The Oral / Olfactory System and Praxis

1. The Oral / Olfactory System and Praxis Powerful regulators with application on picky eating / problem feeding / modulation Do not use or distribute without written permission.

2. Objectives for Class • Differentiate between a “jaw jut” and a “jaw slide” as it pertains to feeding and oral motor skill. • List 3 reasons why the Suck-Swallow-Breathe Reflex would be important to consider as a regulator (or modulator?)

3. Oral Praxis • Overlaps with Apraxia of speech. • Also overlaps with articulation errors • Does not have to affect speech, though may affect feeding • Very impacted by postural control. • Also jaw control supported by postural control • Consider different aspects of jaw (jaw slide), tongue, bite / chew, midline Do not use or distribute without written permission.

4. Apraxia of Speech • Apraxia of speech (AOS)—also known as acquired apraxia of speech, verbal apraxia, or childhood apraxia of speech (CAS) when diagnosed in children—is a speech sound disorder. • Someone with AOS has trouble saying what he or she wants to say correctly and consistently. • AOS is a neurological disorder that affects the brain pathways involved in planning the sequence of movements involved in producing speech. • The brain knows what it wants to say, but cannot properly plan and sequence the required speech sound movements. Do not use or distribute without written permission.

5. Oral Motor Development • 0-3 Months • Suckle/swallow reflex • Tongue, lips, jaw work as one unit • Tongue movement is an in-out pattern • Tongue is cupped to provide backward channel of liquid • Rooting reflex is present • Phasic bite reflex is present • Gag reflex is present • Has lateral tongue reflex • 4-6 Months • Suckle in anticipation of the spoon • Munch-chew pattern (5-6 months) • Tongue and jaw move as one unit • Poor coordination of suck, swallow, breathing • Rooting reflex decreases by 5 months • Phasic bite reflex decreases by 5 months • Gag reflex is present Do not use or distribute without written permission.

6. 7-9 Months • Mixed tongue movements (in/out, up/down) • Active lip movements (closure on bottle, cleans spoon) • Starts cup drinking (unstable jaw) • Tongue protrusion on swallow • Some jaw separation from tongue and lip during bite • Transfer of food- side to center, center to side • Lip closure for swallowing semi-solids • Gag is slightly less sensitive • 10-12 Months • Has true suck • Cleans lower lip with teeth • Improved coordination of suck, swallow, breathing • Tongue protrusion on swallow • Controlled bite on soft cookie • Improved lip closure for swallowing liquids • Transfer of foods across midline is beginning • Active lip, cheek movement during chewing Do not use or distribute without written permission.

7. Examples of Feeding Skills as They Translate to Sound Production • Feeding Skill • Sounds • Lip closure maintained during breast or bottle drinking • Sucking (opening and closing the oral cavity) • Elevated tongue tip during sucking • Graded jaw movement in anticipation of a spoon • Elevation of the posterior of the tongue for swallowing • Active cheek movement during chewing and sucking • Spreading of the tongue during swallowing • m, n • p, b • t, d • glides (w, l, r) • fricatives (f, v, s, z) • k, g • directed airflow for fricatives and affricates • r Do not use or distribute without written permission.

8. Munching pattern emerges • (up/down motion of the jaw) • Poor coordination of suck-swallow- • breathe pattern • Spoon feeding • introduced • Cereal • Pureed foods • Stage II • Applesauce • Pudding • Biter biscuits • Age • Oral Motor Patterns • Self-feeding Skills • Example Foods • 0-3 months • Mouth opening • Suckle/swallow reflex • Rooting reflex • Hand to mouth • Liquids fed from bottle • or breast • Breast milk • Infant formula • 4-6 months • Sucking or suckling used with liquids Do not use or distribute without written permission.

9. 7-9 months • Lip closure observed • Suck-swallow pattern for cup- • Drinking • Jaw movements with tongue • lateralization (tongue moves to • sides of mouth to clear food) • Lip closure on spoon • Controlled bite for soft • solids, (e.g., cookie), • emerges close to end • of age range • Cup drinking introduced • 6-7 months • Liquids • Pureed foods • Mashed table foods • Junior foods Do not use or distribute without written permission.

10. 10-12 months • True suck develops (up/down • movement of the mouth and • tongue) • Diagonal-rotary chew (tongue/jaw • dissociation) • Pincer grasp for finger foods (related • fine motor skill) • Chewing in a vertical or • diagonal-rotary • movement • Liquids • Coarsely chopped table • foods, (steamed • carrots, fruits, • cheese) • Finger foods • Biscuits • Banana Do not use or distribute without written permission.

11. Age • Oral Motor Patterns • Self-feeding Skills • Example Foods • 12 months • True suck • Diagonal-rotary chew pattern • Tongue lateralization • Better fine motor skills • Grasps spoon with • whole hand • Holds cup with two • hands • 4-5 consecutive • swallows for liquids • Holds and tips bottle by • Self • Liquids • Coarsely chopped table • foods • Finger foods Do not use or distribute without written permission.

12. 13-15 months • External jaw stabilization • Good coordination of suck-swallow- • breathe • Bites down on cup • Controlled bite on hard • cookies • Cleaning movement of • the incisors on lower • to lip begin to be • integrated with • chewing • Liquids • Coarsely chopped table • foods (start meats • and raw vegetables) Do not use or distribute without written permission.

13. 16-18 months • Diagonal-rotary chew pattern with • better integration of jaw, tongue, • and lip movements. • Controlled bite through • firm, textured foods • Liquids • Coarsely chopped table • foods (most meats • and vegetables) Do not use or distribute without written permission.

14. Jaw Position for consonant and vowel production • The jaw is the most neglected component of articulation skill evaluation. • The position of the jaw during phoneme production is the first piece of information that an oral motor therapist should evaluate. • Tongue placement and lip placement are secondary to jaw position. • For standard production of each speech sound the jaw must maintain proper height and position. • Jaw jutting or sliding will directly impact the clarity of what is being said. Do not use or distribute without written permission.

15. Dissociation • Head from Body  • Jaw from Head – allows for development of chewing. • Movements in speech are the same for chewing (eating). • Lips, Eyes, Jaws, and Face • Tongue from Jaw Do not use or distribute without written permission.

16. Jaw Instability a. Jaw Jut • A one directional abnormal movement of the jaw associated with function. • This type of jaw instability is generally secondary to asymmetrical jaw weakness. b. Jaw Slide • An abnormal jaw movement which is fluid thereby multi-directional. • This type of jaw instability is generally secondary to symmetrical jaw weakness. • The jaw needs to be in a specific position to produce a specific speech sound. • Jaw stability • Stability in the jaw allows for mobility in the lips and tongue for improved feeding safety and improved speech clarity. Do not use or distribute without written permission.

17. Higher Jaw Fixed • Compensatory posture for function • Low Tone clients • Speech – hear a lateral production. Will also be mumbled, slurred and rapid speech production. Do not use or distribute without written permission.

18. Lower Jaw Fixed • Can be seen in Cerebral Palsy, Brain Injury, Parkinson Disease, CVA. • Do it for compensatory reasons • Associated with high tone • Speech will either be slow with one syllable or fast with sequence of vowels with distorted consonants. Do not use or distribute without written permission.

19. Flaccid Jaw Drop • It is not considered to be compensatory. • Hypotonia or obligatory mouth breathers. • Speech • Interdental (fronting of speech sounds) • Consonant deletions • Syllable ommitions. Do not use or distribute without written permission.

20. Feeding and Eating • Baby is driven by hunger – makes need known • Need for sustenance, but also need for corresponding nurture • Great complexity • Child today might still be triggered by implicit memory of experiences in first year of life Do not use or distribute without written permission.

21. 1. Oral Phase • Oral preparatory phase • Solid food is chewed and has to form a bolus for swallowing • Tongue, lip, and jaw coordination, as well as adequate sensory processing and awareness Do not use or distribute without written permission.

22. 2. Swallow phase – Three sub phases • Oral Transport Phase – moving food to back of oral cavity with tongue • Pharyngeal Transfer phase – bolus at posterior throat – coordinate between breathing and swallowing • Esophageal Transport phase – moved from esophagus down to the stomach Do not use or distribute without written permission.

23. Swallowing • In utero as early as 10 weeks gestational age • Regulation of amniotic fluid volume in utero • Linked to the maturation of gastro-intestinal tract • Tongue cupping (prep for sucking) at 28 weeks • Suckling movements of the tongue between 18 to 28 weeks Do not use or distribute without written permission.

24. Suck, Swallow, Breathe (SSB) • After 32 weeks mostly • May be a reliable indicator of neurological maturation in infants born prematurely • Ratio of one such to each swallow – 40 weeks • With maturity 2 to 3 sucks per swallow • Mature coordination: maintain suck rhythm, increasing speed, larger suck to swallow ratio’s, and increased volume with each suck • Important regulator for setting up modulation / regulation Do not use or distribute without written permission.

25. More on SSB • The primary oral motor mechanism is the suck/swallow/breath (SSB) synchrony. • An intact synchrony of SSB is critical to many elements of sensorimotor and cognitive development including speech and language development, postural control, feeding/eating behavior, eye/hand coordination, and sense of well being. • The SSB synchrony often functions as an organizer for neuromotor behavior and can be used effectively in treatment to bring about more integrated behavior. Do not use or distribute without written permission.

26. Important Regulator • Chewing on shirts, cuffs and other inedible objects • Using the binky / thumb • Sensory / developmental stress pushes toward oral satisfaction • Think about adults who need to diet (relationship with food) or smoke Do not use or distribute without written permission.

27. Our Taste Sense • Ageusia – absence of taste • Hypogeusia / microgeusia – reduction of taste sense • Dysgeusia – distortion of taste sense • Hypergeusia – increased sensitivity to common taste • Gustaphobia – dislike of certain tastes • Heterogeusia – all food and drink tastes the same Do not use or distribute without written permission.

28. Anatomy • Receptors distributed throughout the tongue and to a lesser degree of the oral cavity, pharynx and esophagus • 4600 taste buds in human tongue • Cells regenerate every 10 days, but not axons Do not use or distribute without written permission.

29. Physiology • Nose nerve supply – CN 1 , CNV • Tongue nerve supply – CNV, VII, IX, and X • Touch, pain and temperature – Trigeminal Nerve (lingual branch) – anterior 2/3 of tongue • Posterior one third – Glossopharyngeal Nerve • Taste perception in anterior 2 thirds – Chorda Tympani – joins facial nerve in middle ear • Chorda Tympani also contains secretomotor fibers destined for the submandibular and sublingual salivary glands • Taste perception in posterior third – Glossopharyngeal nerve to the inferior ganglion of IX, then to medulla • Relatively fewer tastebuds in the epiglottis, larynx and upper third of esophagus – supplied by branches of CNX (Vagus nerve) Do not use or distribute without written permission.

30. Projections • Orbitofrontal cortex to amygdala to lateral hypothalamus (joins limbic system) • Olfactory signals also reach orbitofrontal cortex, so this zone integrates taste, vision, olfaction, and probably touch Do not use or distribute without written permission.

31. Primary Varieties of Taste • Salt and sweet at front • Sour on lateral border • Bitter at rear of tongue – lowest threshold Do not use or distribute without written permission.

32. Saliva • Dominant role in taste appreciation – need moisture for transduction of taste • Saliva production diminished – health of mouth is reduced – complaints of burning, pain and metallic taste Do not use or distribute without written permission.

33. Developmental Milestones for Feeding and Motor Skills • Functional sucking or suckling (birth) – lifts head in prone position (1 to 4 months) • Explores objects at mouth (3 to 4 months) – opens and shuts hands (3 to 4 months) • Opens mouth when spoon touches lips (4 to 5 months) – props on forearms, grasps food with hands (4 to 6 months) • Eats pureed foods with sucking pattern (5 months) – transfers objects hand to hand (4 to 6 months) • Skilled with liquid intake, long suck/swallow sequences (6 months) – rolls prone to supine, sits independently (6 to 8 months) Do not use or distribute without written permission.

34. Developmental Milestones • Sucking or suckling pattern on a cup (6 months) – imitates actions, opens mouth for food (5 to 7 months) • Beginning use of lateral tongue movements and diagonal jaw movements (6 months) – Finger feeding (6 to 8 months) • Self feeds cracker or cookie (7 months) – rolls supine to prone (7 to 8 months) • Cleans spoon with top lip (4 to 8 months) – babbles, uses voice to express joy (4 to 6 months) Do not use or distribute without written permission.

35. Developmental Milestones • Uses sippy cup with little to no spillage (7 to 12 months) – crawls on hands and knees (6 to 9 months) • Munches or chews soft or mashed foods (8 to 10 months) – pulls to stand (9 to 12 months) • Controlled bite and rotary chewing of firmer foods (10 to 12 months) – walking with some assistance, copying sounds and actions (10 to 14 months) Do not use or distribute without written permission.

36. Examples of Feeding Skills as They Translate to Sound Production Do not use or distribute without written permission.

37. Gastroesophageal Reflux Disorder (GERD) • Not to be confused with vomiting – involves CNS reflex in small bowel, esophagus, diaphragm and stomach – forcefully expels food from stomach • GERD is a regurgitating action – involuntary backward flow of food and liquid from the stomach, back into the esophagus and mouth • Diagnosis of GERD when regurgitation is accompanied by inflammation and / or tissue damage Do not use or distribute without written permission.

38. Oral Sensory Processing • Food refusal and selectivity (picky eater) common in kids with SPD • Oral sensory over-responsiveness – noxious early experiences (Rudolf and Link) • Intubation or lung suctioning, prolonged lack of exposure to oral experiences, damage to sensory transmissions (neurological disorders) • Overlaps with emotional anxiety and need for control – potential power struggles Do not use or distribute without written permission.

39. Oral Motor Issues • Suck, swallow process • Development of jaw, tongue and oral cavity • Diaphragmatic breathing • Abnormal reflexes such as tonic bite reflex • Muscle tone • Neck, trunk and core postural control Do not use or distribute without written permission.

40. Picky Eaters vs. Problem Feeders Do not use or distribute without written permission.

41. Feeding Therapy (SOS Program – Kay Toomey) Feeding Myths • Eating is the body’s number 1 priority. Breathing is the Body’s number 1 priority. Postural Stability is body priority number 2. Eating is only body priority number 3. • Eating is instinctive. • Eating is only instinctive for the first month of life. Between the ends of the 5th and 6th months of life, these primitive motor reflexes drop out and eating is essentially solely a learned motor behavior. Do not use or distribute without written permission.

42. SOS Program • Eating is easy. • Eating is the most complex physical task that human beings engage in. One swallow for example, takes 26 muscles, and 6 cranial nerves to coordinate. Eating is the only task children do which requires simultaneous coordination of all our sensory systems. • Eating is a two step process: 1 – you sit down, 2 – you eat. • There are actually 32 steps, more or less, in the process of learning to eat Do not use or distribute without written permission.

43. SOS Program • It is not appropriate to touch or play with your food. • Wearing your food is part of the normal developmental process of learning to eat. • If a child is hungry enough, he/she will eat. They will not starve themselves. • This is true for about 94-96% of the pediatric population, for the other 4-6% of the pediatric population who have feeding problems, they will “starve” themselves. • Children only need to eat 3 times a day. • Given their small stomachs and attention spans, it takes most children 5-6 meals a day to get in enough calories for proper growth and development. Do not use or distribute without written permission.

44. SOS Program • If a child won’t eat, there is EITHER a behavioral OR an organic problem. • Various research studies, and the data from our Center, indicates that between 65-95% of all children with feeding problems have a COMBINATION of behavioral AND organic problems • Certain foods are only to be eaten at certain times of the day (i.e., Breakfast foods only for breakfast, lunch foods only at lunch, snack foods only at snacks, dinner foods only for dinner), and only certain foods are “healthy for you”. • Food is just food. It is not breakfast food, or lunch food, or dinner food, or snack food, or junk food. Food is either a protein, a carbohydrate or a fruit/vegetable. Do not use or distribute without written permission.

45. SOS Program • Mealtimes are a solemn occasion. Children are to be seen and not heard. • Feeding is supposed to be fun. Children eat so much better when their food is engaging, interesting and attractive. Do not use or distribute without written permission.

46. Ear Infections • 3 or more before age of 3 • History of fluid in ears • High pain threshold • Pull or dig in ears frequently • Talks rather loudly • Articulation errors • Following directions • Speech delays • Dx of ADHD / ADD Do not use or distribute without written permission.

47. Kelly Dorfman - Nutritionist • Elimination diet, especially dairy, wheat, soy, and eggs (try dairy and soy first) • Probiotics - balance digestive tract and reduce allergies – especially after multiple treatments of antibiotics • Testing for auditory processing skill delay Do not use or distribute without written permission.

48. Brain Building Nutrition – Dr. Michael A. Schmidt • Brain is made largely of fat • Highly specific and elegantly crafted • Nerves are surrounded by a covering, or membrane, that is made up of fatty material • Essential fatty acids crucial for developing brain into maturity Do not use or distribute without written permission.

49. Fats Influence Brain Performance • Protects mood, memory and behavior • Protect brain against neurological disease • Enhances mental, physical and emotional intelligence • Brazil nuts, canola, chia, flax, green leafy vegetables, candlenut (kukui), perilla seed, pumpkin seed, soybean, walnut • Albacore tuna, anchovies, bluefin, caviar, eel, herring, krill oil, mackarel, plankton, salmon, sardine, trout: (careful mercury) • Chicken would depend on what it was fed. Includes eggs Do not use or distribute without written permission.

50. Olfactory System The Early World of Smell • Phylogenetically olfaction developed first; taste is a relatively new thalamic-dependent feature. • Smell also plays an essential role in our social interactions, including kin recognition, sexual attraction, and, to a remarkable degree, parent-infant bonding. • Smell is unique among the mammalian senses, however, in that its information is transmitted directly from the nose to the cerebral cortex – albeit to more primitive areas of the cortex – without first being relayed through lower brain centers Do not use or distribute without written permission.