These are some of the difficulties I see that I feel comfortable and trained to remediate:
-- limited range of motion in the tongue
-- difficulty with tongue-jaw dissociation
-- lack of tongue tip elevation
-- weak jaw strength/stability
-- poor grading of jaw
-- lack of tongue retraction at rest
-- difficulty achieving lateral touch points of the tongue to the palate to produce /s/ or /sh/
All of these difficulties contribute to a resting posture that is not conducive to a mature swallow or precise articulation of speech sounds. Kids like this are easy to spot. They often have low muscle tone in the face, lips and/or tongue. They may have an open bite, cross bite or other malocclusion that requires orthodontic treatment. And they often demonstrate anterior tongue positioning at rest, sometimes with their tongue protruding between their teeth and lips.
I've got several kids working on developing a correct resting posture (i.e. tongue retracted, jaw slightly open, lips closed or slightly parted, and tongue tip touching the alveolar ridge), and let me tell you, it is a tough one! Muscle memory is a tough habit to break, and to replace an old habit with a new behavior is SO DIFFICULT. The process takes lots and lots of repetitions of exercises, which can be tedious and tiring. So I've tried to make it a little more fun. I want to share a number of activities with you that have worked well for me in developing and maintaining correct resting posture.
Let's assume that the clients you are working with can demonstrate jaw grading and have sufficient jaw strength and stability to demonstrate tongue-jaw dissociation, and you're wanting to start working on tongue tip elevation. I always start with activities described in Sara Rosenfeld-Johnson's book Oral-Motor Exercises for Speech Clarity. One of Sara's techniques to achieve the strength and muscle memory for tongue tip elevation is to have the child hold a Cheerio to the alveolar ridge with his/her tongue tip for varying amounts of time and at various jaw heights, keeping the base of the tongue retracted. This technique works extremely well for obtaining placement. I use Cheerios too, but I also like to use Florida's Natural Fruit Nuggets, which are tiny little fruit snacks that are chewier than many other brands of fruit snacks, which is great for promoting jaw strength.
Kids love these! And their parents always ask me where I buy them. Target, in case you're wondering.
Once tongue tip elevation is established, it's time to work on resting posture. Let's get that tongue off those teeth! I like to move away from holding Cheerios/Fruit Snacks in place as quickly as I can and transfer that newly learned tongue placement to other activities. I'm a firm believer that the behavior must be able to be maintained while a child multi-tasks in order for changes to be made.
1. Choose something that repeats an action multiple times and is interesting to the child. One favorite is Lakeshore's Spin and Draw. The child chooses a smelly marker, puts his tongue up to "the spot" and spins the spinner, making circles with the marker. When the spinner stops (after about 10 seconds), the child relaxes his tongue, and chooses another color. He repeats this process until all the colors are used. This is a great way to get 8-10 repetitions of positioning/relaxing the tongue, which will improve tongue strength, jaw strength and muscle memory.
2. A little Angry Birds anyone? This a great game for the next step of performing multiple actions while maintaining correct resting posture. I've broken this game down into steps, which are used as "check points" for monitoring tongue placement. It goes like this:
1. Choose a card. Hold your tongue in position until you select one. Check.
2. Collect the required pieces to build the structure. Hold your tongue in position while you collect.
3. Build the structure. Hold your tongue in position while you build. Check.
4. The structure is complete. Check to see if your tongue is still in the right place.
5. Put a bird on the launcher. Check to see if your tongue is in place.
6. Launch the bird. Hold your tongue in place while you launch. Check.
7. Repeat sequence.
The reason I have all the check points is that I want the students to get into the habit of monitoring their own tongue placement at regular intervals. Creating new muscle memory takes lots and lots of practice and lots and lots of self-awareness.
Every time they cross an item off the list, they check to make sure their tongue is in the correct position.
4. Puzzle games where the students have to manipulate an object with their hands to solve a puzzle while maintaining resting posture are also an excellent choice. Think Fun makes many fun games for kids of multiple ages.
Unhinged is one of my favorites. Students have to arrange a series of connected hexagons to match a picture like this:
Another favorite is Make and Break Game by Ravensburger. In this game, the student chooses a card that features a block structure, and then builds a matching structure.
You can play this a variety of ways to practice resting posture. You could play it the same way as Angry Birds, with a series of check points along the way, or you could play it with the timer and see how many structures the student completes before the timer goes off, all the while maintaining correct resting posture.
5. I like to use word games and brainstorming activities for maintaining resting posture for longer periods of time.
I'll set a timer for 5 minutes, prompt them to put their tongue on "the spot" and have them complete a word puzzle. I will randomly ask them to check where their tongue is throughout the five minutes, and have them nod if they do.
6. Remembering to use correct resting posture outside of the therapy room is EXTREMELY difficult for almost all my kids working on this skill. We've tried sticky notes on the bathroom mirror, on the television and all over the house, but what we've found is that those sticky notes just become part of the landscape after a day or two. One thing that seems to be working for two middle school girls is to involve their cell phones, their most prized possessions! One girl chose to put a small sticker next to the "home" button on the front, so it would remind her to check her tongue placement whenever she pressed the button. The other girl's phone has a security code, so she chose to make a new secret code that would remind her to check her tongue placement anytime she typed in the code. They both report having success with these reminders...of course AFTER school hours!
These are just some of the things I do to keep a tedious (and difficult) task interesting. How about you? I'd love to hear your thoughts.
Keepin' it fun,