oromotor problems

1. Drooling or lack of salivary
control
► Drooling and lack of salicilary control can be
caused by several factors. Saliva
management is an automatic response to
the pooling of saliva in the oral cavity. Saliva
production is individual and is affected by
stress, level of hydration, swallowing ability
and sensory awareness. It can be affected
by the sweetness of food sources as well as
sympathetic nervous system responses.
Management of salivary control is affected
by muscle tone, awareness, coordination,
structural alignment, and strength.

2. ►Frequently sensory awareness is low in
the neurologically involved as well as
in the sensory integratively involved
child. This lack of awareness makes it
difficult to react to saliva, which gives
little sensory information.

3. ►Structurally the approximation of the
lips with jaw closure may be impaired
because of poor jaw strength. Low
tone may affect the intra and peri oral
structures permitting an open mouth
posture and the ability for saliva to
overflow onto the chin or shirt.

4. ► Swallowing rate or competence may also be
impaired in these children. Coordination of
food sources, transit of the bolus and
swallow rate may all be impaired. The
tongue and lips may not be able to collect
and transport liquid efficiently. Swallowing
is influenced by strength, sensory
awareness, coordination and alignment.
► Poor alignment of the head and neck may
also impair swallow with the structures
being out of alignment for adequate tongue
and palatal elevation.

5. ► Swallow rate may be affected because of
low tone and weakness of the posterior
tongue and soft palate and peri oral
structures. Propulsion of the bolus may be
impaired from a strength, timing or
coordination perspective in control.
► The head and neck structures may be
unstable and posture in a forward flexed or
a hyper extended position. A forward flexed
head may encourage spilling of saliva from
the oral cavity very easily. The hyper
extended head observed in some

6. ► categories of CP may over stretch the neck
muscles and stage poor alignment and
control of swallow.
► The hyoid bone, which stabilizes the tongue
base, is suspended on the anterior surface of
the neck. This bone is a dynamic point of
control for the tongue. When the anterior
neck is over stretched and the posterior
shortened the tongue base has difficulty
with control.

7. ►The head and neck function from a
point of balance on a dynamic trunk.
When the trunk is poorly aligned or
controlled the oral mechanism is
misaligned as a result. Frequently the
oral mechanism is sacrificed to add
control to the postural system. Head
and neck extension is often coupled
with abnormal tongue retraction in
some children to elevate the head.

8. ► Over production of saliva can cause social
discomfort for a child who does not manage
his secretions. This also creates the
potential for aspiration. Foods, which are
liquidy and sweet, create the greatest
amount of saliva and may place these
children at risk when managing foods with
saliva. When children have difficulty with
swallowing they may drool in order to create
a strategy for not choking.

9. ► How then do we approach drooling? First you must do an
analysis of the structures, sensory awareness, swallow rate
and competence of swallow with the coordination of breathing
and movement, We must be aware of alignment and
coordination issues which impair swallow. Assessment of
postural control, hydration and any medications, which may
impair oral control, should also be considered. Seizure
medications can impair cognitive awareness in some
individuals. It may also lower oral facial tone and decrease the
rate of swallow leading to drooling.
► When tone, weakness, alignment and coordination are
impairing control we must address all of the above. Expecting
a child to control

10. ► the oral mechanism when it is incapable of
approximation and muscular control is an
inappropriate expectation.
► Identify the problems interfering with oral
control and nonconsicious swallowing
becomes important. Identification of the
problems interfering with control of saliva
can guide us to direct our treatment
methods to the component parts of
swallowing and management of salicilary
control.

11. FEEDING AND THE FEEDING
RELATIONSHIP
► Feeding is a sensory motor and a social interaction
process. Children who are attached to the feeding
process usually have a special bond with the feeder
and the food source. Attachment begins with the
feeding and nurturing process between the feeder
and the child. In most societies feeding is a social
and emotional process as well as a motor ability.
The meaning of food grows during the process of
feeding and is expanded throughout our lifetime.
Intimate feeding of an infant grows to a social
interaction with a family, friends and society. Social
and emotional bonds are integrated with our
feeding processes in most societies. Eating is a time
of social regard and sharing. It also may be a time
of comfort for many people.

12. ► Children initially feed with a parent in close sensual
contact. The feeling of comfort and attachment
between the feeder and the child is one of the
major supports for competent feeding. In many
studies of children who were failure to thrive
attachment was one of the primary issues between
the feeder and the child. However, attachment is
not the only reason for competent feeding and
adequate intake. While it is true the sensitivity of
the feeder to the child’s cues of hunger, satiation
and need for pacing is very important. The child’
neurological capacity of the neuromuscular
mechanism is extremely important for competent
feeding to ensue.

13. ► As the child’s abilities progress the feeding
process expands to include a variety of
feeders, varied environments with
introduction of multiple food sources,
textures and eating experiences. As the
child matures alternate methods of feeding
such as finger or utensil are introduced into
the situation. A child begins to build a social
process, and self-control around feeding
with the interaction with others who share
the feeding environment.

14. ► The attachment to the feeding process as
well as the feeder is sensory motor
modulated as well as is socially emotionally
integrated. Feeders, who are attached to the
child and can create a positive environment
during the feeding process, are the most
successful in feeding. Control issues often
arise between the feeder and the child when
amount and types of food sources are the
focus of the interaction. The feeders
responsibility is to provide food sources to
the child the child’s responsibility is to eat

15. ► High levels of stress and anxiety in the feeder are reflected in
the child’s ability to feed comfortable. Children intrinsically
attach to the anxiety and nonverbal postures of the feeder and
may not feed well. There can be much emotion surrounding
the inability to competently feed your child and have them
grow. Parents often feel a sense of failure or rejection from a
child who does not feed easily. When children do not give the
feeder clear cues during feeding the feeder may be
conditioned to not offer food sources as often. Children who
require excessive amounts of time and special management
require great commitment and patience form the feeder. A
busy household, high demands and a difficult child to feed
may make the feeder reluctant to feed.

16. ►Children who have difficulty feeding
may appear lethargic, cranky, aversive,
or not interested in feeding. Normal
hunger cycles and difficulty with
maintaining an alert state may give
the feeder poor reward or inaccurate
cues about hunger and satiation.

17. ► Feeding a special needs child often creates
conflict in the home situation. Parents often
have high demands on their time within the
home and feeding a child who requires a
great deal of time interferes with their
ability to perform other duties. Also in
modern society frequently parents have
alternate caregivers when the parent is
absent.
These caregivers may not be as sensitive to
the child’s needs in feeding.

18. ► Children with sensory motor difficulties can stress
the feeding relationship as well as are stressed by
the feeding relationship and mechanical
presentation of foods by the feeder. An
understanding of the child’s abilities, emotional
reactions and best method of port is entwined with
competent feeding by the feeder and the child. The
assessment of the feeder and the child’s ability to
provide competent intake and interaction often
requires the attention of a specialized individual
who can support the process.

19. ►STIMULATION OF THE ORAL
MECHANISM

20. ►Manual interventions and sensory
treatment of the oral mechanism have
been developed to assist the child to
gain control of the oral structures for
feeding, swallowing and sound
production. These techniques used
with adapted methods of feeding can
assist children who exhibit oral deficits
to gain motor control and maintain the
ability to orally feed.

21. ►Treatment of the oral mechanism to
address abnormal motor control and
feeding issues should be approached
respectfully. It should be guided by
the acknowledgement of the personal
nature of the intervention to the
recipient. Treatment and its
relationship to the child and
caretaker’s responses require
sensitivity from the interventionist.
Oral mechanical treatment should not
be undertaken in an invasive manner.
Nor should the caregiver be made to