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Part I: Straws - Using Simple Tools in Oral-Motor Therapy

Film writers and novelists know that one quick path into a story line is through the reliable, dramatic tool of food. Oral-motor therapists are no different.

This article is the first of a two-part series exploring the use of simple tools to facilitate therapy for a variety of speech disorders. The use of straws is addressed in this article, and applications for horns in oral-motor therapy will be discussed in the second article, which will appear in the May 31 issue of ADVANCE.

Straws can be used by many clients. The primary goal of the use of straws is to address insufficient tongue retraction. This treatment encourages increased speech clarity, whether the client has an interdental lisp or other phoneme distortion.

Therapeutic straws also have been found to be useful when working with patients who have velo-pharyngeal insufficiency or 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

The use of straws in speech therapy is not uncommon. For many years straws have been an important utensil in feeding and lip-rounding exercises.

On the client's level, the straws themselves are viewed as fun, and the food is experienced as a reward. At the therapeutic level, straws have the promise of addressing a multiple array of disorders and muscle groups far beyond traditional practice.

A little over 12 years ago, while initially using straws for feeding or lip-rounding goals, I was struck by the improved tongue retraction--and, therefore, speech clarity--that was its side effect. Since then, straws have become one of my most important therapy tools.

Traditional therapy methods start with the assumption of adequate tongue muscle function. Using a multi-sensory approach, the premise of traditional therapy would follow that if you listen to me when I say "ball" (auditory stimuli), look at a ball when I say it (visual stimuli), and hold the ball (tactile stimuli) when I say it, you will acquire the ability to say "ball."

Oral-motor therapy does not work like that, particularly with our special education clients who have reduced visual or auditory capabilities. Oral-motor therapy asserts that the translation of this tactile information has to take place in the mouth. Therapists must put something into the client's mouth that will increase awareness of the mouth and strengthen the target muscle groups in a series of measured progressions. This oral muscular development and control is an important prerequisite that enables the clinician to use traditional articulation therapy.

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. 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.

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>At birth, babies have approximately a 50 percent back and 50 percent forward movement from the resting position called a suckle. As children get older and begin spoon and cup feeding, they achieve about a 75 percent retraction and 25 percent protrusion. They do not stick their tongue out during feeding.

Those who do frequently present with feeding problems. Straws have been prescribed routinely for these occurrences because, at the very least, the client can return to the 50-50 suckle through straw feeding.

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 actually can 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 percent/25 percent 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 percent 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 who 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 3-year-old interdentalizes on /n/, there is already a problem.

In fact, any 3-year-old with an interdental production on /t/, /d/ or /n/ needs help to retract the tongue. Further, any child with an identified speech problem who suckles, whether it's a bottle, cup or straw, is maintaining speech errors if they are secondary to interdental tongue placement.

If a developmentally normal 4-year-old does not interdentalize on /t/, /d/ or /n/ and 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 should they begin? Muscles can be toned at any age, 1 or 100. These techniques will work anytime; however, the younger the client, the easier.

Young children with an identified dysfunction often can be started as early as 1 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 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 2, 3 or 4, suckling. In virtually all cases, straw therapy can be successfully undertaken by the age of 2.

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 clutch the bottle while learning to draw liquid up through the straw. The caregivers of low-tone children who may not be able to pull liquids up on their own initially can assist by gently squeezing the liquid up.

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 from thin liquids to thickened liquids while varying the diameter, overall length and structural complexity of the straw via elbows, curves, twists, and placement of a lip block.

At the outset of therapy--making sure that clients are sitting up straight in a stable position receptive to drinking--I provide a simple, straight straw of regular diameter 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 I can take the straw out and measure the length from the entry point to the tip of the straw inside the mouth.

There are several things to watch for at this stage. Is the straw more than one-fourth to one-half of an inch inside the mouth? If so, the client is either suckling or biting it. Biting the straw can 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 that encourages sealing and rounding.

Over a succession of visits, as the client exhibits proficiency, 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 three to four ounces once a day. As each straw is mastered or seems to be too easy, move on to the next. For some clients this may be as frequently as one new straw a week.

That 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 (e.g. 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. We often find that this type of therapy reduces the duration of speech therapy as they get older.

Clinicians who are targeting specific sounds in therapy 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/, and /r/.

Clients with velo-pharyngeal insufficiency comprise another population that benefits from straw drinking. For them it increases tongue retraction and changes resonation and elevation of the velum.

Clients recovering from a cerebral vascular accident (CVA) often exhibit lip asymmetry. Therapeutic straw drinking works to bring their lips to symmetrical midline, thereby improving speech clarity.

An extra advantage of treatment through therapeutic straw drinking is that it can be equally effective with clients, irrespective of cognitive abilities. The therapeutic results--tongue retraction and tongue grading--for a client with severe cognitive impairment and limited or no language skills can be almost the same as with a developmentally normal child or adult. This adds to its promise as an important tool in the arsenal of all oral-motor and speech-language pathologists.

Sara Rosenfeld-Johnson is owner and director of Innovative Therapists International, 3434 E. Kleindale Rd., Ste. F, Tucson, AZ 85716; (520) 795-8544; (520) 795-8559 (fax); e-mail: oromotorsp@aol.com; or http://www.oromotorsp.com/ on the web. Diana Manning is a freelance writer.

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