Help Parents Find and
Work with Professionals, pp. 310-311





Contact child’s pediatrician; other
parents; local infant-toddler program,
hospital, university
Speak directly with the professional, ask
questions, discuss treatment evidence
Be a partner in treatment
Get a second opinion when needed
Know that all professionals are not
created equal, and that is OK
www.changemag.org
198
[email protected]
66
Resources (Appendices A & B)


For parents and care
providers
 Articles, books,
materials, DVDs (pp.
349-354)
 Websites (pp. 355-358)
 Companies (p. 358)
For professionals
(pp. 359-363)
199
Some Thoughts from Di




We need accurate and detailed
developmental information to help
children stay “on track” as much as
possible
Tactile-proprioceptive learners need to
feel/experience movement to learn it
There is a hand-mouth connection for
feeding, speech, and mouth
development
In order to improve feeding or speech
movement, we must work on the
processes of feeding or speech
200
Please Subscribe and Network with us on
the Topics of Feeding, Motor-Speech, and
Mouth Function





Site: www.agesandstages.net
Email: [email protected]
Receive notifications of new blogs,
Q & A’s, upcoming courses, etc.
Ask clinical questions about feeding, motor
speech, and mouth function
Network and interact with professionals and
parents on these topics
201
[email protected]
67

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