Oral Motor and Feeding Skills

Sharon Fiocca, M.A., C.C.C., RSP
Speech and Language Pathologist and Resource Specialist
Copyright © 1999; Updated 2007

Reprinted with the permission of the author

Feeding skills, oral motor skills, and articulation development are all related to each other in that they develop side by side and one builds upon the other. A child with poor oral motor skills will have feeding deficits in certain areas and delays in articulation. Therefore the information presented below covers development of feeding and oral motor skills and possible interventions that you as a parent can do to improve function.

SUCK SWALLOW-BREATHE AND ORAL MOTOR DEVELOPMENT

The sucking reflex usually develops in utero. Many children with Down syndrome have trouble with this very refined oral motor sequence at birth and afterwards. The following exercises/techniques are compiled for you to stimulate this sequence. When the reference is known it is given. Otherwise it is reported here as learned from experience or from interaction with other specialists. Most of these exercises should be done before or during feeding time. (Caution: never leave a child unattended with a "Nuk" toothbrush because the end can come off.)

Rub the index finger along the gum ridge where the molars would develop. Then follow this with a few quick swipes across the palate left to right. Allow your baby to attempt to suck on a bottle/nipple giving support to the bottom lip. Your baby may only take a few sucks before this procedure has to be repeated again. Additional support from your fingers to the upper lip and chin might be required. See report page 3 or page 9 for information on maximum support.
Use an infa dent toothbrush (fits over your finger; is made of plastic and has little, raised, soft plastic spikes at the end of it) inside your baby's mouth to rub gums, insides of cheeks, and tongue. This tends to stimulate awareness of intra oral cavity.
Wipe the face off with a face rag and pull the muscles gently but firmly towards midline (middle of the mouth area).
If still having difficulties around 4 months of age, you can go to a cross nipple (or make your own by cutting an "x" into a nipple with an exacto knife). After doing this, add a few teaspoons of rice cereal to your formula or breastmilk. You will need slightly more if using breastmilk, because it is thinner than formula. This thickens the formula/breastmilk and aids in teaching an infant to suck/breathe/swallow. A word of caution: Do not do this for an extended period as it may reinforce tongue thrust behavior which most children with Down syndrome will have the first few years of life if not longer.
Debra Beckman has created some oral motor exercises that help develop an infant's suck reflex. Many of her exercises involve the use of a "Nuk" toothbrush and involve stimulation and resistance. You can locate a speech therapist or an occupational therapist who has been trained in her exercises at her website referenced at the end of this article.

If you are choosing to bottle feed, the best nipple is one that is going to discourage tongue thrusting. When my daughter was an infant, I preferred two types, the Evenflo preemie or formula nursing nipple and the Evenflo disposable. Others that may be touted as the orthodontic nipple may not be the best choice. You may find that some professionals do not know which nipple is the best. I recommend trying a few and observing what happens with your child's tongue. Another word of caution: some people give supplements/vitamins via an "x" cut nipple and they do not thicken the liquid inside. This will definitely reinforce tongue thrusting because the flow of the liquid will be too fast. The tongue will develop a humping in the back and a forward push against the nipple to slow the flow of the liquid. So the bottom line is, if you are going to give supplements via an "x" cut bottle, then thicken the formula first (by adding rice cereal). As soon as possible, switch to giving the supplements on a spoon, perhaps sweetened with black cherry concentrate or other bottled concentrates generally available at a health food store.

NOTE: Following are some nipples/feeding systems that I have not personally used but have heard good reports about.

Baby nipple from Japan designed for cleft palate but requires minimal effort to feed from a bottle. It is available from Respironics at 1-800 345 6443 and can be used on any bottle. It is a soft, pliable nipple and therefore would not interfere with palate growth and oral motor development.
Haberman bottle: good for babies who swallow with positive pressure instead of negative pressure. Available from Medela, Inc., P.O.Box 660, McHenry, IL 60051-0660; phone is 1-800-435-8316. They also supply information and supplies for breastfeeding. They will refer you to a breastfeeding specialist in your area.
Innovative Therapists International (referenced at the end of this handout) also offer the Haberman bottle as well as other infant feeding systems.

SPOON FEEDING

When to move on to pureed food is a matter of personal preference. Some say the longer you wait the fewer allergies that are likely to develop. I'm not sure if this is true or an old wives tale! Your choice of eating utensil/bottle nipple/cup may influence your child's oral motor development. For spoon selection, choose one that is small and flattened. Choices such as the "maroon" spoon, in my opinion, are too big (when older, the small maroon spoon could be used). It is better not to use a plastic coated spoon because they eventually crack and bacteria gets under the plastic leading to placing bacteria in your child's mouth every time he eats! My favorite spoon that I used with my daughter was the baby spoon available from Oneida China. The following are a few strategies to use while feeding pureed foods.

Take a small amount of food on the spoon. Place the spoon in your child's mouth horizontally and at about the middle of the tongue push down quickly on the tongue. In the beginning you will have to assist with jaw closure using your other hand in order to teach the sequence: spoon in/jaw up/lips close. The reason you push down on the tongue muscle quickly, is to get the muscle to push back (the goal is upward movement, instead of a forward tongue thrust). This exercise should be used beyond infancy and possibly even through preschool years to inhibit the strong tendency to tongue thrust.
What do you do when you are spoon feeding your infant, and he doesn't close his lips? The answer is two fold and pertains to bottle feeding as well. When a baby is learning to bottle feed and learning to make closure on the bottle, you provide lip and jaw support. Maximum support would be an index finger right above the top lip, a middle finger right below the bottom lip and the ring finger under the chin. Gradually you would fade the amount of support removing maybe one finger at time and watching to see what happens and modifying as needed. You don't want the tongue sticking out of the mouth when your child is bottle-feeding. Well, when spoon feeding you place the spoon in horizontally and push down rapidly on the tongue. Then as you are pulling out you could provide lip and/or jaw support along with a verbal cue "close your lips". You could first try just a slight push up on the jaw and say "close your lips". If this was not effective then you could add lip support with the verbal cue "close your lips". This added support over time should be faded. Lip strength exercises would benefit such as whistle blowing at a later age. I play a game with some of my young clients where I hold a flavored tongue blade between their lips and vibrate it slightly (I shake my hand slightly) while saying "mmmmm" along with a verbal cue, "close your lips". This works on lip closure and lip strength (to some extent). You will also be teaching the command, "close your lips" so your child will know what this means.
Try various feeding spoons until you find one that works best for you. If your child is having trouble gagging, then try placing the food along the inside cheek and gradually work toward the center of the tongue.
Nuk techniques: Give input to the tongue such as touching it or pushing gently on it, and then touch various parts around the mouth telling your child to "go find it". Thus you may touch and tongue and then touch the furthest back upper right tooth and say, "go tickle it" or "go find it". Continue touching the tongue first followed by touching places in the mouth such as the lower side tooth, front upper tooth, front bottom tooth, upper back left tooth, lower back left tooth, behind the front teeth (alveolar ridge), etc. This is a necessary skill for a child to learn to clean the teeth and to identify food that may be stuck in various parts of the mouth or teeth. It will probably require years of intervention to establish and transfer to food. (Note: if your toddler cannot perform this exercise, then wait until he is older and can follow commands and perform the task).

TRANSITIONING TO MORE TEXTURED FOODS

Because children with Down syndrome are more fragile in their health, I do not encourage use of any artificial foods/preservatives, foods sprayed with pesticides, or processed foods (except rice cakes/rice crackers/rice or corn chips). In addition, it is good to avoid all high allergy foods including wheat (also difficult to digest), dairy, citrus, sugar (except brown rice syrup), peanuts (mold in peanuts), or peanut butter (also contains mold which can cause earache; instead I use almond butter). So basically it is best to cook your own food as much as possible. This will not only benefit your child's health but also your child's overall development. The dietary advice is my own personal opinion based on the health needs observed in my own daughter who has Down syndrome as well as observations made with my clients. Some professionals may not like this advice because it involves a little bit of creativity on their part. I found that the mini cuisinart food processor is a very handy tool for quick meals. I recently purchased a Vita-Mix machine, which can be paid for in installments, as it is very expensive. With the Vita-Mix you can make anything including grinding meat for burgers and grinding rice to make rice flour. The following information was modified from Suzanne Evans Morris' book "Pre-Feeding Skills" (order from Speech Dynamics or Mealtimes catalogs referenced at end of handout). Food transitions in typical developing children are as follows:

children aged 1 to 6 months = liquids
children aged 4 to 7 months = liquids, cereal, pureed foods
children around 8 months = liquids, pureed foods, ground or junior foods, mashed table foods
children around 1 year old = liquids, coarsely chopped table foods, and soft easily chewed meats
children from 1½ to 2 years old = liquids, coarsely chopped table foods, meat, raw fruits, raw vegetables

Progression of food textures includes the following:

strained (homemade baby foods or commercial baby foods)
thickened liquids/smooth foods (baby cereals; strained food thickened with rice cereal)
semi solids = mashed early solids, textured early solids, lumpy solids (see below)
firm, chewy foods (see below)
crisp foods (see below)
sticky foods (see below)
combination foods (see below)
difficult chewy solids (see below)

The above needs to be adjusted according to your child's oral motor development. Please consult with your speech therapist and occupational therapist if unsure about your child's capabilities. To increase food textures from pureed to those with more consistency, I add small rice puffs, brown rice crisps (fruit juice sweetened), or crumbled rice cakes. I do not use other commercial cereals or other thickeners like oats, bran, etc. because of the possibility of poor digestion/added sugar/allergy/celiac disease. Add the rice puffs or crumbled rice cake slowly. You may have to add one piece at a time in the beginning. Most "typical" children don't have problems with semi solids and lumpy foods. Children with Down syndrome don't chew these because they can't feel the texture and the muscles fatigue quickly. One way to help with this is to do oral motor work before and during feeding. Or, you might try alternating a bite of food with a bite of something crunchy if your child is able to do this. Placing a small bite of rice cake on the molars will usually stimulate chewing. Chewing on a Chewy Tube will help also. The following is a list of semi solids, textured early solids, and lumpy foods (ground or junior foods):

mashed bananas or other ripe fruit
mashed potatoes, avocado, squash, carrots, yams
mashed vegetables
mashed stew
mashed homemade noodles or rice noodles (rice noodles in gluten free gourmet cookbook or can be purchased at health food store)
mashed scrambled eggs
soup broth with softened crumbled rice crackers or softened rice cakes
applesauce
mashed beans and rice
mashed tofu
thicken smooth solids with crumbled rice cakes (previously mentioned)

Next, move on to firm and chewy foods. The following are some suggestions:

chopped cooked vegetables
canned green beans
easily chewed meats that are soft and easy to manage: tuna fish, salmon, seabass, other fish, fish sticks, small chicken strips (make sure no bones in the meat)
chicken sausage cut into small pieces and skin removed

Next are crispy foods. Remember to initially place on the molars to facilitate chewing. I include the following:

baked corn chips
rice crackers
rice cakes
rice chips
apple strips (fresh not dried)
small pieces of jicama dipped in hummus for increased taste
small pieces of cucumbers dipped in hummus for increased taste
if giving salad, only give hard white part of the lettuce, as the loose leafy part may cause choking
thin strips of green, red, or yellow pepper if your child likes them

Sticky foods are next but use with extreme caution.

rice cakes with almond butter
rice crackers with almond butter or other nut butter
dried fruit (I usually hold onto one end while a child chews); dried fruit may get stuck in the teeth so follow up with liquid or may need to use toothbrush to avoid dental problems.

Combination foods follow. Avoid combination foods until your child can chew and swallow less complex foods:

homemade chicken veggie soup
soup made with rice
commercial toddler foods
dry cereal with rice or soy milk (almond mild may also be an option if no nut allergy)

More difficult chewy solids (high choking hazard) would include the following:

small cut up pieces of carrots
small cut up pieces of celery (try to peel off some of the thin ribs from the top to avoid choking hazard)
nuts and popcorn (I avoid because of choking hazard)
if you eat beef, here is where a steak comes on the criterion.

It is important to progress through the previous categories of foods slowly. Once your child proceeds to a more difficult level of texture, keep going through all the previous levels. Just try not to stay at an easy level for the entire day. For example, if you have mashed fruit for breakfast, then try to add something requiring more chewing for lunch. It is important to work on chewing every day, or at least several times a week. This can be accomplished with the Chewy Tube, giving tactile cues by touching face, and verbal instruction to "chew". The next section will discuss chewing in more detail.

Note: I never advocate candy, but if you do choose to give candy to your child, never give him hard candies. This shouldn't be given to most children but it should be especially avoided with children who have low tone. It is not safe and can cause choking.

CHEWING

Chewing is something that takes a long time to develop consistently in children with Down syndrome. The reason for this is that the low tone and reduced sensorimotor skills in the mouth make it difficult to perceive certain food textures and also causes premature muscle fatigue. Children with DS will prefer foods that are well flavored because this will improve sensory information and thus improve the motor function of chewing. Children with DS will also prefer things like rice cakes, because the hard crunchy texture improves the sensation of having food in the mouth. When techniques are used to improve sensation, this in turn improves the motor function of chewing.

If you sing along with your child as you teach chewing this may improve chewing attempts. Singing along with the actual up-down movement of the jaw especially helps if paired with a tactile cue, such as tapping the table with each chew or tapping the arm or shoulder of your child.

Songs such as, "(NAME) on the bus goes chew-chew-chew, chew-chew-chew all around the town" (Sung to the tune "The wheels on the bus").
Another song to sing while chewing is "This is the way we chew our food, chew our food, chew our food, this is the way we chew our food each and every day" (Sung to the tune "This is the way we ____").

Verbal instructions can also be utilized with a tactile cue on the outside of the face. For example you would say "chew" and touch the right cheek and then the left cheek to encourage lateralization of the food bolus to both sides of the mouth. You could also place your hand under the chin paired with verbal instruction.

I recommend having a professional (feeding specialist, occupational therapist, or speech therapist) evaluate your child's chewing skills. A parent may think a child is chewing because he/she is demonstrating up and down movement of the jaw but there are many types of jaw movement patterns. For example "phasic biting" is described as quick rhythmical up and down movements of the jaw but lateral movement is absent. In addition this type of chewing is very limited in strength and control. The ultimate goal is "circular rotary chewing" which is demonstrated when the jaw moves laterally/downward/across the midline to the other side/and then upward to close. (Beckman seminar)

Following are some additional ideas that should be used as soon as your child is ready to chew. Ideally these techniques should be done before eating or even during a meal.

Chewy Tubes: These are now available from many vendors and are excellent to develop chewing. Infants can start using them as early as 10 months. In the beginning, dip one end into pureed food or other smooth food such as applesauce and place along the gum line where the molars are or would be. This should stimulate a chew. Just as with anything there are differing opinions as to how to use an instrument. The creators of the Chewy Tube suggest pushing down slightly on the jaw to exhibit a chew, while others may recommend pushing up on the jaw to stimulate a chew. If your child has a tonic bite then I suggest you experiment with both techniques to see which one works best. I myself prefer to push down on the jaw to avoid a child's head from moving backwards with my input (which can happen if you push upwards). It should be noted that while you are using a Chewy Tube, you will observe an increase in saliva and possible drooling. However this is normal and over time you should see better saliva control and tongue retraction. With older children you can put the end in your child's mouth and tell them to close their mouth and try to move the Chewy Tube to the other side of the mouth. (see the end of this handout for various catalog information to order). I do not recommend giving the Chewy Tube to your child as a play toy because they will try to use it as a whistle and it may make it more difficult for you to work on chewing as a therapy intervention.
An important point to remember when working with a Chewy Tube, is that children with DS tend to have jaw instability and they will jut their jaws forward or to the side. You will have to apply pressure on the jaw along with a verbal command such as, "Jaw back" if the jaw comes forward (apply mild pressure with your hand backwards), or "Jaw in" if the jaw moves to the side (apply mild pressure with your hand to correct alignment). Then make sure you reinforce when the upper and lower jaws are in alignment with something like, "Good chewing, I like the way your jaw is moving".
Move your child through a hierarchy of difficulty in things to chew. Here is a possible order of things to chew (chew each item approximately 10-15 times before progressing to the next item): start with the Red Chewy Tube, move to the Yellow Chewy Tube, then the Pink Grabber, and end with the Green Grabber (Many catalogs carry these, but all are available from Achievement Products referenced at end of handout).
Z-Vibe and many Accessories: waterproof oral motor vibrator that stimulates the gums, palate, jaw, tongue and cheeks. Has different attachments including probes and spoon. Can stimulate area needing increased awareness, before progressing to Chewy Tube or other oral motor devices (carried by many catalogs such as Achievement Products).
The previous section gave information regarding food transitions and how to increase texture. Move your child through the appropriate levels throughout the day adding texture to thicken and/or improve sensory information to the mouth. Don't forget that placing food on the molars usually stimulates chewing.
Give jaw assistance/resistance manually by placing your hand under the jaw if wide jaw excursions are present. Also pushing up on the base of the tongue (located outside of face slightly behind the chin before the neck), will assist with tongue protrusion.
"Nuk" exercises to encourage lateral tongue movement and tongue tip elevation will help teach your child to move food around in the mouth more efficiently. You can perform a series of resistance exercises with the Nuk to the tongue and lips. A tool actually designed for lateral tongue movement is called the Oro-Navigator and is available from Achievement Products (see end of handout). Debra Beckman has a series of exercises that she recommends to enourage lateral tongue movement and tongue tip elevation. Her website offers information about therapist's who have received training in her techniques.
Toothettes are frequently used in oral motor therapy. Toothettes consist of a soft pink sponge on the end of a stick used medically as a toothbrush and can be ordered from catalogs or ordered directly from pharmacies. Place the toothette in the middle or your child's tongue. Instruct your child to push his tongue up to the palate (roof of the mouth) to squeeze the sponge. If your child has tactile sensitivities you will have to progress slowly with this exercise. Initially your child may require you to push up on the jaw to obtain the squeeze.
Parents have asked me, how do children chew when they don't have any teeth? Babies are learning to chew all along way before their permanent teeth come in. When a baby picks up something and places it in his mouth and maybe gnaws at it or makes up-down chewing motions, this is pre-chewing behavior. When a baby picks up a cookie and takes a bite, he at first mashes it and then may make a munching movement. He is beginning to learn to chew. The Chewy Tube will help with chewing development, and as I stated, can start being used as early as 10 months. Then when teeth do come in, your child will have many of the muscle patterns already developed. I recommend you get both the red and the yellow Chewy Tubes. If your child does not have his molars yet you can not move up on the food hierarchy. I personally wouldn't attempt anything in the difficulty chewy solid category if my child did not have his molars. You can however chew/mash really soft meats and small pieces of bread/crackers, etc. Typical children have most of their temporary teeth by 24 months. Our children are slower in this so you have to individualize and progress up the food hierarchy slowly under the guidance of a specialist who regularly works with infants. (Note: Suzanne Evans Morris' book goes much more in depth into chewing. You can order from Speech Dynamics or Mealtimes catalogs referenced at the end of the handout)

STRAW DRINKING

For some children straw drinking will be easier to learn initially than cup drinking. This is due to difficulty with managing thin liquids and severe oral motor delays. Therefore a brief discussion on "how to teach" straw drinking follows. The "typical" child can learn to drink out of a straw as early as 10 months of age. Children with Down syndrome may take longer than this, but keep trying every few weeks to see if your child is ready to learn this skill. I suggest starting between 1 to 2½ years of age. If you make drinking "fun" your child will think it is fun too! When beginning to learn straw drinking, a child may need varying degrees of manual support from you: a) upper lip support (finger on upper lip above vermilion which is the pink part of the lip,), b) bottom lip support (finger on bottom lip [below pink part of lip]), c) both upper and bottom lip support (index finger on upper lip with middle finger on bottom lip), d) or maximum assistance (index finger on upper lip, middle finger on bottom lip, ring finger under jaw for jaw support). Following are ideas for teaching straw drinking. Initially your child may be confused between sucking and blowing especially if you have encouraged whistle blowing.

Place a straw into a full glass of water or other liquid. Cover the end of the straw with your finger. This will hold the liquid in the straw. Remove the straw from the glass and place the open end in your child's mouth. Remove your finger and the liquid will flow into your child's mouth. You may want to give a verbal cue such as "close your lips" so your child will close his lips around the straw. Slowly present the straw at lower and lower angles so eventually your child will have to suck the liquid out of the straw.
Use a boxed-juice drink with straw. I prefer ones that have no added sugar. Place the provided straw into the drink. Put the end of the straw into your child's mouth. Squeeze the drink and a little liquid will come out of the drink into your child's mouth. The provided straw on this boxed drink may be difficult for some children to learn from because it requires a lot of lip closure. So in this case, make the hole larger and use a wider straw. With my own daughter I found that the thinner straw was easier than the wider straw because she had a great deal of difficulty managing all thin liquids. The thinner straw helped limit the amount of liquid being sucked, thus helping her achieve better control to swallow adequately without choking. So experiment with different straw widths.
Make your own squeeze bottle. Go to a beauty supply store and buy a clean unused applicator bottle (used for hair color treatment). Go to a hardware store and buy "food-grade" polyvinyl chloride tubing. After washing everything, assemble your drinking bottle by snipping off the end of the applicator bottle so that the tubing will fit snugly inside, down to the bottom and extend outside the top of the bottle an inch or so. Now place liquid inside and every time you squeeze the bottle you can control the amount of liquid going into your child's mouth. I usually start with thin tubing, but as stated above some children may not have the necessary lip closure to be successful with a thin width.
When I first start teaching straw drinking, I try to encourage lip protrusion and extension and tongue retraction. (Debra Beckman's exercises help with this) You do not want your child's tongue to be under the straw at any time when learning to drink from a straw. If the tongue touches the straw or is under the straw you are encouraging tongue thrust behavior. I encourage the use of lip blocks on straws so a child will not put too much of the straw into his mouth. To make a lip block cut off about 1/3 of a wine cork. Keep poking out the middle with some instrument such as a skewer or exacto-knife until you get a hole big enough for your straw to fit through it. Place the cork on the end of the straw so no more than ¼ to ½ inch is available to put into your child's mouth. You may have to place a rubber band or tape under the cork to keep it in place. This way your child will be unable to bite the straw or place his tongue under the straw. He will be using true lip protrusion/extension with tongue retraction. You can also puchase plastic lip blocks from Innovative Therapists International.

CUP AND STRAW DRINKING

Next we will discuss cup drinking and cup selection. I am on a constant search for good drinking cups. It is my opinion (based on my study of myofunctional therapy) that cups with a protruding spout are not a good choice, but especially should not be used with children having low tone. What happens is that children with low tone will usually bite on the spout, put the tongue underneath the spout, or develop other incorrect swallowing patterns. Cups with an attached straw or ones having a sunken lid with holes are better selections. If using a cup with a straw, it is important not to allow your child to put more than about ½ inch into the mouth. You do not want the tongue to be under the straw or the cup rim as this will reinforce tongue-thrusting behavior. To control this when using a straw, you can slide a lip block on the straw to prevent the lips from going beyond the designated point (discussed previously).

Trainer Cup has an inverted lid to reduce the flow of liquid and helps children to drink from a regualr cup; has a spill proof lock lid; available from Achievement Products. I have not used this cup but it looks like one of the best of the spout free cups.
Sassy makes a cup called the "Snack 'n Sip Infa-Trainer Cup" and it can be ordered online from www.baby-wise.com. My Sassy cup tends to leak if the lid is not screwed on correctly. I don't know if they all leak. It is a nice transition from bottle to cup drinking as it controls the flow of liquid, has a slight rim and a sunken lid with a few holes in it (I actually tape some of the holes to make the flow even less). The Sassy web site www.sassybaby.com lists lots of cool baby products but you cannot order directly from them you have to locate a store in your area carrying their products.
Cut-out cups (nosey cups) are good for cup drinking. They help control the flow of liquid and have a cut out section for your child's nose. In this way the head can remain flexed forward for drinking. Does not have a lid. Can be ordered from many special-ed catalogs and also from Achievement Products which also carry nosey cups with child's handles.
Playtex Cup available at Target, Walmart, etc., has flexible straw that bends and folds down when you snap the lid forward (closed); with the Playtex straw, you can cut the straw to a shorter length or slide a lip block onto the straw; sometimes children will still tongue thrust if you cut the straw so always monitor where your child is placing his tongue while drinking; this cup has leaked for me so be careful when tipping on its side.
Spill-Proof Cup with attached straw is available from Achievement Products (referenced at end of handout) is great because it doesn't tip over and spill and has a straw, but you can only fill the cup half-way. Also available from www.kcup.com
Some sports bottles with straws (may need a lip block if too much is placed into the mouth). Lip blocks can be hand made from corks with holes placed in them or plastic ones can be ordered from Innovative Therapists International at 1-888-529-2879. This company also offers cups with straws.

Periodically evaluate your choice of cup and your child's drinking skills by looking for the following negative behaviors. If any of these behaviors are present it's time to change cups or to work on oral-motor skills to extinguish. For example, a simple behavior such as lip licking will need to be extinguished by calling attention to it initially and rewarding when the behavior is absent:

Chew marks on the straw or cup rim (your child needs more jaw stability).
Tongue thrust while drinking; you will see the tongue come out to meet the straw or the cup when drinking; when swallowing the tongue will be seen coming between the teeth.
Previously discussed was spoon feeding. Tongue thrust while eating soft semi-solid foods will influence drinking also; as in above you will see the tongue coming out between the teeth upon swallowing.
Incorrect tongue placement under the cup rim or straw while drinking (a tongue should be retracted into the mouth while drinking and you should not see it at all).
After taking a drink you may see negative habits such as licking lips. This is a negative habit that reinforces tongue thrusting and needs to be extinguished.

OTHER TOOLS FOR ORAL MOTOR

A complete set of straws, sequenced in a hierarchy according to level of difficulty, is available from Innovative Therapists International (see end of handout). These straws offer excellent ways to achieve additional oral motor control, especially tongue retraction, lip protrusion/extension. So after your child masters straw drinking, you may want to purchase a set, and take them through the straw sequence to further improve oral motor function. You can order the video along with the straws which details the program, or ask your speech therapist to order it. I have found controlled straw drinking helpful with children having tongue protrusion/tongue thrust but they are not the complete answer. Make sure to use lip blocks with the straws. They advocate the use of pudding at one point in straw drinking treatment, and you can use a homemade fruit/juice smoothie (difficult to control thickness) or a brand of pudding by Imagine Foods that is made from rice starch and brown rice syrup as a sweetener (it's a little sweet for me!). You may have to dilute the pudding with water to a thinner texture initially. Innovative Therapists International also offer a set of whistles designed to accomplish the same outcome which is lip protrusion and tongue retraction. Other claims regarding how these influence sound development I haven't found to be true. However the whistles are an excellent tool to help your child develop oral motor integrity.

A word of caution: Oral motor treatment does not always equal "talking". Oral motor treatment yields good oral motor skills and the appropriate environment for good articulation.

The best of luck to you all as you endeavor to help your wonderful children. They challenge us to be our best.

MATERIALS SOURCES (others referenced in article)

Achievement Products:: A one stop shopping place with many oral motor supplies, cups, feeding utensils, perceptual aids, fine motor/handwriting tools, gross motor and sensory-motor tools, etc.; can be reached at 1-800-373-4699 or online at www.specialkidszone.com
ARK Therapeutic Services:: A designer and manufacturer of speech therapy products, occupational, adult care, eye care, and respiratory products, and early childhood developmental toys and tools; contact at 803-438-9779 or on the web at www.arktherapeutic.com
Debra Beckman:: Website and contact information regarding oral motor exercises and locating a therapist in your area with Beckman training: www.beckmanoralmotor.com; dbec1998@aol.com
Mealtimes Catalog: New Visions:: A good resource for oral motor, feeding and mealtime programs; contact at 1-800-606-7112 or on the web at www.new-vis.com
Medela:: Medula is a distributor of the Haberman feeding system and can be reached at Medula, Inc., P.O. Box 660, McHenry, IL 60051-0660; phone is 1-800-435-8316; they also have information and local resources in your area for breastfeeding
Respironics:: Referred to in article as distributor of baby nipple from Japan; can order at 1-800-345-6443
Speech Dynamics:: oral sensory-motor training techniques and tools, lots of oral motor and feeding supplies; contact at 1-800-337-9049 or on the web at www.speechdynamics.com
Super Duper Speech Company:: A favorite catalog of speech therapists containing a wealth of supplies for oral motor, articulation, language, etc.; contact at 1-800-277-8737 or on the web at www.superduperinc.com
Talk Tools: Innovative Therapists International: Lists many oral motor tools including whistles, cups, videos, and infant feeding tools; contact at 1-888-529-2879 or on the web at www.talktools.net