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Normal Development

Before you can go into detail about various types of oral motor activities, you need to have a basic understanding of oral motor development.  We encourage you to refer to your occupational therapist and speech pathologist for a more detailed explanation and help in understanding where your student is in his or her oral motor development.   Prior to working with any special needs child with oral motor problems, a proper assessment should be completed, which may include medical testing, such as a swallow study.

Development in Utero   

Oral motor development begins in utero.  By 7 weeks of gestation, the fetus develops lips.  By 12 weeks the fetus begins to suck and swallow.  When the fetus’ lips come in contact with the developing hand at 13 weeks, it begins to suck on the thumb.  The Active Learning process has already begun. By 24 weeks the fetus will suck and swallow approximately one liter of amniotic fluid per day.  The brainstem matures by 35 weeks and finally by 37 weeks oral motor reflexes including the rooting, suckling, tongue, swallowing, bite, gag, and transverse tongue reflexes are already present.  At birth, the infant comes ready with the developmental skills necessary to coordinate breathing, sucking and swallowing.

Development Birth to Three Months

BabyNursingAn infant from birth to three months of age spends most of his or her day in a reclined position.  The infant is introduced to liquids only and uses an in and out motion of the tongue, or a suckle, to move liquids in the mouth.  The tongue may protrude out of the mouth, and the infant is working to coordinate the suck and swallow with breathing.

Think about the activities the infant age birth to three months engages in.  The child is developing head control and flexion of the body.  These patterns include moving the chin to the chest, moving the arms into midline, bending the knees and bringing the legs up toward the body.  The development of flexion patterns helps to bring stability to the trunk, pelvis and head.

For refined motor development to occur, the body must have stability to gain mobility.  Stability usually develops proximal to distal – or from close to the body to farther away from the body.  Movement patterns will evolve from gross skills, such as moving the arm, to fine skills such as grasping with the fingers.  Oral motor skill progression occurs in the same manner.

Development Four to Six Months

A child four to six months of age moves from a semi-recline position to a more upright position.  This child has gained the ability to roll over and is beginning to sit upright.  There is increased trunk stability and strength.  Typically, children who are unable to roll over are fed with formula/milk and may be beginning to suckle thinner, very smooth purees off of a spoon. A child who is able to sit up  is introduced to thicker/lumpier pureed foods.  The tongue begins to move up and down instead of in and out.  At this age, the social aspect of eating is also more apparent. BabyPureedFoods

Development Six to Eight Months

At six to eight months of age, the child is able get into a seated position independently and usually begins to crawl.  He or she is eating while upright and table mashed foods are introduced.  Reciprocal movements of the extremities are observed, and these more complex movements are also seen in the mouth. 

Once a child can weight shift at the hips, he or she can begin to weight shift at the lips. The tongue not only moves up and down, but begins to move laterally to the sides of the mouth.  A phasic bite and release or rapid up and down movement of the jaw is seen.  This child is also introduced to a sippy cup for the first time. 

Development at Eight to Twelve Months

ToddlerChoppedFoodAt 8 to 12 months of age, a typical child consistently eats in an upright position.  This child is beginning to pull to stand and bears weight in standing.  Reciprocal leg movement occurs.  He or she is eating finger foods and is introduced to pureed meat.  The child has a controlled bite, and develops first a diagonal then rotary chewing pattern.  Chewing requires strength.  Articulation and speech require agility.  At this age, both strength and agility of the mouth are increasing, and the child becomes produces more vocalizations. 

Development at Twelve to Eighteen Months

Lastly, the child 12 months to 18 months learns to chew with his or her lips closed.  This child is a mobile child, walking independently.  Table foods are offered, although meats are still chopped.  A straw is introduced, and the child does not need to extend the neck when accepting food. 

Issues with Oral Motor Development

Now that you have a basic understanding of oral motor development, let’s focus on Active Learning environments and activities.  Prior to creating any intervention strategy, you must first complete an assessment.  There are three main components to oral motor deficiencies that we will be discussing today. They are sensory, motor, and behavioral.  A child can have deficits in one, two or all three of these areas. 

Sensory Deficiencies

Oral sensitivity is a physiological issue due to neurological differences.  It is a physical problem related to sensory processing.  Children diagnosed with autism, septo-optic dysplasia, and other neurological disorders frequently exhibit sensory processing problems.  Oral sensitivity should not be confused with oral defensiveness which is a psychological issue based on past experiences.  There are behavioral causes to oral defensiveness which we will discuss later. 

The development of trust is of utmost importance when working with children who have oral sensitivity.  New sensory experiences are stressful situations.  Recognizing and respecting the responses of a child, while slowly introducing changes to routines is the best method of intervention.  It may take a child months or years to improve his or her sensory processing skills.

Sensory- based oral motor problems are focused on the characteristics of food and liquids including texture, smell, temperature, or taste.  A child can be hyper- or over sensitive, or hypo or under sensitive to these characteristics.  Evaluate the current preferences of a child related to texture, smell, temperature and taste. Then offer new learning environments which introduce slight developmental changes. 

Texture

For example, the texture of food and liquid can alert the senses or calm the senses, as texture provides tactile sensory input.  Liquids are typically the least alerting texture.  After liquids, smooth puree and then lumpy puree slowly alert the senses, offering more input.  Next mushy and soft foods increase alertness, then ground or chopped foods increase alertness a bit more.  Firm and crunchy items that can be easily dissolved challenge the senses even more, followed by crunchy items that are hard.  Finally, foods that contain mixed textures are the most alerting to the body, such as fruits with skins still attached, or yogurt with fruit mixed in inside.

An autistic child who enjoys crunchy items such as potato chips and crackers for example, may have difficulty with mushy foods like soft cooked vegetables.  Active Learning intervention for this child would introduce crunchy but easily dissolved foods or firm foods during play activities.  For example, a child could use hard vegetables such as carrots or celery as drumsticks in music therapy.  Crushed cereal could be used in art projects.  Chocolate chips can be used in sensory activities to increase a child’s tolerance to soft food items, such as chocolate chips that may melt with touch. 

It is not unusual to have a child who exhibits a specific sensitivity in the mouth, but another type of sensitivity of the hands.  For example, a child might eat smooth puree foods, or drink only liquids, but will only touch dry, hard items with his hands.  

Oliver snow 2Temperature

Some children have difficulty with the temperatures of foods.  Room temperature foods are the least alerting to the body, followed by warm items.  Cool foods, such as those found in the refrigerator are next, followed by cold foods – such as those items found in the freezer.  Hot items and finally foods with alternating temperatures are most alerting.  A piece of warm apple pie with a scoop of cold ice cream creates alternating temperatures and can be a difficult sensory experience to process.  

Taste

Taste is another characteristic of food that influences a child’s awareness of the environment.  Bland foods are least alerting to the senses, followed by savory flavors which includes onions and spices like sage or rosemary.  Sweet items follow, then salty and spicy.  Spicy items may include pepper, curry, or cumin.  Sour flavors are more alerting to the body and include citrus foods such as oranges or lemons. Lastly bitter flavors such as cabbage, Brussel sprouts, and radishes are the most alerting. 

Oral motor activities should be fun learning experiences offered outside of mealtimes. Mealtimes focus on food intake instead of necessarily the developmental process of acquiring oral motor skills.

Pressure

Lastly, the pressure applied to the lips and tongue is another tactile characteristic that occurs during mealtimes.  Deep pressure is least alerting to the body where light pressure is most alerting.  Be aware of vibrating tools as they can provide low or high amplitudes of stimulation, and these variations can cause children to respond differently.  The skin around the mouth is an extremely sensitive area.  Simply attempting to bring an object to this part of the body can be viewed by the child as aversive.  The introduction of oral motor activities performed improperly can have a negative effect on oral motor development.

Motor Issues

Motor problems affecting oral motor development will be the next area we explore.  A child might have difficulty or exhibit premature movement of the lips, tongue, jaw, teeth, head or other part of the body.  These motor challenges can result in immature oral motor skills. 

There is a relationship between sensory perception and motor movement.  The more sensory input received, the harder the muscles will work and the greater the impact on the motor pathways.  We move to experience sensory input, and sensory input influences movement.  Participation in daily oral motor activities allow a child the opportunity to progress through the Dynamic Learning Circle to experience new movements of the head, lips, mouth, cheeks, and tongue.   

zain support 8Children with limited mobility or with oral motor deficiencies must be allowed to engage the mouth to explore.  Use of the Little Room, Support Bench, Position Boards, HOPSA Dress, Activity Boards or Velcro Vests may provide enriched environments for this learning to occur. 

When time allows, adults may also assist in providing oral motor activities from which motor skills can be practiced.  Such skills may include opening and closing the mouth, moving the lips, biting down, and moving the tongue in and out, up and down, laterally and rotary.

When presenting an object for a child to explore using the mouth, offer it in a position that allows the child to move.  Present the object near the mouth, close enough so that when the child moves independently, contact is made.  The child, not the adult, makes the decision whether or not to repeat movements. 

Behavioral Issues

Behavioral-based oral motor problems include such challenges as picky eaters, aversion to eating, food refusal, and limited eating.  Past medical, sensory, motor, psychological or social experiences influence our reactions to familiar circumstances.  Behavioral responses are a form of communication and should be acknowledged.  If we can identify the real reason for the behavior and address the underlying issue, behavioral responses will decrease.  

Why might a special needs child primarily mouth objects?  The child could be trying to explore the environment, gain attention from adults, receive sensory input, or is simply relating to the world at his or her emotional level of development.  Responding in the wrong manner can results in continued behavioral actions.   

Take time to review the basic principles of Active Learning including the Dynamic Learning Circle and the Five Phases of Educational Treatment to understand behavioral based reasons for a child’s activity.   

Video Examples of Oral Motor Issues and Tips to Facilitate Development 

Oral Motor- Exploration of Chime

Description: In this video of a young boy, notice the protrusion of his tongue. He is unable to eat liquid or food by mouth and receives his nutrition from a gastro-tube. The chime activity allows him to gain head control and allows for exploration with the mouth.

chime2
Downloads: Transcript (txt)

Oral Motor- Using a Spoon and Cup

Description: The 2-year-old girl in this video is introduced to the use of a spoon and cup. Although in this video her foods are pureed, she is currently eating table mashed foods.

spoon cup
Downloads: Transcript (txt)

Oral Motor- Interacting with Hard, Crunchy Candy

Description: The 6-year-old boy in this video receives all of his nutrition from sippy cups and takes no food from a spoon. In this video he interacts with hard, crunchy candy broken into fine pieces, as he is reluctant to touch mushy textures.

candy
Downloads: Transcript (txt)

Oral Motor- From Smooth to Lumpy Puree

Description: This boy has oral sensitivity to lumpy textures of food and is resistive to feeding himself at meals. In this video the staff increases food texture from pudding, which is sweet and has a smooth puree texture, to cottage cheese, which is a more salty or sour flavor and has a lumpy puree texture.

puree
Downloads: Transcript (txt)

Oral Motor- From Sippy Cup to Open Neck Bottle and Spoon

Description: Prior to starting any meal, this boy is offered the opportunity to interact with the tools to be utilized during that meal. This video shows meals two months apart and by the second recorded dinner, the sippy cup has been replaced with an open neck bottle and a spoon is introduced during dinner.

sippy cup
Downloads: Transcript (txt)

Oral Motor- Vibrating Toothbrush

Description: In this video, a boy is presented with a vibrating toothbrush. He is allowed to become aware of the toothbrush, to experiment, explore and repeat his actions.

toothbrush
Downloads: Transcript (txt)

Oral Motor- Hard Candy and Licorice

Description: In this video a boy moves a hard candy in his mouth (to ensure safety, the candy was attached to a string). He is also introduced to licorice with the use of a Buncher, which allows him to hold it independently.

licorice
Downloads: Transcript (txt)

Oral Motor- Learning to Scoop with a Spoon

Description: In this video, a boy is able to grasp the spoon independently, but watch how, when he is encouraged to scoop food onto the spoon, he lets go.

scooping
Downloads: Transcript (txt)

 

oral motor collage