In conversation during therapy, six year old Nikki could accurately say S and Z words like “Stephanie”, “sorry” and “pretzels“. The second her mom joined us to wrap up our session and discuss homework, Nikki immediately lost correct tongue placement, exhibiting a tongue thrust.
Oral placement therapy had previously been addressed. Nikki’s jaw, lips and tongue were strong and stable to support all speech sounds.
Nikki’s mom found it frustrating to frequently remind Nikki to use our techniques, and Nikki didn’t enjoy the nagging. What to do? We added Sticky Tape (AKA Sticky Spot)!
Sticky Tape acted as a tactile reminder. Nikki’s tongue tip was naturally drawn to the tape. We also found when Nikki’s mouth was at rest, she did not exhibit her classic open mouth / tongue protrusion posture. Sticky tape helped to habituate appropriate tongue and lip position.
Sticky Tape is a smooth, thick, medical grade tape. We fixed a small square (about 2cm x 2cm - sometimes a slightly bigger size is more effective) just behind, but not touching, the two top central teeth (upper central incisors) at midline on the hard crescent shaped area (alveolar ridge).
This spot might also be called the special spot, secret spot or as Robyn Merkel Walsh calls it, The Smile Spot.
When I asked Rhonda Collier of myomadeeasy what the Sticky Tape is made of, she wrote:
My prior research into concerns about possible allergens revealed that the content of the product is free of common irritants or vegan objections. The main ingredients are pectin (if you’ve ever made jam you know how sticky this is!) and fruit cellulose which is technically the cell walls of plant fiber. We use similar flavorings as used in orthodontic offices to flavor impression molds.
The unflavored tape from activeforever and the tape from myomadeeasy are both Stomahesive Skin Barrier made by ConvaTec. Myomadeeasy just adds flavoring.
Children enjoy the option of the flavors, but the flavor wears off quickly.
I found Sticky Tape to work most effectively when it was applied after meals. The tape may dissolve, fall out on its own, or it can be carefully removed. Some children don’t mind eating with the tape in place. Generally, three small squares are used each day.
The Sticky Tape sticks best when a child swallows saliva first. Next, dry off the alveolar ridge with a small piece of paper towel. Take the small square of Sticky Tape you have previously cut and hold the tape in the correct place while you sing a song or tell your child about your day. After about a minute, the tape should adhere.
In addition to using the Sticky Tape, Nikki and her mom followed the plan below for homework:
Tongue Tip Placement Reminders:
1. Nikki should follow the rules below for swallowing all food and liquid. These rules are adapted from Sara Rosenfeld Johnson’s Therapeutic Straw Drinking / Single Sip Swallow technique:
A. Place the top ¼ inch of the straw between your puckered lips at midline (or if you drink from an open cup, lips only on the rim (no teeth)
B. Sip in the liquid until you feel it in your mouth
C. Remove the straw but do not swallow the liquid
D. Close your lips as you put your tongue tip up to the secret spot
F. Swallow the liquid without moving your tongue tip
G. Open your mouth, your tongue tip should still be on the secret spot
3. Tongue Tip Elevation with Cheerio - Place a Cheerio on the secret spot. Nikki should place her tongue tip into the center of the Cheerio. Her jaw should be relaxed and open about one inch. She should hold the Cheerio with the tip of her tongue for 50 seconds, 3 times per day.
Traditional Carryover Tasks:
When Nikki is turning a page, encourage her to self-monitor. Encourage Nikki to point to a drawn out “happy” or “sad” face to let you know how she thinks she did.
2. Talk about using accurate S’s and Z’s before school, when she gets home, and before you practice.
3. Have a focused period of time (about 15 minutes) each day where Nikki is concentrating on using S and Z properly in conversation. Set a timer, as necessary.
4. Choose high frequency target words that she must always say correctly (e.g., please, strawberry, school).
5. Use a mirror for visual feedback or a video camera to record a sentence or two Nikki says. Have her critique her own speech.
6. Encourage Nikki to speak slowly all the time.
Additional Notes / Tips:
Nikki has a bad habit of clenching her jaw when she tries too hard to say s/z or when she fatigues. Encourage her to relax her jaw if this occurs.
Watch out for words that trip her up: S at the beginning and at the end of the same word (e.g., socks) – and TH blends close to S and Z (e.g., the zebra).
We also found it helpful to recruit Nikki’s teacher to help with carryover. Nikki and her teacher made up a private hand signal. If Nikki mispronounced S or Z, her teacher made eye contact with her and touched her own nose. Nikki knew to slow down and say s/z correctly. Her teacher also gently reminded Nikki to use her special swallow at snack and lunch time.
Additionally, a few therapy sessions in the outside world (e.g., grocery store, library, toy store) using our techniques with store employees helped to solidify our work.
This summer, Nikki is happily using correct productions of S and Z in conversational speech without Sticky Tape or reminders!
Stephanie Sigal is a New York City speech therapist working on Manhattan’s Upper East Side. She works with children with articulation and language delay. You can read more about her work at sayandplayfamily.
A speech therapist recently wrote to me about a child she is working with. Some of the information has been edited for privacy purposes.
Question: Stephanie, I am working with a 6 year old boy who is drooling. He had his adenoids recently removed. His parents have noticed a decrease in his drooling, but the problem still persists.
He does not have open lip posture, his top teeth slightly protrude and he swallows nicely on command. His awareness of his excessive saliva is poor. This saliva impacts his articulation. When he swallows, his speech (articulation and vocal quality) are more intelligible.
What can I do to help this student? Any specific oral motor exercises you recommend?
Answer: Take a look at his tonsils. I’m wondering if he has a tongue thrust since you noticed his top teeth are protruding. The tongue thrust may be occurring for a variety of reasons, including large tonsils (the tongue will be misplaced anteriorly if the tonsils take up too much room posteriorly). If you feel his tonsils are enlarged, it may be appropriate to revisit the pediatric otolayngologist (ENT).
If you are in NYC, you can find a list of pediatric ENT’s here.
As with any oral motor work, you have to start from the bottom-up. Make sure his body posture and jaw are strong and stable, then the tongue, and finally the lips. Weakness at any of these levels needs to be addressed. Have you taken any good oral motor courses? Try renting Talktools / Sara Rosenfeld Johnson’s level one class to get started, if you feel this is an area you need experience. Once you know his jaw, lips and tongue are strong and stable, here are some Ideas To Eliminating Drooling:
1. Help him become aware of his mouth
2. Improve his swallowing frequency and efficiency (he needs to fully retract the saliva)
3. At rest, his lips should always be closed
Talk to him about wet vs. dry mouth, lips and chin to build his awareness. Have him wear terrycloth wristbands. Ask him to wipe his lips and chin when they are wet. Each time he wipes his lips and chin, he should be reminded (until he does this independently) to swallow. You may need to teach him the concept of swallow. Wristbands will also act as a visual reminder to dry his face and to swallow. Purchase a few pairs as they need to be washed daily.
If you or his parents do catch him with lips apart, remind him to keep his lips together, especially at rest and when he is actively involved in a task. Can he keep his lips closed during a fine motor task?
To help him build awareness of his lips, have him put on flavored Chapstick, make “raspberries” and smack his lips. If it is safe to, and he can tolerate vibration, use a gentle, child-sized battery operated toothbrush to brush his teeth, inside of his cheeks and tongue. With firm (not too hard / not too light) pressure, run the toothbrush over his lips, to stimulate them / make him more aware.
Good luck – please let me know if you have more questions.
P.S. Should you actively work with this child for 4 weeks (and speech homework is consistently practiced) and improvement is not observed, a follow-up pediatric ENT visit is critical.
Stephanie Sigal, M.A. CCC-SLP is a New York State and ASHA certified Speech and Language Therapist. She works with children with articulation and language delay, as well as with children that drool and suck their thumbs on Manhattan’s Upper East Side. You can contact Stephanie at email@example.com.
Additionally, should a speech therapist suspect enlarged tonsils or that there is an anomalous issue contributing to the tongue thrust, a referral may be made to a pediatric otolaryngologist (ENT).
A bill that required a dental decay warning label on sippy cups and baby bottles was vetoed by Governor David Paterson yesterday. The label would have alerted parents that there is a risk of tooth decay from prolonged use of a “vessel with a duckbilled lid, bill-shaped extension or bill-shaped spout”.
In his veto message, Governor Patterson wrote: “Brief warning labels are simply not the best vehicle to convey detailed information about general parental practice and proper use of a product that is not inherently dangerous.”
Sippy cups and prolonged bottle use may cause more than dental issues, they may cause speech delay / articulation delay. Each time I speak with parents of a new client, I always ask what type of drinking cup their child uses. Children age 4 or younger often use a sippy cup because it is convenient for the parents (the cup won’t spill liquid) and toddlers and young children love it because the suckling motion used to remove the liquid is soothing and organizing.
When a child suckles from a sippy cup, bottle, breast or on a pacifier, thumb, etc., the jaw, lips and tongue all move simultaneously. This movement is repeated over and over when a child drinks from a bill-shaped spout or sucks on a pacifier throughout each day. This does not allow the jaw, lips and tongue to work separately, which is what is necessary for clear speech.
Children with tongue thrusts have often used a sippy cup or the like way past age one, when their usage should have been eliminated. This of course should not be the case if nutrition is compromised. When the tongue thrusts forward, it may push against and displace the front teeth resulting in orthodontic issues.
What type of cup should your child use instead?
Teach your child to drink from an open cup, which they should use while seated at the table. Encourage your child to take sips with only his or her lips on the cup, not the teeth / jaw.
When you are outside, you can try having your child drink from a straw cup (preferably one without a one-way, spill preventing valve). Although it is very likely he will suckle on the straw (he may place an inch or so of straw between his teeth and pump the liquid into his mouth with help from the jaw) you can encourage him to only place the tip of the straw between his puckered lips and not to use his teeth.
If you feel that your child already has articulation issues, and you have eliminated the use of sippy cups, etc., it may be best to meet with a speech therapist who can guide you on good speech habits, including therapeutic straw drinking.
I provide private speech therapy in children’s homes in Manhattan / NYC’s Upper East Side. You can contact me, Stephanie Sigal, M.A. CCC-SLP, at firstname.lastname@example.org or 646-295-4473.
Read the article from Crain’s.