Assessment and management of problems arising from oral
Assessment and management of problems arising from oral motor dysfunction in children with Down’s Syndrome Leela Baksi Speech and language therapist Symbol UK Ltd
Problems arising l l Eating and drinking difficulties: conservative about diet and texture, restrictive patterns of eating and drinking. Speech production: articulation of speech sounds. Social consequences of patterns of oral motor activity: saliva control, mouth posture. Impact of oral motor based behaviours on interaction and learning
Oral Motor Dysfunction l l Challenge of accommodating anatomical differences: “motor impairments impact on the children's ability to adapt to their physical structures” (Miller and Leddy). Functional impairments related to • hypotonicity, • impaired praxis, • impact of patterns of postural control, • sensory processing deficits.
Sensory processing deficits “The sensory processing characteristics of the child with Down’s Syndrome include deficits in sensory registration and modulation in the l Vestibular system l Proprioceptive system l Tactile system l Visual system l Auditory system These negatively impact motor performance and behaviour” (Blanche et al)
Sensory processing: oral motor skills l l l Hypo sensitivity: low responsiveness, low tone, seek out sensory stimulation. Hyper sensitivity: avoidance of stimuli, strong aversive reaction to stimulation, conservative in trying wider range of experiences. “See motor, think sensory”: manage sensory issues to increase adaptive motor responses.
“See motor, think sensory” l l l Address sensory issues that contribute to behaviours Provide sensory experiences that support desired motor behaviours “Sensory diet”: providing appropriate sensory stimulation supports positive behaviour and skills development.
Oral motor intervention l l l Increase awareness of oral structures and normalise sensation Capitalise on/create motivating situations that demand skill development Provide motor facilitation and facilitative sensory input, with specific instruction Support self monitoring through visual and cause -effect feedback Provide descriptive feedback and praise for success Motor training through drill activities
Assessment l l Referenced to function Observation in naturalistic situations Observe response to specific demands/activities Trial intervention and monitor outcomes Informed by knowledge and experience of: • Down’s Syndrome • Oral Motor Function and typical patterns of movement and development
Management of issues: Billy aged 4 Skills at outset: l communicates through actions, l selective engagement in activities- lack of active participation in adult lead activities, l occasional speech attempts with limited range of speech sounds and combinations of sounds, l eats pureed diet- totally dependent on “feeding” for food. Takes drink semi-independently from spouted beaker.
Management of issues: Billy aged 4 Targeted areas: l Extend communication l Progress feeding skills l Stimulate development of oral motor skills for speech
Management of issues: Billy aged 4 Intervention strategies included: l Modify diet- support to expand range of foods taken l Provide facilitative support for drinking from an open topped cup and self feeding l “Sensory diet”- food play sessions and deep pressure in interaction routines. Billy actively enjoyed these activities and allowed adults to share these with him.
Management of issues: Ben aged 6 Skills at outset: l Strong motivation to share information including accounts of events l Limited spoken and signed vocabulary: struggles to put ideas into language l Speech intelligible to familiar people, in context l Speech intelligibility reduced by a number of factors including limited range of speech sounds used. l l Fingers-in-mouth and lax jaw, open mouth indicate low tone and hyposensitivity at rest Startle response and low tolerance of oral stimulation manifest hypersensitivity to stimuli.
Management of issues: Ben aged 6 Targeted areas included: l Vocabulary skills- action words/signs l Language skills- increase use of 2 and 3 word combinations l Speech skills- production and use of “blowy” sounds f, th, s, sh, h, ch, v, z, j. l Address issues around sensory processing
Management of issues: Ben aged 6 In intervention, Ben demonstrated the ability to: l Copy articulatory postures, with effort and gradual modification of attempts l Blow into toy placed in mouth (e. g. bubble pipe) but not with remote toy (e. g. bubble wand)
Management of issues: Ben aged 6 Sensory diet: l Touch on face routine l Increase effectiveness of nose clearing: use routine pattern and modelling; talk about nose blowing. l Use of “blowy” toys demanding more sophisticated co-ordination of movement l Opportunities to opt in and reinforcement for attempts and success l Work towards tolerance of sensation resulting from production of blowy sounds.
Key messages l l l Effective management of oral motor dysfunction support the development of eating and drinking skills, speech clarity, positive presentation, and interaction and learning. Effective intervention addresses sensory processing and takes a detailed, problem, solving approach to promoting age appropriate mealtime routines, oral motor skills, and speech sound production. Intervention include creating opportunities for the client to develop skills through motivating activities appropriate to current skill level.
For further information l l l l Introductory information on Sensory Integration for families and professionals: 1. “The Out of Sync Child”, and “The Out of Sync Child has Fun: Activities for Kids with Sensory Integration Dysfunction”, two paperback books by Carol Stock Kranowicz 2. Sensory Integration Network UK and Ireland website www. sensoryintegration. org. uk. The network publishes and distributes: 'Sensory Integration Information Booklet - a resource for parents and therapists'. This booklet is available for purchase through the postal address on the website. Training and resources for speech and language therapists: Suck Swallow Breathe training by Olwen Morgan, occasionally advertised in RCSLT Bulletin Quick Look dates. Talk. Tools: website details resources, books and training courses: www. talktools. net. Occasional courses in the UK- see website. MORE (Motor Oral Respiratory Eyes) courses occasionally advertised in UK. Book and DVD available from: www. pdppress. com Oetter, Patricia, Richter, Eileen, and Frick, Sheila. M. O. R. E. : Integrating the Mouth with Sensory and Postural Functions, Second Edition. 1995. PDP Press, Inc.
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