Teaching Pragmatic Skills

Zosia and Basia, 2011

Term pragmatics refers to the ability to communicate in social situations.

Some children have difficulty in understanding how to use language in a range of different social situations and can make very inappropriate remarks.

2012

Children who have difficulties in this area may:

• have problems with taking turns in a conversation or in games
• be unable to change the style of conversation to suit the listener
• be unable to interpret tone of voice in others
• have difficulty interpreting non-verbal communication (i.e. facial expression, gestures)
• have difficulty keeping to the topic of a conversation
• have problems with judging the amount of previous knowledge that the listener has when relating information
• have difficulty understanding other points of view
• have strengths in specific area of the curriculum
• have a particular interest or hobby which can sometimes act as a stimulus to learning
• have a good memory for rote learning.

2013

Activities to develop social communication skills:

• Role play – adults and other children model social situations at home, shopping, etc.
• Puppets – adults and children model social situations through puppet plays and stories.
• Take part – children with social communication difficulties are encouraged to take an active part in both role play and puppet activities after watching modeled situations.
• Tell me – children are asked to talk about personal experiences. Subtle adult questioning should ensure that a child keeps to the topic and gives relevant background information.
• Making faces – miming activities, specifically teaching children how to show feelings through facial expression. This could be part of miming scenes from well-known stories (e.g. the three little pigs being frightened of the wolf).
• Board games – these involve turn-taking.
• Parachute games –these involve collaboration and need to be introduced gradually until the children can work as a team.
• Circle time – gives opportunities to develop the ability to listen to other children's points of view, even if they have difficulty in understanding them.
• Reactions – children are asked to choose a reaction, from a choice of three, to a particular social situation. Then talk about the possible consequences of each reaction.
• Speech bubbles – using well-known story characters. Adult reads loud a scene from a story and then asks children to write, in the speech bubble, what the character might say at the end of the scene.
• Just a minute – children are asked to talk about a particular subject for one minute. This is good practice to keep to the topic.
• Comic strip conversations – is a well-researched and published approach to help children cope with making choices in certain social situations.
• Social stories – is a well-researched and published approach to help children cope with certain social situations that they find difficult.

By BP, 2014

Social stories

Social stories were first introduced by Carol Gray (1994). Social stories are a way of helping children, especially those with Autism, learn social skills. They are used to teach children to recognize facial expressions, body language and other social skills necessary for interacting with their peers. They aim to give children a concrete description for the very abstract things that occur in social interactions. They should be accompanied by relevant pictures. They are written specifically for a child and a situation that the child may be finding difficult. For children who may have a very literal and concrete way of understanding their world, social stories can be very useful.

References:

To read more about social stories reach for the following books and websites.

• The New Social Story Book, Carol Gray,
• Comic Strip Conversations: Illustrated interactions that teach conversation skills to students with autism and related disorders, Carol Gray,
• Writing and Developing Social Stories: Practical Interventions in Autism, Caroline Smith,
• Carol Gray’s website http://www.thegraycenter.org/ to find a list of useful publications,
• Tony Attwood’s website http://www.tonyattwood.com.au/ to find a list of useful publications on socialization,
• Sue Larkey’s website http://www.suelarkey.com/index.php?pr=Home_Page

·   Social Stories

o  Social Stories (http://www.polyxo.com/) - Teaching Children with Autism.

o  Anatomyof A Conversation: Social ScriptsSuggested Conversational Messages 

(www.lburkhart.com/chat_ideas.htm) by Linda J. Burkhart and Caroline Ramsey Musselwhite

o  Sample Sequence social Sctrips
(www.lburkhart.com/chat_scripts.htm) by Caroline Ramsey Musselwhite 

o  SocialStories, (www.autism.org/stories.html) written by Meredyth Goldberg Edelson is for working with people with autism.

·   ABA Educational Recourses (www.abaresources.com) provides many free downloads including Thematic Token Economy Boards

·   Tin Snips (www.tinsnips.org) - a special education resource that includes worksheets and activities for students with autistic spectrum disorders

·   Ridgit Resources (www.widgit.com/resources/index.htm) - symbol-supported learning materials and symbol stories

·   Children with Special Needs – Downloads

(http://www.childrenwithspecialneeds.com/pecsdownloads/) is a treasure chest of materials compressed (.zip) and in .pdf format, including 

Picturesymbol downloads, McDonald's menus,action pictures and MORE 

(www.childrenwithspecialneeds.com/downloads/picturesymbols.html)

·   Tipsfor Teaching High Functioning PeopleWith Autism 

(www.udel.edu/bkirby/asperger/moreno_tips_for_teaching.html) by Susan Moreno and Carol O'Neal

·   Pragmatic language tips 
(http://www.kidsource.com/ASHA/language_tips.html) from ASHA

Signs of Dyslexia and First Steps

When your child begins to learn how to read, write, and count you get exited, but when you compare him with the other peers you start noticing some differences, mistakes he is making, names he is forgetting, frustration he is building up. Even when you support him there is not a big progress in the outcome. He is athletic, social, bright, analytical and creative but reading, writing, or counting becomes challenging. What is that? Dyslexia is what your child might be exhibiting. Dyslexia can affect reading, writing, spelling, and math. There are some common symptoms of Dyslexia, however every dyslextic is different. Many of the areas individuals are struggling with diverse from each other and they can range from mild to extreme.

These are general signs of Dyslexia:

• writing letters and numbers backwards, reversing words;
• presenting poor fine motor coordination, awkward pencil grip, clumsy cutting;
• struggling with recognizing phonemes and putting them together;
• experiencing difficulties with processing information, organizing and communicating thoughts;
• indicating difficulties to memorize lyrics, names or directions.

Here is an example.

Michael is 6 years old bilingual boy; fluent in his mother tongue; English is his second language, but reads and writes only in that language; presents as a very creative, artistic soul; with good fine motor skills; gets pleasure from solving mathematic problems; curves for writing down own thoughts, likes physical activities, acrobatics and swimming; loves listening to live stories or audio books; recognized by most people as a quiet, focused, and well behaved child; determined to accomplish own goal; chooses not to compete if not sure about winning; gets motivated from verbal price; prefers small groups; shy to speak or perform in public. 

In reading:

• Jumps on different word, line, or page.
• Confuses or skips over small words - at, to, said.
• Reads already known words following phonological rules, e.g. door/dur.
• Reverses letters: b/d, p/q, l/i, z/s, words: on/no, was/saw, own/won/one, big/dig, bed/deb and numbers: 5, 7, 3, 5, 17/71, etc. when reading or writing.

In writing:

• Shows size or shape letter inconstancy, e.g. house – Haws, houSe, good – gooD, have – HavE, sleeping – SlePing, disappear - DisiPer.
• Presents with luck of punctuation, e.g. ferst Plan is going todrow it wil be a Parot and his name is going to Be  rabaw andorched
• Spells the same word differently, e.g. home - hoem, hame, castle – kastle, kasoll, casul, casol, come – kam, came, care – kar, car, because – becos, becose, bekus.
• Squeezes text in the upper left corner.

He demonstrates confusion with directional discrimination (right/left, front/back) or visual trucking fast moving objects, letters or numbers.

He doesn’t mind disorganization in his surrounding, e.g. room, working place, table, etc.

He needs support with organization when working on project, a help to make a plan, e.g. that’s what he wrote down:

• wate to Drow
• wate toDrow with
• Pick your klowting
• getting good luk
• names caracter

He needs an extra time to follow multi-step directions or routines.

He faces difficulties with memorizing lyrics, rhyming patterns.

He has difficulties to evoke the right word or friends’ names.

He gets frustrated when fails in reading or writing, or when can’t recall a name or place.

He makes more mistakes when people are watching.

He shows little interest in learning how to bike or scooter.

The questions are rising. What to do? Where to start?

Step 1: Assess whether the child displays any, all or several of the common problem areas of Dyslexia.

Preschool age children:

• May have difficulty pronouncing words;
• May talk later than most children;
• May be unable to recall the right word;
• May have difficulty with rhyming;
• May be unable to follow multi-step directions or routines;
• Fine motor skills may develop more slowly than other children;
• May have difficulty with sequencing;
• Often has difficulty separating sounds in words and blending sounds to make words.

Grades K-4:

• Has difficulty decoding single words in isolation;
• May confuse or skip over small words -at, to, said, and;
• Makes consistent reading and spelling errors including letter reversals, word reversals;
• May have trouble remembering math facts;
• May have trouble telling time;
• May have poor fine motor coordination (trouble tying shoes).

Grades 5-8:

• Is usually reading below grade level;
• May reverse letter sequences-soiled for solid;
• May have difficulty with spelling, spells same word differently on the same page;
• May struggle with long division;
• Poor organization skills;
• May have behavior issues due to frustration and failure.

Step 2: Have your child go through a diagnostic assessment.

This can be done by a clinical or educational psychologist, school psychologist, learning disabilities psychologist or a medical doctor provided they have special training and experience in assessment of learning disabilities.

If you choose to have a school psychologist test your child, beware that most public schools do not specifically test for Dyslexia. Rather, they are testing to see if you child would qualify for special education services. This is not the same as testing specifically for Dyslexia or another learning disability.

The earlier your child is diagnosed, the more prepared you and your child can be to deal
with the challenges that will arise from Dyslexia. 

Dyslexia is Correctable! Turn Learning Problems into Learning Solutions!

Check my other post for intervention and tips or mirror writing

http://slpzone.blogspot.com/2013/10/dyslexia-intervention-and-tips.html

http://slpzone.blogspot.com/2012/11/backward-or-mirror-writing-in-young.html

Read “When Bright Kids Can't Learn” by John Heath. The book presents an exciting and fundamentally different approach that can help many children and adults who struggle with learning. http://www.learningtechnics.com/ The book is available free for a limited time. Click on the link, fill out the form you’re your name, address and telephone number. This will automatically make you eligible for a free e-copy of "When Bright Kids Can't Learn". 

GI Issues and Feeding in Children

Step-by-step approach to food tolerance and diet expansion

The condition of a child's GI system has a direct effect on feeding. If the GI system is not functioning efficiently it's going to impact feeding tremendously.

Many of the children with GI system present with:

• gastroesophageal reflux disease (GERD),
• constipation due to the limited diets related to food refusal,
• vitamin and mineral deficit, which in consequences affect the GI tract and put things off balance,
• eosinophilic esophagitis, an allergy-based esophageal inflammation
• necrotizing enterocolitis in premature infants - an occurrence when intestines become inflamed or infected. The intestines need to be repaired and reconnected through surgery, causing serious GI complications.
• negative associations with feeding, e.g. If the child is refluxing and it's causing pain, he associates pain with eating so he stops eating.

It is the same with eosinophilic esophagitis. If the child is constipated and feels bloated and full, he doesn't want to eat and does not have any hunger cycles. The chiled can learn that negative association within a month or two and starts refusing the bottle.

Many of the children treated by speech-language pathologists on the feeding team are tube-dependent. As a result, they are seen by a team consisting of speech pathology, gastroenterology and nutrition. The collaboration of these three specialists is necessary.

The speech-language pathologist requires a constant line of communication with the dietitian because these nutrition decisions are tied so closely to oral intake. Feeding is the only activity that involves all your organs and all of your muscles. Everything goes into feeding, so everything impacts it.

Families of tube-fed children often struggle with the idea that their children will never be hungry enough to eat orally if they remain on the tube. It's a double-edged sword. We can not pull back on the tube just because the child is not eating enough.

Generally, the preference of the treatment team is to put children who are tube-fed on bolus feeds rather than continuous feeds. However, if the child cannot tolerate a bolus feed, the continuous feed will continue.

A fairly normalized mealtime schedule is arranged for children who can tolerate a bolus feed. In an ideal situation the feed would be given by a pump over 20 to 30 minutes because that is a more normalized mealtime that the child would take if they were given everything PO (orally).

The 20-minute feed time presents an ideal opportunity for the speech-language pathologist to put the pump behind the child's chair, where it is out of sight, and begin PO trials. The children learn that something is going in they mouth and they stomach is feeling full, but they don't associate feeling full with the sight of the machine.

Children still can learn proper feeding positioning by sitting in a chair and can sit with their family to establish mealtime traditions and precedents, even if they are not fed orally yet. That can work even if the child is an aspirator. They can still get positive oral stimulation.

Appropriate oral stimulation toys or devices and textured plastic play food should be used to reinforce oral associations with feeding. There would be kids who will point to their tube and say 'hungry' because they know that's how they are fed. Nobody wants that association. Speech-language pathologist wants the child to point to his mouth and say “That.”

In the feeding program SLP uses several activities with an empty spoon and cup before introducing food. If a child can't tolerate an empty spoon in his mouth, most probably he won’t be able to put a spoon with pudding in his mouth.

Even when food finally is introduced, the child may tolerate puree but reject a "wet" texture food, such as green beans or mandarin oranges. Food chaining posits that children are more likely to accept a new food if it is similar in some way-color, shape or texture-to a food they already like. If a child eats Goldfish crackers, for example, clinician may use a fish-shaped cookie cutter to cut slices of cheese to reflect the color scheme. Clinician then introduces the food to the child by discussing its likeness to the previously accepted food.

Another sensory technique used by the team targets the large number of children with GERD who present with sensory processing difficulties caused by the pain they experience while eating. These children are pulling back on a lot of oral stimulation that they would normally be doing, so they're not putting things in their mouths, they're not mouthing on a toy, and they're very sensitive to the texture or temperature of foods. When it's reintroduced, they're hypersensitive.

It is not uncommon for these children to gag or vomit food. With those kids SLP has to work on tolerating the food on the tray.

The clinicians use the Sequential, Oral, Sensory (SOS) Approach to Feeding developed by psychologist Kay Toomey, PhD. Dr. Toomey's approach seeks to lessen the fearfulness of feeding for children by breaking down the process into much smaller steps. There may be 28 to 32 steps before a child takes a bite and swallows. These steps include kissing the food, licking, putting it into the mouth, and spitting it out.

The therapy is pushed as much as the child can tolerate it and until the kid is finally eating the bite.

The step-by-step approach incorporates an "all-done bowl" that allows the clinician to maintain control of the feeding therapy. For example, if a child starts throwing the food, which is very common, instead of saying: No throwing, Stop, the clinician would say, The food stays on the table. If you're done with it, you can clean it up and put it in the bowl. If the child gets distressed about the food does not just throw it off the table. The child has to follow an instruction to complete the task. It allows for a much more efficient, less battle-oriented mealtime, which is something a lot of parents deal with.

Speech-language pathologist on the team also works with the parents on using appropriate, positive language during mealtime to allow them to remain in control. The parents should avoid questions, such as: Will you take a bite? Do you like it? or Will you eat a bite for Mommy? but use positive statements, like: You can take a bite. Mommy wants to see you do it.

During feeding therapy, children must remain seated with appropriate positioning in the chair. They are not permitted to walk around the room and come back to the food when they want it. This reinforces normalized mealtime scheduling and the routine of family interaction at the table.

Infants don't have trunk support yet. When we hold them in a cradled position, they're slumped down and putting a lot of pressure on their abdomen, which causes the reflux to come up a little easier. As they learn to crawl and walk and sit upright, there's not as much pressure on the stomach and as the result half of infants outgrow reflux by 9 months of age.

Children who had reflux as infants need to be monitored for less visible but still present symptoms of GI disturbance. The reflux instead of coming out of the mouth might be coming up and down into the esophagus.

Older children with reflux often present with a chronic cough, hiccups, burping and frequent ear infections. They may only be able to tolerate small feeds but in frequent intervals.

Dental caries also can serve as an indicator for a speech-language pathologist. When a toddler has had a lot of dental work, which can be a red flag because the acid is coming up and eroding tooth enamel.

Recurrent pneumonia is another serious concern and GI problem indicator. Reflux is typically worse at night because we sleep lying down, and by doing so we lose the benefit of gravity. It comes up, spills over into the larynx, and goes into the lungs. The children are getting aspiration pneumonia, but they're aspirating reflux.

Phonological Processes and Elimination in Typically Developing Child

http://www.hanen.org/Guidebooks---DVDs/Parents/It-Takes-Two-to-Talk.aspx 

A concerned parent asked me about the phonological development and processes in typically developing child. In replay I presented him with two tables created by Caroline Bowen. I frequently use the tables for my clients.

“All children make predictable pronunciation errors (not really 'errors' at all, when you stop to think about it) when they are learning to talk like adults. These 'errors' are called phonological processes, or phonological deviations. In Table 2 are the common phonological processes found in children's speech while they are learning the adult sound-system of English.” Caroline Bowen

TABLE 2: Phonological Processes in Typical Speech Development COPYRIGHT ©1999 CAROLINE BOWEN
PHONOLOGICAL PROCESS (Phonological Deviation)	EXAMPLE	DESCRIPTION
Context sensitive voicing	"Pig" is pronounced as  "big" "Car" is pronounced as "gar"	A voiceless sound is replaced by a voiced sound. In the examples given, /p/ is replaced by /b/, and /k/ is replaced by /g/. Other examples might include /t/ being replaced by /d/, or /f/ being replaced by /v/.
Word-final devoicing	"Red" is pronounced as "ret" "Bag" is pronounced as "bak"	A final voiced consonant in a word is replaced by a voiceless consonant. Here, /d/ has been replaced by /t/ and /g/ has been replaced by /k/.
Final consonant deletion	"Home" is pronounced a "hoe" "Calf" is pronounced as "cah"	The final consonant in the word is omitted. In these examples, /m/ is omitted (or deleted) from "home" and /f/ is omitted from "calf".
Velar fronting	"Kiss" is pronounced as "tiss" "Give" is pronounced as "div" "Wing" is pronounced as "win"	A velar consonant, that is a sound that is normally made with the middle of the tongue in contact with the palate towards the back of the mouth, is replaced with consonant produced at the front of the mouth. Hence /k/ is replaced by /t/, /g/ is replaced by /d/, and 'ng' is replaced by /n/.
Palatal fronting	"Ship" is pronounced as "sip" "Measure" is pronounced as "mezza"	The fricative consonants 'sh' and 'zh' are replaced by fricatives that are made further forward on the palate, towards the front teeth. 'sh'  is replaced by /s/, and 'zh'  is replaced by /z/.
Consonant harmony	"Cupboard" is pronounced as "pubbed" "dog" is pronounced as "gog"	The pronunciation of the whole word is influenced by the presence of a particular sound in the word. In these examples: (1) the /b/ in "cupboard" causes the /k/ to be replaced /p/, which is the voiceless cognate of /b/, and (2) the /g/ in "dog" causes /d/ to be replaced by /g/.
Weak syllable deletion	Telephone is pronounced as "teffone" "Tidying" is pronounced as "tying"	Syllables are either stressed or unstressed. In "telephone" and "tidying" the second syllable is "weak" or unstressed. In this phonological process, weak syllables are omitted when the child says the word.
Cluster reduction	"Spider" is pronounced as "pider" "Ant" is pronounced as "at"	Consonant clusters occur when two or three consonants occur in a sequence in a word. In cluster reduction part of the cluster is omitted. In these examples /s/ has been deleted form "spider" and /n/ from "ant".
Gliding of liquids	"Real" is pronounced as "weal" "Leg" is pronounced as "yeg"	The liquid consonants /l/ and /r/ are replaced by /w/ or 'y'. In these examples, /r/ in "real" is replaced by /w/, and /l/ in "leg" is replaced by 'y'.
Stopping	"Funny" is pronounced as "punny" "Jump" is pronounced as "dump"	A fricative consonant (/f/ /v/ /s/ /z/, 'sh', 'zh', 'th'  or /h/), or an affricate consonant ('ch' or /j/) is replaced by a stop consonant (/p/ /b/ /t/ /d/ /k/ or /g/). In these examples, /f/ in "funny" is replaced by /p/, and  'j'  in "jump" is replaced by /d/.

TABLE 3: Elimination of Phonological Processes

Phonological processes are typically gone by these ages (in years ; months)

COPYRIGHT ©1999 CAROLINE BOWEN

PHONOLOGICAL PROCESS	EXAMPLE	GONE BY APPROXIMATELY
Context sensitive voicing	pig = big	3;0
Word-final de-voicing	pig = pick	3;0
Final consonant deletion	comb = coe	3;3
Fronting	car = tar ship = sip	3;6
Consonant harmony	mine = mime kittycat = tittytat	3;9
Weak syllable deletion	elephant = efant potato = tato television =tevision banana = nana	4;0
Cluster reduction	spoon = poon train = chain clean = keen	4;0
Gliding of liquids	run = one leg = weg leg = yeg	5;0
Stopping /f/	fish = tish	3;0
Stopping /s/	soap = dope	3;0
Stopping /v/	very = berry	3;6
Stopping /z/	zoo = doo	3;6
Stopping 'sh'	shop = dop	4;6
Stopping 'j'	jump = dump	4;6
Stopping 'ch'	chair = tare	4;6
Stopping voiceless 'th'	thing = ting	5;0
Stopping voiced 'th'	them = dem	5;0

References:
Bowen, C. (1998). Developmental phonological disorders. A practical guide for families and teachers. Melbourne: ACER Press.
Grunwell, P. (1997). Natural phonology. In M. Ball & R. Kent (Eds.), The new phonologies: Developments in clinical linguistics. San Deigo: Singular Publishing Group, Inc.

Check Caroline Bowen’s page http://www.speech-language-therapy.com/  

If Someone prefers more visual version can go to Tracy Brading page to see the chart 

http://firstyears.org/c4/u6/alpha.htm

"By the age of ___________, 90% of children have suppressed the phonological process of _________________."

Age 3

AF = Affrication (e.g. "cho" for "show") 
BA = Backing (e.g. "buk" for "bus") 
VC = Voicing Change (e.g. "dief" for "thief")

Age 4

CD = Consonant Deletion (e.g. "bu" for "boot") 
DE = Deaffrication (e.g. "sew" for "chew")

Age 5

FR = Fronting (e.g. "tey" for "key") 
SY = Syllable Deletion (e.g. "mado" for "tomato")

Age 6

AL = Alveolarization (e.g. "tum" for "thumb") 
CR = Cluster Reduction (e.g. "poon" for "spoon") 
CS = Cluster Simplification (e.g. "twa" for "tray") 
GL = Gliding (e.g. "wug" for "rug") 
SD = Stridency Deletion (e.g. "but" for "bus") 
ST = Stopping (e.g. "toup" for "soup") 
VO = Vowelization (e.g. "penco" for "pencil")

Age 8

LA = Labialization (e.g. "fad" for "sad")

Reference:

Lowe, R.J.  (2000) ALPHA (Assessment Link Between Phonology and Articulation Phonology) Revised Test of Phonology.  (2000)  Mifflinville, PA: ALPHA Speech & Language Resources

Decrease Tongue Protrusion and Improve Oral-motor Strength

Tongue protrusion is very closely associated with Down Syndrome and is regularly cited as a feature of the condition. It has been traditionally stated that this is due to the presence of an enlarged tongue, however current thinking favors a combination of physical and developmental factors, specific to each individual.

Tongue movement should be considered within the context of the whole body. All parts of the body are connected and factors affecting normal motor development in one area may also influence the mouth. In order to develop movement and skills, we must have a stable trunk. Without that stability, our function is affected. Think of a young baby – their body movements are uncontrolled and random, but become more organized as they learn to control various parts of the body. Once trunk stability is established, body parts such as arms, legs, head, etc. can develop more refined movement. For example, before a child can reach and grasp a toy, they must develop control over the shoulder and trunk.

Similarly, oral stability depends on neck and shoulder stability, which is dependent on trunk and pelvis stability. A stable jaw is necessary for the development of controlled tongue and lip movements and as the range of tongue movement develops, children develop a sense of their tongue’s natural resting-place in the mouth (e.g. in the middle).

It is important to remember that not every child with Down Syndrome protrudes their tongue but also, that it is a normal part of early development. It may become exaggerated or persist due to one or many of the following factors:

• Children with Down Syndrome have a weak suckle as infants and learn to control the flow of liquid by protruding their tongue.
• Individuals with Down Syndrome have a smaller, higher arched hard palate which means that the tongue is contained in a smaller than average space.
• There is lower than average tone in the muscles of the tongue. This makes it appear larger because it is floppier. Tongue movement depends on the actions of a variety of muscles in the mouth and it plays a role in swallowing, breathing, chewing and speaking. Individuals with Down Syndrome have difficulty with producing and co-coordinating the necessary movements to control the tongue.
• During normal development, the tongue grows at a different rate to other parts of the face such as the jaw, which in the early years, normally results in the tongue a high, forward position in the mouth. This, combined with a smaller oral space and low tone in the tongue, may result in the tongue protruding.

• The muscles of the tongue constantly correct and readjust the tongue’s position in the mouth, based on the sensory feedback it receives. Many children with Down Syndrome have difficulty receiving and integrating sensory information and may not develop these skills as quickly or completely. Consequently, they may not be aware that their tongue is protruding.
• Tongue protrusion may also result from an inability to move the jaw separately from the tongue. This is a skill that develops over time and is dependent on jaw stability. Without this stability the tongue protrudes as the jaw lowers.
• Tongue protrusion may develop due to airway compromise such as large adenoids or tonsils, which are common in individuals with Down Syndrome.
• The ability to self-correct a protruding tongue requires some degree of insight and motivation to change. Depending on a child’s age and developmental level, this self-monitoring may not develop fully, or may develop much later.
• Many children with Down Syndrome have delayed motor development and therefore may not have the stable base from which oral-motor skills can develop.
• Upper respiratory tract infections, which block the child’s nose, may cause them to breathe through their mouth rather than their nose. In mouth-breathing the jaw lowers and the tongue is no longer contained within the mouth. These infections may develop as a result of middle ear infections, which are common to individuals with Down Syndrome. This develops due to a dysfunction of the Eustachian tube, which is located at the back of the throat and is connected to the middle ear (its function is to equalize air pressure on both sides of the eardrum). If there is low tone in the muscles surrounding the entrance to the tube, fast-flowing fluid may enter the middle ear, causing an infection over time. 

In my own experience of working with children with Down Syndrome, tongue protrusion has generally been a transient phase, often associated with periods of teething or throat infections. Cases that have persisted have been a reflection of a more significantly reduced overall body tone and consequently, more significantly delayed oral-motor development. These children have also demonstrated more delayed eating and drinking skills, which is reflected in reluctance to transition from smooth to lumpy foods and delayed biting and chewing skills. Biting and chewing relies on graded jaw movements and the ability to move the tongue in a variety of directions. In encouraging a child to experience biting and chewing safely, both areas can be developed at the child’s own pace.

From an oral-motor viewpoint, there are a number of areas that can be focused on. While the primary focus is on improving oral-motor skills, there will be a knock-on effect in relation to feeding and speech development. Be aware of your child’s level of development and consult with your speech & language therapist, physiotherapist and occupational therapist, to ensure you select an appropriate starting point. To minimize tongue protrusion, your child needs to develop some or all of the following:

• Stable, central base (i.e. control over the trunk, head, etc.)
• Increased oral/facial muscle tone
• Increased oral sensitivity
• Improved lip movements
• Improved jaw movements
• Improved tongue movements. 

As you can see, tongue protrusion may occur for a number of reasons. Many children with Down Syndrome may simply be exhibiting a generalized delay in their development, of which tongue protrusion is one feature. It is important therefore, that a full assessment is carried out, to ensure that the correct remediation path is chosen. It would be inappropriate to focus on skills that the child is unable to achieve. In normal development, these oral motor patterns are generally established by the age of 24 months, but your child may have a developmental delay and difficulties with low tone, so starting any activities at this age may be inappropriate. Every child presents a different picture; therefore every therapy plan should be tailor-made. It is essential that you consult with a speech and language therapist, occupational therapist and physiotherapist to get an overall picture of your child’s physical, sensory and oral-motor development and discuss the value of working on this area. These are the professionals qualified to guide you through the process.

Without the possibility of meeting therapists, you could try some of the suggestions below. Eliminate any medical reasons (e.g. enlarged adenoids/tonsils, teething, throat/respiratory infections, etc.). Select one or two exercises to try, but be aware that doing them all at the same time could be harmful. Adults can often become overenthusiastic and if the child is unable to co-operate with the exercises, they may become resistant to any form of intervention in the longer term. It is vital therefore that you are aware of your child’s strengths and difficulties and give them lots of praise for any attempt that they make. They may require many opportunities to practice and will need you to demonstrate it clearly, in a way that they will understand. Observe your child and take note of the times their tongue protrudes, what they are doing at the time, how long it persists, if they correct it themselves, etc.

Be patient and be prepared to repeat the activity over and over again. It may take time before the skill is achieved. Most of all - make it fun!

Precautions  

• Don’t do all the activities at the same time.
• These activities should not be done at mealtimes as this could lead to aversive behaviors around food.
• These exercises should be dome for short periods of time.
• Talk through what you are doing, each step of the way.
• Ensure you are both positioned in a relaxed, comfortable position.
• Ensure your child is in a stable, supported position.
• Minimize distractions e.g. TV, radio, other people etc.
• Pause to allow time to swallow any saliva that may have accumulated.
• These exercises can be done throughout the day, washing, drying at bathtime, using a towel, sponge, facecloth, etc).
• Don’t attempt this if your child has a cold.
• Stop if your child becomes distressed at any time.

Some oral-motor exercises

• If your child is sensitive around their face, prepare them before you approach their face. Use slow, firm strokes over the hands, arms, shoulders, body and neck with a rough texture (e.g. towel, etc.)
• Using firm strokes/touch with a rough texture (e.g. towel, etc.) start at the sides of the face / forehead / chin and gradually work towards the centre of the face.
• Massage the cheeks using circular movements, particularly around the mouth.
• Use 2 fingers to press the top and bottom lips firmly together. Hold for a couple of minutes and release.
• Stroke firmly downwards on the area between the nose and top lip while using your finger to push the bottom lip upwards.
• Using your thumb and index finger, pull the top lip down, starting under the nose and working towards the top of the lip (without touching the lip itself).
• Do the same for the bottom lip, working from chin to the lip. Support the jaw if necessary.

• Press the lips together by pressing one index finger below the nose and the other below the bottom lip - rotate the fingers towards the lips.
• Gradually introduce stronger flavors at mealtimes:

1. curry,  Chinese sauces, garlic
2. chips: vinegar, garlic, mayonnaise dip, brown sauce, ketchup, etc.
3. tangy or bitter flavor fruits and yoghurts: kiwi, lemon, forest fruits, grapefruit, cranberry, etc.

• Extremes of temperature:

1. ice-cream, ice-pops
2. worm food

• Sensory toys:

1. “Bumble Balls”
2. Teethers that are textured or battery operated for vibrations, etc.

Practical ideas for developing jaw and tongue movements

• When spoon-feeding your child, place the food centrally on the tongue and apply firm downward pressure. This will reduce tongue protrusion that occurs during swallowing.
• As the protrusion reduces, place the food at the sides of the mouth, between the teeth. This will encourage munching and sideward tongue movements.
• To stimulate biting, munching and sideward tongue movements:

1. Initially, do this at times when your child is relaxed.
2. Initially, these activities should not be done at mealtimes.
3. Use items such as tethers (ridged etc.), foods that do not break up, bite and stay firm foods, dried, but not too dry fruits: bananas, peaches, apricots, Liquorices sticks, etc.

• Place the item in the mouth, between the teeth, along the line of the jaw and ensure that it is not placed so as to stretch the lips. Do not place too far back in case your child gags.
• Place on the best side initially, than move to the other side.
• If the child is not munching, pull the item out slightly and gently or press down.
• When you feel your child is confident about their biting skills, introduce food items. Initially use bite-and-dissolve foods (Boudoir biscuits, meringues, Skips/Snax, etc.)
• If the child is not biting off the food, break it off for them while they are biting down on it. Do not force your child to take foods that their mouth is not ready to handle.
• Over time, gradually introduce chewier foods in the same way.

Practical ideas for developing lip movements

• Using a mirror, make “oo” sounds (e.g. a ghost/owl/ monkey/wind etc.) and “ee” sounds (e.g. mouse, E-I-E-I-O, etc.) using exaggerated lip movements. You might need to gently push the lips from a tight stretched position (smile shape) to the round position (kiss shape).
• Practice kissing. You might need to gently push the lips from a tight stretched position (smile shape) to the round position (kiss shape). Put on some lip stick or face paint and make kiss marks on a mirror, tissue, paper etc.
• Sucking through a straw. Make a tight lip seal around the straw.
• Blowing bubbles, blowing cotton wool balls across the table, blowing whistles/party blowers, blowing bubbles in water with a straw, etc.