The easiest way to improve overall oral-motor function for speech purposes is simply to exercise the muscles while eating. A very useful tool would be a straw. The
use of straw in speech therapy is commonly known. For years straws have
been an important utensil in feeding and lip rounding exercises. In the
clients' opinion the straws are fun and the food is a
reward. The primary goal of straw is to concentrate on insufficient tongue
retraction. These exercises encourage increased speech clarity whether the person
has an inter-dental lisp or other varieties of phoneme distortions. Therapeutic
straws have also been found to be useful when working with velo-pharyngeal
insufficiency or patients that are recovering from a cerebral vascular accident
(CVA). In these instances and numerous others, specially gradated straws are
used in a hierarchical succession to work on a specific component of oral
movement.
Internationally well known an American Speech Language Pathologist - Sara Rosenfeld-Johnson, M.S.,CCC/SLP has created a line of straws along with the related step-by-step exercises. She said that when
she was initially using straws for feeding or lip-rounding goals, she was
struck by the improved tongue retraction and as the result speech clarity.
Since then straws have become one of my most important therapy tools for her.
Further she says: “Traditional therapy
methods start with the assumption of adequate tongue muscle function. The
premise of traditional therapy would follow that if you listen to me when I say
"ball" (auditory stimuli), and you look at a ball when I say it
(visual stimuli), and if you hold the ball (tactile stimuli) when I say it, then
through this multi-sensory approach you will acquire the ability to say
"ball". Oral motor therapy (OMT) does not work like that,
particularly with our special education clients who have reduced visual or
auditory capabilities. OMT asserts that the translation of this tactile
information has to take place in the mouth; that therapists must put something
into their client's mouths that is going to increase their client's awareness
of their mouth and that will, in a series of measured progressions, strengthen
the target muscle groups. This oral muscular development and control is an
important prerequisite which then enables the clinician to use traditional
articulation therapy. At the therapeutic level straws have the promise of
addressing a multiple array of disorders and muscle groups far beyond
traditional practice. Let's review some basics. In English, in order to have
connected speech (co-articulation) and speech clarity we have to stabilize the
back of our tongue on the back of the palate. Then, whatever else our tongue is
required to do, it moves from that position of stability. The tongue elements
work with four basic movement components:
- retraction/protrusion
- back
elevation/depression
- tip
elevation/depression and
- the ability to
spread the sides of the tongue.
When babies are born they have approximately a 50% back and 50% forward
movement from the resting position called a suckle. As the child gets older and
begins spoon and cup-feeding they achieve about a 75% retraction and 25%
protrusion. They do not stick their tongues out during feeding. Those who do
frequently present with feeding problems. Straws have been prescribed routinely
for these occurrences because, at the very least, through straw feeding, the
client can return to the 50%/50% suckle. But there is no reason to stop there,
and, I would argue that allowing clients to suckle straws is therapeutically
wrong IF treatment stops there. Suckling can actually exacerbate protrusion of
the tongue. (It should be mentioned that sippy-cups, a popular feeding tool,
encourage suckling, once again falling short of the preferred 75%/25%
retraction/protrusion goal.)
By continuing to use a progressive series of increasingly more complex
straws and thicker liquids we can teach the tongue muscle to retract. The goal
is to achieve close to a 75% retraction; to achieve that position of stability.
The back of the tongue in stabilized retraction allows the tip of the tongue to
move side-to-side to alternating back molars; the very movement that is needed
to chew food effectively. At this milestone we have clients who attain more
eating independence and improved nutrition, both very important for children
that have not progressed well with cups or spoons.
How do therapeutic straws address speech clarity goals? Children or
adults with interdental lisps are missing this important component of
stabilized tongue retraction. Clients who stabilize their tongue at the front
of their mouth between their teeth, rather than in the retracted position of
stability, are said to be fronting their sounds. If a client is using an
interdental production on /t/, /d/ or /n/, which are the first stable retracted
sounds in the developmental scale, the mastery of these sounds must occur
before attempting to master /s/ or /z/. If a developmentally normal
three-year-old interdentalizes on /n/ there is already a problem. In fact, any
three-year-old with an interdental production on /t/, /d/ or /n/ needs help to
retract the tongue, and further, any child with an identified speech problem
who suckles, whether its a bottle, cup or straw, is maintaining their speech
errors if they are secondary to interdental tongue placement. (If a
developmentally normal four-year-old does not interdentalize on /t/, /d/ or
/n/, has correct tongue blade retraction, but lisps on /s/ it is possible that
the lisp is secondary to a developmental delay and may not need therapeutic
intervention.)
How do we get clients on therapeutic straws and at what age or point in
therapy? Muscles can be toned at any age; one or one hundred. These techniques
will work anytime but the younger the client the easier.
Young children with an identified dysfunction can often be started as
early as one-year-old. Many of our clients with Down Syndrome are started this
early because we are working on the concept of retraction as a critical oral
motor skill that then cascades into other oral motor benefits. Other clients with
a low tone diagnosis also benefit from this early intervention. Many of these
children are still on a bottle at ages two, three or four; suckling. In
virtually all cases, by the age of two, straw therapy can be successfully
undertaken. Some children need an assisted transition. I use a squeezable
"honey bear", emptied, cleaned, filled with slightly thickened liquid
and retrofitted with a straw. The child can still clutch the "honey
bear" bottle while learning to draw liquid up through the straw. The care-givers
for low-tone children who may not be able to pull liquids up on their own
initially can gently squeeze the liquid up to assist.
Exactly what is straw drinking? Normal straw drinking requires complex
movement from the jaw, lips and tongue. Through the coordination of these
movements a vacuum draw is created. Each of our speech sounds are made with a
different combination of these graded movements.
Over many years I developed a successional group of straws with each
individual straw working on a specific part of those graded movements. After
initial experiments with ordinary straws, which offer such limited results as
to be therapeutically unusable, I located every conceivable type of straw
produced and jury-rigged them when necessary. Ultimately I was compelled to
persuade straw manufacturers to custom-produce a few of the straws for the
specific attributes that I needed.
This hierarchy of straws progresses through a matrix that advances from
multiple sips to single sips and then from thin liquids to thickened liquids
while varying the straw's diameter, overall length and the structural
complexity via elbows, curves, twists and placement of a lip block.
How would therapy begin? At the outset - making sure that the client is
sitting up straight in a stable position receptive to drinking - I give them a
simple, straight, regular-diameter straw to see how they will use it, allowing
them to drink from it like they normally would. I place my finger at the point
where the straw is entering the mouth so that I can then take the straw out and
measure the length from the entry point to the tip of the straw that is inside
the mouth. There are several things to watch for at this stage. Is the straw
more than 1/4 - 1/2 of an inch inside their mouth? If so, then they are either
suckling it or biting it. Is the client biting the straw? If so, that could be
an indication of jaw instability. The correct position for the therapeutic use
of the straw is with jaw stability, tongue retraction and lip rounding to fully
enable drawing.
The first straw in my hierarchy is cut to the length that I measured
above. The straw has a lip block which encourages sealing and rounding. Over a
succession of visits as the client exhibits proficiency I surreptitiously
reduce the length from the lip block to the internal tip until the client has
achieved primary retraction and at least minimal lip rounding. At this point
the client is said to be therapeutically drinking from a straw and I am free to
move through the remainder of my hierarchy. Clients are taking these straws
home and using them daily for drinking all thin liquids. As they progress,
thickened liquids and purees are introduced using specifically identified
straws in the hierarchy. The clients use these straws to drink 3-4 ounces once
a day. As each straw is mastered or seems to be too easy, I move onto the next.
For some clients this may be as frequently as one new a straw a week, as it
might be in the case of a developmentally normal child with an interdental
lisp. For this client a full, successful course of treatment may last as short
as four months.
Other clients, depending on the diagnosis, for example cerebral palsy,
the therapy, while still effective, may continue for a longer period of time. A
client with Down Syndrome may complete the full treatment in one to two years
and we often find that this t ype of therapy reduces the duration of speech
therapy as they get older. Clinicians who are targeting specific sounds in
therapies with their clients will find that therapeutic straw treatments have
proven to be effective with the standard production of /t, d, l, n, k, g, s, z,
ch, sh, j, & r/.
Clients with velo-pharyngeal insufficiency are another population that
benefit from straw drinking. For them it increases tongue retraction, changes
resonation and elevation of the velum. Clients recovering from Cerebral
Vascular Accidents (CVA) often exhibit lip asymmetry. Therapeutic straw
drinking works to bring their lips to symmetrical midline thereby improving
speech clarity.
I personally attended the courses
presented by the master, Sara Rosenfeld-Johnson and truly recommend to have a
look, get familiar or buy a set for yourself to try
http://www.talktools.com/straw-kit/
