Questions and Answers?

Lila says:

 

 

QUESTION:

I wish I had known of your website sooner! My daughter, Isabella was born with Down Syndrome and is now 4 years old. We live in a 3rd world country (Honduras), so as you can imagine, finding professional services for her therapies are limited although we have been blessed to have an organization in our city that offers them for free and we have taken her there since the age of 10 months for physical therapy, early intervention, and currently for speech therapy and nursery school (special eduacation).
I had learned thru another blog that sippy cups were not recommended and threw them out to buy her cups with straws…we found and like the Toss n Go type, but since she chews on the straws, we now use disposable straws with them. I did notice however, after reading your post on FB that she tends to stick her tongue out under the straw sometimes, but she is improving in that area (she can and does pucker her lips). She also has a drooling problem as she usually has her mouth open and tends to forget to swallow, even when eating and especially if she is distracted. I was told by her speech therapist to try placing drops of lemon, strong coffee or other bitter or sour tasting things on her tongue to stimulate swallowing, but this makes her drool more and spit. How can I help her with this?
From what I understand, speech therapy also involves some sort of oral exercises or massages which she did not receive; her speech therapies began at the age of 2 and moslty have consisted in perfecting fine and gross motor skills thru games, coloring, painting and other activities which I understand are necessary for speech development. She did not have problems with eating, tho I suspect sometimes she has trouble chewing completely. They also work with flashcards and games to identify and name objects, colors and shapes and she is currently learning numbers 1-10. She is able to say over 50 words although some not so clearly and she is starting to form 2-3 word sentences, but for the most part, she still needs her family to “translate” so others can understand.
Our home is a bilingual home (Spanish/English; Spanish being the local language) since I am a US citizen living abroad and our other 2 children go to a bilingual school. My HUGE question is: Am I confusing her or holding back her speech development trying to teach her both languages at once as I did my other kids or should I let her learn one first and try the other later? Her speech therapist considers her high functioning and says to teach her both (one parent speaking Spanish, the other English), but her special ed teacher, who also considers her high functioning, is not so sure nor is her psycologist (who works at the same center). None have had experience with this I believe. I’ve spoken English to my children since birth, tho somewhat inconsistently since everyone else speaks Spanish and I tend to forget to speak English sometimes. I only let them watch TV, videos and movies in English for the most part and read to them in English. I usually repeat in English whatever I say in Spanish. I have done this with Isabella also since birth and, to me, she seems to understand both. She will point to her body parts, for example, when you name them in either language, but usually says them in English. If I give her a simple command such as “give me a kiss” in either language she understands both. I have noticed she learns to say things easier in English, but I think it may be because the words are shorter in English (apple vrs manzana). What do you think?

ANSWER:

Hi Lila….I am so happy to help…..I have a lot of input….so thought best to post as a POST….and this way I can go through your questions…and reply back with a response to each one…so here goes!

First….regarding sippy cups…yes glad that you threw them away….they do promote more of the forward tongue movement..and they do not promote tongue retraction.  The Toss and Go cups are good as well…however, since she is biting on the straws….and we do not want her to do that….I would suggest that you buy the HONEY BEAR offered through www.talktools.com   And also buy the lip blocks…this way you can control how much of the HONEY BEAR (the straw specifically) is inside of her mouth….I like to see only 1/2 inch of the straw inside of a little one’s mouth…you can use the lip block to prevent more than 1/2 inch of straw going inside of her mouth (also sold through www.talktools.com).  This also will help with lip rounding and lip protrusion as well as lingual retraction and decreasing lingual protrusion.  Try to encourage her NOT to bite on the straw.  After she has successfully used the HONEY BEAR straw cup…you can buy the straw kit offered through www.talktools.com  There are eight straws in the kit…when you get to that point…I can help you as you go through the hierarchy.  The straw kit is great for lingual retraction, lip rounding and decreasing lingual protrusion (I do not work for talk tools nor do I receive compensation for promoting their products….I just love their materials!).  Also using the straws correctly will help to decrease her tongue sitting underneath the straws…you do not want that!

In reference to drooling…below are some oral motor exercises that decrease drooling…they do need to be done with a speech and language pathologist…but you did indicate that she does see one…hopefully these will help:

 

 EXERCISES TO DECREASE DROOLING:

Oral Motor exercise to only be used with a speech and language pathologist

 

 

Oral-Facial FacilitationThe aim of this technique is to improve oral function therefore increasing the ability to control saliva.Oral-facial facilitation is a technique which attempts to improve oral-motor control, frequency of swallowing and sensory awareness. Oral-facial facilitation techniques have been used to improve control of saliva with people who have hypertonic (high tone) and hypotonic (low tone) muscles. (Scott & Staios, 1993)Once the individual is in a stable and comfortable position, one (or a combination) of the following can be tried:

  1. Icing
  2. Brushing
  3. Vibration
  4. Manipulation
  5. Oral-motor sensory exercises

Do not attempt any of these techniques without supervision or instruction from a Speech Pathologist.

It has been shown that with some people oral-facial facilitation techniques can be effective in reducing but not eliminating drooling.

Icing

Icing is a procedure which aims to normalise muscle tone in some individuals, thereby improving oral-motor function and enhancing sensory awareness. It involves the application of ice directly over the target muscle.

To maximise the effectiveness of this procedure, an oral activity such as eating or exercise should directly follow icing. The effects of icing are immediate and may last between 5 and 30 minutes.

It has been found that ice helps to stimulate a delayed or absent swallow reflex.

This technique may not always be effective and considerations need to be taken into account. (Scott & Staios, 1993)

Brushing

This technique is also reported to normalise tone and increase sensory awareness. This technique involves using a brush to stroke the muscle in the direction of muscle movement.

The effects of brushing are said to occur 20 to 30 minutes after the procedure. Brushing should take place half an hour before a meal, or half an hour before an oral activity/exercise. (Scott & Staios, 1993)

Vibration

Vibration aims to increase the awareness of the position of the muscles and facilitate more normal tone.

This technique has clinically been found to be more effective than brushing. This is perhaps due to more intense stimulation. This technique involves applying vibration directly to the target muscles in the direction of the movement for approximately 6 to 10 seconds.

The vibration technique is considered not only to be effective for stimulating hypotonic (low tone) muscles, it has also been found useful for those with hypertonic (high) muscles. (Scott & Staios, 1993)

Manipulation

Manipulation techniques such as tapping, stroking and patting are applied directly to the muscles, using fingertips only. This technique involves applying firm even pressure. A quick stretch along the muscle fibers may be useful for stimulating hypotonic muscles. Manipulation procedures are useful not only for their direct effect on facilitating normal movement patterns but also for improving oral function through increased oral awareness and discrimination. (Scott & Staios, 1993)

Oral-Motor Sensory Exercises

The following are suggested exercises that may be incorporated into an individual’s program to improve oral-motor function, with the ultimate aim of improving saliva control.

These exercises should immediately follow oral-facial facilitation techniques.

Lip Exercises:

  • Make faces in mirror making various shapes with lips (for example, smiling, pursing etc)
  • Hold spatula or piece of paper between lips
  • Use a wide-diameter straw to suck up thickened fluids (for example, pureed apple) and blow items such as paper and cotton wool.
  • Place foods such as jam or peanut butter on the top lip and encourage removal with the bottom lip.

Tongue exercises :

  • Attempt to lick lips.
  • Try to touch the teeth with your tongue.
  • Try and make the tip of your tongue touch the nose.
  • Encourage the person to lick envelopes, stickers, lollipops and so on.

Swallowing:

  • · Encourage the person to attempt to close the lips at the start of the swallow.
  • Place subtle visual cues around the environment to remind the person to swallow their saliva.
  • Remind the person to keep their head up.

Behavioural Approaches

A behavioural learning program may be suitable for some children or adults. It is designed to remove or introduce particular behaviours for the purpose of reducing drooling. A behavioural learning program is based on learning theory. Behaviours that may be encouraged are swallowing behaviours (eg. lip closure) or regular wiping of the chin. Examples of behaviours that would need to be discouraged are decreasing open-mouth behaviour or reducing hand sucking.

Involvement in a behavioural learning program requires that all people involved in the person’s health improvement are fully committed to the program. The planning of the program may involve a team of people who know the person well such as teachers, a parent, friend or siblings. There must be at least one person who can spend time with the person every day who will administer the program consistently.

Behaviours can be rewarded with verbal rewards “well done!” or objects or events such as tokens, money, TV time etc.

For more information, an assessment for potential participation in a behavioural learning program or a referral, contact a local Speech Pathologist.

Other Tips and Strategies

Despite all the treatments available for drooling, it is at times inevitable that something immediate must be done to counteract the problem. Sometimes, even after treatment- a drooling problem may persist. Here are some practical compensatory tips for when and after a child or adult drools:

  • Children can wear bibs for the purpose of moppng up the excess saliva, although this may become innappropriate for adults and older children.
  • Towelling can be attached to clothes (sewn on).
  • Scarves of absorbant material can be worn for around the neck. A variety of colours may be necessary for coordinating with different outfits.

 

 PRE-FEEDING EXERCISES/ORAL MOTOR EXERCISES:

The following pre-feeding exercises have been suggested by the amazing Lori Overland…I will include them below….most importantly for your daughter right now may be the munching exercise…please see below….I also plan today to post about an oral motor exercise that promotes chewing…so be sure to look for that….if you subscribe to my blog…which is free of course…you will receive notification when I have posted a new POST:

 

I have been taking another class offered by Lori Overland…and wanted to post pre-feeding exercises that should be used prior to your feeding sessions.  These exercises are not only for children that have Down Syndrome…but also for those who present with low muscle tone.  The goal of the exercises is to improve strength and mobility of the muscles needed for feeding and also for speaking.

 

PRE-FEEDING EXERCISES: 

 

1. Palatal massage:  the goal of the palatal massage is to maintain the shape of the palate.  Find the palatal raphe:

The palatal raphe is a rather narrow, low elevation in the center of the hard palate.  You can run your tongue along the palatal raphe…starting from the bump behind your teeth…follow the palatal raphe until you get to midline.  It is like you are running your tongue along a line…you should be able to feel it.  The reason you are running your tongue along the raphe is because you need to find the midline point.  You will know that you are midline on the palatal raphe when you have found the bump.  So that will be your starting point for this exercise.

I think it is pretty easy to find the bump at the top of the palate.  Remember to start your tongue behind your front teeth…and run your tongue along your palate…straight back….when you find the bump you will know that this is the starting point….the point where you will start this pre-feeding exercise with your little one.

Now…inside your little one’s mouth you will find the bump…the bump lies between the two halves of your palate.  Once you find the bump on her palate….use your index finger and run the pad of your index finger down to the lateral ridge (the spot where her teeth will insert)….then roll back up to mid line to the palatal raphe…and then back down to the other side of the mouth.  So to be clear…you are running your finger sideways…from the bump on the top of the palate to the lateral ridge…(the spot where her teeth will insert)

Each side should be massaged four to five times prior to the feeding.  The goal of this exercise is to maintain the shape of the palate.  Remember the palate fuses around one year of age. 

2. Maintaining Lateral movement of the tongue:

For this exercise you should use:

A Toothette  ….be sure to cut the wings of the Toothette when working with an infant or toddler…the Toothette is too large for an infant or toddler with the wings. 

 

An infa-dent

 

A Nuk brush

 

All three of these tools can be purchased at www.talktools.com

 

The goal of this exercise is to stimulate the sides of the tongue to improve tongue lateralization.  This means the child’s ability to move the tongue to the side.  Remember this is a skill she will need for feeding and for speaking.  When working on this exercise start at the back of the tongue and move towards the front of the tongue.  Be sure to use four to five strokes on the left side of the tongue and then four to five strokes on the right side of the tongue.  When  you are doing this exercise….you should see the tongue moving to the side.

 

3. Maintaining Phasic Bite/Munch Pattern:

What is a phasic bite?:  A neurologic reflex present in infancy where pressure on the gums causes rhythmic opening and closing of the jaw.

Use your index finger and stimulate the lower gums from back to front.  You are looking to see if this caused a rhythmic opening and closing of the jaw……a munch pattern.  This exercise will teach chewing skills.  ( I will post over the next week or so…the chewing hierarchy….specific to exercises that should be done to improve chewing skills in little ones with Down Syndrome or with low muscle tone).

4. Pacifier Rock:

I could not find a good picture of the pacifier that you should use…just be sure it is not one that has a flat-bed on the bottom of the pacifier (the part that goes in the baby’s mouth)….it should be an elongated shaped pacifier.

With your middle finger under the jaw….and your pointer finger on one side of the mouth…in the corner…and your thumb on the other side of the mouth…in the other corner….you will be ready to help your little one.

Use your middle finger to help the jaw to come forward…and your thumb and index finger to move the lips into a pucker/kiss.  You will be using your middle finger to rock the jaw back and forth….and your index finger and thumb to improve lip rounding.

 

5. Tongue Bowling:

Children with low muscle tone may have a flat tongue that may protrude forward. 

Stroke the tongue…start at the tip and work towards mid-line…this should create tongue bowling.  This exercise should be done four to five times.

6. Massage:

Using your hands or the textured sensory bean bags offered by www.talktools.com

The following exercises should be done four to five times:

1. Start at the TMJ  and move down towards the corners of the lips.

2. Start on the sides of the nostrils and work down towards the lips.

3. Start under the nostrils and work down towards the lips.

Massage wakes up the muscles…very good for children with Down Syndrome and children with low muscle tone.

 

 

***if your licenses speech and language pathologist wants you to use a vibrating tool.. www.talktools.com has 3 cute ones…

 

talktools

 

Jigglers add calming and organizing sensory input, and can be used for oral exploration, reducing “fixing” in the jaw, and increasing awareness. Instructions included. Requires one AA battery which is included with the Jiggler.

However….be sure to know that too much vibration on low tone children may break down muscle tone.  Be sure to consult with your licensed speech and language pathologist before using a vibrating tool.

 

7. Tap and tone:

Just like if you were going to the salon and getting a facial….you will be “tapping” the child’s face with the palms of your hands….the goal is to tone and strengthen the muscles of the face and cheeks.  To strengthen the lips….tap on the lips and make the “O” sound….just like in the song Old MacDonald had a farm…remember….E-I-E-I-”O”.  Tapping on the lips will improve the tone and strength of the muscles of the lips and improve lip rounding.

 

8. Upper lip mobility:

You will be using the Toothette indicated above…found on www.talktools.com to improve upper lip mobility.  Remember for infants and toddlers you may have to cut off the wings so that it is the right size for your little one.   You can wet the sponge if the child does not like the texture of the Toothette.

The Toothette goes inside of the mouth….start on the corner of lips…and move the toothette under the lip to midline….repeat this four to five times…and then move to the other side of the mouth.   Midline…is the middle of the top lip. 

With older kids you may purchase:

Vibrator & Toothettes – TalkTools®

 

This will add more sensory information and more likely to get mobility.

With the older kids you may also use the Z-vibe….it comes with three different heads.

To promote upper lip mobility use the Z-vibe with the yellow head.  You will be doing the same exercise indicated above under upper lip mobility.  The Z-vibe adds more information.  It has a firmer rubber tip.  Remember to perform the exercise from corner to midline.

If the older child is resistant to using these tools…use the back of a toothbrush…use a vibrating toothbrush….some of the older children can be taught how to do this exercise on their own.

 

9. Ice Stick to improve lip rounding:

 

Ice Sticks can be used to develop oral placement/feeding and speech therapy programs and are excellent for achieving lip rounding and lip closure.  The ice stick can be purchased at www.talktools.com

In order to improve lip closure place across the lips (so the ice stick should be presented horizontally) and have the child make closure with their lips on the ice stick.  You can also ask the child to kiss the ice stick to improve lip rounding.  To further improve lip rounding: place the ice stick inside of the child’s mouth (vertically).

Lip rounding can also be addressed with the Jigglers indicated above….turn the Jiggler on and ask the little one to kiss the Jiggler.

What if your child can NOT pucker her lips for a kiss.  How can you help her with lip rounding……therapist should stabilize the jaw with her middle finger under the mandible….so you do not want the jaw to move….index finger and middle finger should be in either corner of the mouth.   Since the child is not able to pucker her lips for a kiss just yet….you will be using your index finger and thumb to help her to get her lips into the pucker…being sure to keep her jaw stabilized with your middle finger.  Now help her to kiss the Jiggler.

Remember…..too much vibration for children with low tone may break down muscle tone….so be sure to consult with your licensed speech and language pathologist for guidance.  The vibrating tools should not be used as a toy….it should only be used therapeutically.

 

In reference to her clarity of speech…if you tell me the sounds she is having trouble with….I can tell you if it is developmentally appropriate….and if needed how to remediate the sound.

 

With regard to hearing two languages…you state that she is high functioning and that she understands both languages…how wonderful!  Continue to speak both languages to her….children living in a bilingual home do have more demands placed upon them with regard to language development…of course!  They are acquiring two different language systems.  When a child is struggling with regard to cognitive development and receptive development-understanding of language…then NO I would not want her to have the demands of two languages….because she needs to understand at least one…in order to acquire words……this does not seem to be the case for your little one….so my professional opinion is that she continue to hear both!

Please post with more questions…and keep in touch with regard to the information above.

Have fun!

Kim

 

 

 

 

 

 

 

 

 

 

 

 

About Kim

My name is Kim Marino and I have been practicing as a licensed speech and language pathologist since 1993. I work on Long Island providing diagnostic evaluations and services to children from birth to age 21. My experience is vast and am proud to say that I work with children that may present with articulation and phonological concerns, oral motor feeding concerns, Down Syndrome feeding, cognitive rehabilitation, auditory processing delays, receptive language delays, cleft palate feeding and sound development and expressive language delays. Most importantly, I am the mother of four amazing children and am happily married to my childhood sweetheart. I feel blessed to have my four children and so lucky to share this journey in life with my husband. I always had it somewhere in my head that I wanted to develop a blog or a website of some sort so that I could provide families with an additional resource....so that parents could help their little ones become a better communicator. And as I was developing this blog....I realized that I also needed to share the stories about my life and my children....and the funny things along the way that help to keep me smiling. Whether you are a working mother or not...finding balance between home, children and life can be a challenge....I hope that my blog helps to bring a smile to your face..and also some tools to help you help your little or big one. I hope you enjoy! Kim
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