Unknown Speaker  0:03  
Hello everyone and welcome to our special session where we discuss speech and feeding techniques for children with Moebius syndrome. Our guest presenter today is Rene Roy Hill. And we are thrilled to have her just to tell you a little bit about Renee. Renee is a speech and language pathologist, certified orofacial myology artist, and has provided therapeutic assessment and program planning for adults and children with oral placement, beading and motor speech deficits for over 17 years. She's the owner of Crossroads therapy clinic in New Braunfels, Texas, and a member of the top tools speaker's bureau. Renee has been an invited speaker for assha state conventions and has specialized training in speech, oral motor feeding therapy approxima sensory processing disorders in di t training and prompt. Rene is the co author of AI sticks and the author of top tools.

Unknown Speaker  1:05  
Apache kit,

Unknown Speaker  1:06  
approximate a kit. Yes, sorry. Thank you, Renee. Renee has also we've been so lucky she's attended several Moebius Syndrome Foundation conferences, and is also a member of the Moebius Syndrome Foundation Scientific Advisory Board. Welcome, Rene, thank you so much for being here.

Unknown Speaker  1:21  
Thank you for having me. I wish we were in person, but we're gonna deal with this one more year. And then we will all be together next time for sure. Let me go ahead and share my screen here. So we have something to look at. Okay. So yes, thank you for having me, I, I miss going to my Mobius conferences, I, I cannot remember, I need to go back. And look, I don't remember the first conference. But it it was with Sarah rose and Phil Johnson. And she brought me every couple of years when we had our conferences, we did little mini evaluations. And I started to learn more and more about working with people with Mobius. As all of you probably know, it's pretty rare and for those of us practicing around the country, as a therapist, in my own clinic, we don't see a lot of kids or adults with Mobius. So my my primary exposure and my primary work has been in the conferences, and then following some of those kids that I evaluated over the years and have really enjoyed my, my work with you guys. So what I wanted to talk about today is, um, some of the speech and feeding issues that we run across with people who have Moebius syndrome. And it's, you know, it's obviously a motor speech or a motor motor problem, but it's a motor problem. That's a lot different than what we typically work with when we work with people with motor issues. And years ago, when Sarah was first introduced to working with people with Mobius, we really didn't know how our approach the top tools or oral placement approach was going to work. But like Sarah always said, we're always willing to give something a try. And we never know where it's where it's gonna go. And that's kind of how Sarah started. And she had a client who had some success, who's then shared that success with another family, and it just kind of grew from there. So I, I consult and talk with all therapists and families all over the world on Mobius. And so I don't forget to tell you at the end, if you ever have questions, or your therapists have questions, because they've never met a person with Mobius, and they're not sure about what to expect, I'm going to have a handout available from this presentation that a lot of therapists have said have been very helpful. And then I will be giving you my email address at the end. So you can always share that information. So I'm just going to jump right in and see how much time we have and what we can get through. This is really going to be an overview. Obviously, we're not going to have enough time to teach everything I would love to teach you as a parent or as a person with Moebius, but give you the things that we look at. And we think about when we're talking about treating speech and feeding problems from our motor perspective. And we know most people with Moebius the primary issue is a motor issue. And sometimes we see other issues with it as well. We might see sensory issues and some kids who might have cognitive delays or autism as well, but we're going to Really focus today on the motor side of things and how we needed, what we need to be looking at and thinking about and how we're going to go about treating some of those problems that we see. So some of the common deficits that we see that affect feeding and speech and Moebius that also affect their progress are a few of these things listed here. So first thing, reduced oral sensitivity, when you have muscles that don't have good nerve innervation, and from what we know about Moebius, that's kind of one of the biggest problems is the nerves don't go to the muscles, so the muscles don't fire and move, that also can be accompanied by

Unknown Speaker  5:49  
a different type of oral sensory system. Some of our kids we work with can be over sensitive and certain parts, and under sensitive and others, and that can kind of be confusing when you're trying to learn, to eat and to speak. And some of our clients have maybe a normal sensation on one side, and then maybe limited or, or less sensation and others. And so oral sensitivity is a big part of what we look at. and try and understand a little bit more individually. I wish I could say that all people with Mobius have this type of sensory system and this is what we do. But it's that's not the case, it varies person to person. And so we we have to take into account that reduced oral sensitivities, especially in the areas that aren't moving well, where the nerves aren't getting there. And that's a that's a big part of what we think about as we start to provide treatment, how can we increase oral sensitivity, so that we can get those muscles to move, and we're going to talk about that for feeding in for speech. Another big one is incomplete lip closure. And we see this typically in our bilaterally affected clients. Sometimes our clients who only have one side affected will have more lip closure, because they can use the other muscles on the other side to help pull some of those muscles that aren't activating. But incomplete lip closure is one and one that was thought maybe not to be able to that we might not be able to do anything about but through Sarah Rosenfeld Johnson's work with people with Mobius in the early the early times, and don't say early times, like it was 100 years ago, it wasn't that long ago. But when she first started, we started to recognize that we could get lip closure for some of these clients. And I'm going to talk a little bit more of that as we go. Reduce tongue control is number three. And this results in limited abilities to suction. And so when I talk about suction, that's the tongue going up into the roof of the mouth that we use for oral rest posture. So if you're sitting here watching and your mouth is closed, if you think about where your tongue is, if it's in the right place, it should be sectioned up slightly into the palate of your mouth, the upper palate, and we see that some of our people with Mobius have trouble with this retraction, which is the ability to pull the tongue back into the mouth lateralization. That's the movement moving of the tongue side to side. And we see that sometimes they have trouble doing this side to side movement that's needed for managing solid foods. And then tongue tip pointing being able to contract all the muscles of the tongue to make a point. And pointing is really important when we think about speech because we use our tongue tip to make lots of sounds. And so some people with Moebius not all have some trouble with with tongue control. And that's just telling us that there's maybe multiple nerves that are impacted with these particular clients. Weak jaw musculature is a is another big one that we see across the board with many of our clients with with muscle base deficits and in Mobius, whether it's just inability to use lip movement, or tongue movement, or the combination of both your jaw muscles really develop as you develop function from when you're born. And most of that is developed through speaking and eating.

Unknown Speaker  9:51  
And so a lot of people with Moebius tend to learn different ways to manage food and eat food and different ways. To speak, and that results in those muscles just not developing the way they're supposed to. So we do a lot of work with on the job as well. And then number five, poor oral rest posture affecting overall mouth development. And this is something that I've just gotten into in the past few years, I've become what's called a Certified Oral facial biologist. So if you've heard of orofacial, myology, we look at how the rest posture of somebody's mouth affects how dentition is coming in how the jaw grows, how the whole face grows. And then it also will affect speech possibly, and nose breathing, which is a big, a big part of just healthy oral development. So when we, when we talk about a good oral rest posture, our jaw is up high, our lips are closed, our tongue is suctioned up into the palate slightly, and we're breathing through our nose. And that's the posture that we want, we want to see people in and when you have jaw weakness, and limited tongue control and incomplete list, lip Crow's closure, that oral rest posture changes. And a lot of times what we'll see as at birth, even even babies with Mobius, will have lip closure and their jaws is in the right place, and their tongue is up. But as they grow as their skeleton grows, and all those muscles start to grow, the mouth opening gets wider and wider. And because those muscles aren't functioning, that oral rest posture changes over time. And so when you see some adults with Moebius who haven't had the opportunity to have early muscle based therapy, their oral rest posture might be bigger than somebody who's maybe two or three. And that's that happens with all of that growth. And so part of what I'm looking at now, with all of my clients, Mobius and and other diagnoses is, what is that oral rest posture? And how can I help them develop healthy, that a healthy oral rest posture as part of my oral motor program. So we're really kind of looking at oral rest, posture, feeding and speech more than just feeding in speech. Now, we're, we're getting smarter. as we learn more. One of the other things, so those are characteristics that we can control, and we can work on and we can change, what we can't change is the is the the underlying structural piece. And so by that, I mean, what has happened with that particular client's nerve innervation. So, you may have heard people say, your child has paralysis of the muscle, they may say paralysis, sometimes they're used interchangeably, even, even though they have two completely different meanings. And if you're not sure, this is something you might want to try and look a little more into before starting a program. Because what we know is if the muscle is paralyzed, that means there is no motor function and no sensation, which means the nerve isn't getting to the muscle at all. There's there's no nerve there, it might have incomplete growth. And so it doesn't get all the way to where it needs to go. When there is a paralysis, we can't create movement just by working on exercise, because exercise and movement requires some amount of motor function. And sensation is what we use to help us get that motor function. And so one of the things we're trying to do with our clients and are in the very beginning is determine if there's paralysis or paralysis through some sensory tests. But nowadays, we can often get that information from MRIs and scans and things and so a lot of families in the last couple conferences that I've been to have been able to say we know that there is a nerve

Unknown Speaker  14:42  
it had they it's been observed. And so then that's what we call paralysis, where there's a partial paralysis. So there's, there's limited motor function and there's reduced sensation, so that that limited sensation and that limited nerve getting to the muscle is affecting how that muscle moves. And so therefore we can we can try and add more sensation to the muscle to try and get more movement. And that is what the top tools program and muscle based therapy, the way we do it is all linked into. So we're we're able to potentially make some changes and improvements for people who have some paralysis. So the the nerves that we're always looking at. So what are the primary nerves that are affected to be able to receive the diagnosis of Mobius, there is some there's an effect to the sixth cranial nerve and the seventh nerve. So are we focused as speech and language pathologists, when we're talking about oral rest, posture, feeding and speech on the seventh cranial nerve that controls the expression and facial movements. And then we also see that some people have other nerves that are impacted. So they might have any one of these affecting the fifth affecting their ability to chew the eighth affecting Hearing and Balance, which can impact a lot of times the whole body sensory system, and sometimes food choices and feeding. And then the ninth nerve, which is the, into the one of the parts of the tongue, that impacts swallowing, and then the 12th, which is another muscle of the tongue. So some people have trouble here with swallowing, some people have trouble up here with eating and moving food. And then some people might have a combination of those. So the more we know about those nerves, and there's, there's way to do nerve testing and those kinds of things. The more we know about that, the better. But a lot of that is observed when we do functional assessments by looking at what, what is happening functionally when they attempt to talk and when they attempt to eat. So that just gives you a little more detail on what we're trying to what we're looking at underneath the surface. So I think one of the things that we need to know, before we talk about what we do specifically is what are the goals of oral placement therapy for feeding and speech. Let me just start off by saying that this therapy does not replace traditional therapy in many ways. It's a piece that we add. And so what we find is that people who are not familiar with oral placement therapy, or muscle based therapy tend to try and improve speech specifically and feeding by putting food in their mouth and practicing and then trying to practice speech and speech sounds. And what we know with people who have muscle based disorders is that we need to work on the underlying system first, so that when we teach speech, they have the motor skills to do it. So let's just go through some of these things that when I when I teach my courses, this is what I'm teaching my, the therapists as, as we begin learning about world placement at their therapy, so Oh, PT, I'm going to call it a PT just for the sake of time, that's what that's the acronym for it is used to increase the awareness of or of the neural mechanisms. So if you're familiar with talk tools at all, you know that we use tools and different things to help to help exercise muscles and get muscles to move the way we want them to. And those tools help give tactile input or the touch feel, which helps many of our children be more aware of their oral mechanisms. So one good example is close your lips and say, you can do that just fine because your your nerves go right to your muscle. You cognitively understood what I asked you to do. And you were able to close your lips turn your voice on direct the air nasal Lee and Satan is a pretty complex sound. So somebody who doesn't have that movement and they say, oh, or Oh, or,

Unknown Speaker  19:43  
um,

Unknown Speaker  19:44  
they don't have the same awareness many times of what muscle needs to move. Okay. We can tell them all day long you need to move your lip but if you can't feel your lip and you can't figure out how to get that that upper lip to move It's gonna be really hard for you to copy my sound. So my tools, for example, let me just grab one here that I can kind of show you as an example here, my tools, this one vibrates. And I can place this here and let you feel it. And a lot of times that feel will help me get more movement. So we're working to, we're using tools and using our hands to help increase the awareness of the oral mechanism. We're helping normalize oral tactile sensitivity. So for somebody with Moebius who has reduced sensation in their upper facial muscles, we're going to do some things to really try and give their give their those muscles in that skin and an all of those, those sensory receptors in there, a lot of feedback so that we can see if we can get some movement from there. So we're trying to help bring it to more of a normal, a normal sensation. We're also trying to improve the precision of the literal movements of the oral structures for speech production. So what this means is, we're trying to help our, our children and adults with Mobius, move those muscles that they're not able to move on their own, to help them then move it into speech. And we're trying to teach them how to do it correctly. And without abnormal movement patterns. So for example, sometimes people who have maybe a unilateral paralysis, one side can close and the other side doesn't close her when I say close your lips. And they use the side that works to try and pull this movement. That's not real precise. So we're going to try and get it to be more symmetrical, because speeches is symmetrical, we're trying to get the left and the right to work as best as it can, together. We're also trying to get in to increase differentiation of oral movements. So this is what we call dissociation, which is the separation of movement based on stability and adequate strength in one or more muscle groups. So I'm going to show you a slide in just a minute, but you base your basic muscles in your in your mouth, or your jaw, your lips and your tongue that we think about for for speech and for feeding. And for people with Mobius, they tend to use the biggest muscle system to help compensate for the loss of the muscles that aren't working. So if my upper lip doesn't move, I'm going to try and use my jaw, which is my biggest muscle group to try and help me get my movement that I'm wanting to. And so we're trying to teach that system to not do that. We're trying to teach that system that your jaw needs to stay still and your lips need to move independently. And my tongue needs to move independently. Okay, so people who don't have good dissociation, tend to have speech, that's not as clear. It's not as precise we it might sound slurry and slushy or some of the kind of descriptors that we use when we're talking about poor differentiation. And so if we can start to isolate those muscles and teach those muscles to move independently, we can help improve clarity and we can help improve feeding function. Because feeding also requires dissociation. If I want to chew at an adult, in an adult in an adult way, my jaw needs to be able to do one movement, my lips have to stay closed, and my tongue is lateralized. And all of that is happening together. If you think about people who maybe don't have that same skill, we might say, ooh, they chew with their mouth open or they smack. Well, that's the lack of differentiation, everything is moving together rather than everything moving independently, okay, so we're going to try and help work on that dissociation. And we do that very systematically. And we do it following normal development of, of the motor system. Grading is the controlled segmentation of movement through space based upon dissociation. So once I can teach you to move your tongue around in your mouth without your job moving. Then I want to teach you how to do that with control. Na, Na Na La la la so that I can get more precise movement and that's what speech is speech is probably the most refined smallest movements we make in our entire in our entire body. So we have to do very precise movements in a very limited amount of space which requires muscles to be functioning at a really high level number five to improve feeding skills and nutritional intake. So one of the goals of oral placement therapy is to help improve the motor skills for eating, chewing, spoon feeding, cut drinking straw drinking on to improve nutritional intake so that we can sustain

Unknown Speaker  25:31  
good

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good hydration and good nutrition and weight gain and those kinds of things, but also to help us work on those muscles that are later going to be used for speech as well. So when we when we're asked how early Can we start with a child who has Moebius or any any diagnosis? The answer is if we know there's a diagnosis that involves muscle disorders, or the potential for some problems with muscle development, we can start from the very beginning, because we can help develop these muscles through feeding in the early years. So that when they get to speech, we have less we have more skills to work with, because we taught them to eat and drink and chew and swallow as normal as possible, which is going to impact what you're going to hear later when when speech starts to come out. So we we have kind of almost two reasons to work on feeding, if we think about it that way. And then number six to improve speech sound production to maximize intelligibility. So as a as a college graduate, back in 1998, I was taught that to work on speech sound production, I've got to work on the sounds. And if I work on the sound, and then I put it in a syllable and I put it in a word and I put it into an phrase, then I'm going to have good intelligibility for that sound, and then I need to teach another one. Well, what we know with people who have muscle based issues, is if we teach a sound on a motor system that's not functioning properly. So we don't have good dissociation, we don't have good grading, we don't have sensory awareness, we don't have movement, then I'm going to have to learn how to make that speech sound as an approximation. And an approximation of a sound turns into sometimes in an unintelligible word when we start to put it with words. So it could kind of sound okay when we when we say it in isolation. Um, but then when I tried saying, Mom, it starts to sound different. So our goal is to help improve speech production by knowing that their motor system is functioning as best as it can. And I say, as best as it can, because we know with Mobius, we are never going to have perfectly cleared normal movement, because we have, we have nerve, the the deficit is at the nerve level, not just a weak muscle. But we can get a lot of weak, we can potentially get a lot of new movement that they're not developing on their own by doing this type of work. So a good oral placement program is addressing sensory needs, motor needs, and then it's transitioning them to function, which is feeding and speech where we've been taught beating and speech is where we work. And we're not taught to think about how the sensory system and the underlying motor system are impacting things. So here's that graphic I was talking about. If you think about these, like acrobats, if you've ever taken a classroom, you've probably seen this. But the ones at the bottom, these are your strongest acrobats to support the pyramid. And if those acrobats aren't strong enough, and they're not stable, and they're moving around, I'm just going to give you the answer normally I asked you, but this guy on top, he's gonna fall down. So in your mouth, your jaws, your foundation, those are the largest muscles. And if your jaw isn't stable, it doesn't matter what you try and get your lips to tongue and tongue to do, they're never going to do their jobs effectively. So if I talk with big jaw movements, it's gonna distort my speech, even though I have good lip and tongue movement, but if my jaw is staying where it's supposed to, then now my lips and tongue can do what they're supposed to do. So the jaw is a piece that's often missed. And not identified because we're just not taught to look to look at it. And you don't have to have a wide open mouth. To indicate that you have jaw issues. You can have your jaw in a in a high position, maybe your teeth together, or maybe you you keep your teeth, you know where they're supposed to be. But you can still have issues in movement. And so we assess each one of these parts individually, as well as looking at how they're all working together to really get a good picture. So my, my therapy program is going to address jaw function, it's going to address all the movements needed for feeding and speech and in the lips, and all the movements that are needed in the tongue.

Unknown Speaker  30:31  
So some things to consider and thoughts to just kind of keep in mind. Number one, the muscles you use for feeding are the same muscles that you use for speech. And so many times when I'm working with a client, and I've done my evaluation, I've recognized that your child is doing as best as they can in speech, and I can't get any better speech because the muscles aren't going to make any changes by just working on speech. So then I think about working on feeding because feed, if I look at is feeding more than likely, even if he he eats everything, he doesn't choke, he may be eating in different ways or what we call compensatory ways to adapt for one muscle not working really well. So for example, some people with Mobius will learn to drink from a straw, but they do it this way. Okay, because their tongue muscles work better than their lip muscles. So they start to compensate by using their tongue instead of their lips. Okay? Well, if I'm wanting to work on lip closure for speech sounds, and I can't get any movement, I might be able to get some movement by working on some things to get them to learn to drink with their lips. And then that's going to help me get that lip closure that I want for speech so that when when we work on movements for feeding, were we working on the prerequisites for what we want to see in speech? And we know for most people with Mobius, it's not that I don't know how to make the sound it's I can't make that muscle do what you're asking me to do. Another statement, why is lips closure so important for feeding and for speaking, and this whole kind of begin to answer a couple of questions that have already come in and I'm going to address lip closure, is what creates the seal to allow for the intra oral pressure to help move food back. Lip closure is needed to help hold the food in. And so it's a it's a really important skill. And we know a lot of people with Mobius have trouble with that, and will often assist in chewing and eating by holding their lips closed. Because those lips don't close. And so our goal is to try and help them so that they don't have to assist or cover their mouth because they're embarrassed of where a food may be falling out. And then for speaking, we have we have several sounds that we make with our lips. The specific lip closure sounds are. And they come up a lot. And it's commonly a hard sound as well as rounded sounds that don't require lip closure but require lip rounding. Oh, wah. So that lip closure is the first step in lit development to get then to lip rounding. So muscles develop in a sequence. And I didn't spend a lot of time in this particular presentation going through that but just know that lip closure is the first skill. And so if lip closure isn't developing then all of those other lip movements that we want to have had trouble developing there. Another statement, how can Oh PT exercises help my child eat better? Well, so and speak better. So all PT exercises all mimic the movements we need for feeding and speech. So depending on the goals, and the goals are are always established. First we're going to pick oral placement exercises to help them isolate particular parts of eating and speaking to develop those and then as one part develops, then we can work on another part and it can all come together. And as I show you these exercises, some examples of exercises. I think it will it will make sense but oh pts exercises address the underlying motor system. And they always are movements that are needed for feeding and for speech. So we don't do oral oral motor exercises that have no functional

Unknown Speaker  35:15  
gain. So for example, they'll never be an exercise for oral placement therapy that is stick out your tongue and touch your nose. If your child is having difficulty moving his tongue around in his mouth, we're going to work on that inside the mouth, because that's where speech and feeding are. And we're going to help him learn to elevate his tongue to the top of his mouth for his oral rest posture for the beginning of his swallow, and then for his TD in L, SD, sh, ch, j, k, and G sounds that require the tongue tip to either be up or down. Okay, so all of our all of our exercises go match a feeding or

Unknown Speaker  36:02  
a motor goal,

Unknown Speaker  36:03  
or speech goal. And then one of the final statements to consider is stability in the body will allow for maximum mobility in the mouth. And this isn't the case, this isn't a problem for all people with Moebius. But we do work with a fair number of kids who also have motor development, delays or difficulties in their body. So if your child is in OT, or PT, because they're having difficulty with posture and movement and stability in their body, then we need to think about that as part of our motor or muscle based program. So when we're considering that I think it's the next slide, let me see, nope, it's not, it'll come up in just a minute, when we're thinking about that, we want our client or your child to be as stable as possible in their body, so that they can focus on the movements of their mouth. And so with our young ones who were trying to work on some of that early feeding and early pre motor work, we're going to give them that stability, so that they're not using those muscles excessively, to try and help increase the movement in their mouth. That's, that's poor dissociation. And we're keeping them in good posture so that they can they can achieve the best movements they possibly can. So I have a, I think, I'm pretty sure I have a slide in here that will kind of show you what kind of seating that looks like. So just always remember, if they're an OT, or PT, one of the things you always want to think about is, what kind of seeding Are you using, when you're working on eating and speaking and oral placement activities, you might have to be a little more thoughtful about it, if they have some of that instability.

Unknown Speaker  37:55  
So here's some examples just to kind of show you what some of the things that we're working on. This young man was the first client that Sara rose and fell Johnson ever worked with. He was the test subject, he was the one that we didn't know what we could do with somebody who has Mobius we didn't know that there was a difference between paralysis and precice. Back then, it was all trial and error. And so if you can see here, when he's younger, his mouth is barely closed. This isn't too bad, his lips are touching. He's a bilat. He's bilaterally affected. Um, but they're, they're closer together than they are here. So if you notice here, his lips are a little more open, well, his lips are more open because his face is getting bigger, and this muscle still isn't moving well. And so as the structure gets bigger, the opening is appearing to get larger. But what we do see, Sarah started when he was very young, you can see he has a symmetry, okay, which means one side of his face is doing something different than the other. So he has more movement on his right side of his face, you can see this dimpling over here, and he's kind of pulling down, and then this side isn't moving so much. So one of the first goals is to try it see if we can get symmetry. So even though the opening is a little bit bigger here, he's now symmetrical, which means that his right side is working more equally to his left side, and that's good. And you can kind of see that maintained, can't see it in this picture as much because of the angle but he's keeping that you can see a little more definitely on this right side. But he looks more, more even. So here we've got some change in symmetry. And here, you see how wide open his lips are here. And we're asking him as he is. Looking at the camera to close his lips, and he's doing his best to do so. So here he is now trying to close his lips, and you can see they're closer, you can also see that there's a little more definition to his upper lip. So that means more sensory information is getting to those muscles, those muscles are firing here and they're there, they can be stimulated to move more than they could back in this picture. And he's he's getting more movement. And then several years later, you can see as he starts to try and close his lips, now his lips are touching. And so this is our goal, if we can start when they're young, working through some of this, and a lot of it when he was little was all in feeding. And then we added some oral placement exercises specific to what we do more for speech. And then you see over here, we're getting some of that movement. So the earlier we start, the better we have, in the past, gosh, probably maybe eight or 10 years started to consult with adults because more adults became interested. And we have seen this same change with some of our adults that we've worked with. But not all of them. So it it's it's partially dependent on what the structure looks like, as they are an adult on and how much nerve innervation how many nerves or do we have problems with And usually, the more nerves that are affected, the more, the more, the more difficult it is. But this is what we're trying to work on. Here's a picture, this is a client that this is actually a client that I evaluated at a Mobius conference and I didn't treat, I worked, I wrote him a program, they took it home, worked with their speech therapist, and then came back to see me and the change in the tongue was unbelievable. So this is a little girl who not only had lip problems with lip closure, she also had a lot of problems moving her tongue. And so through exercise, as you can see here, it's very lumpy looking, that's all of those muscles just not not moving, not working. And we did systematic work to work on tongue retraction, tongue lateralization, and then working to try and get tongue elevation. And I can't remember I don't think she had tongue elevation yet when we took this picture. But we did a lot of this through eating activities, and then activities to try and get her tongue to do some of those additional movements. So that was a really interesting change to be able to see and get a photo of.

Unknown Speaker  42:56  
Okay, so next piece here, the tactile system, why is it important? Well, what we feel tells our muscles how to move. So if you can keep that in mind, then it that's that's kind of the basis for everything. If we don't see movement, our goal is to help you feel it more, so that we can hopefully get it to move more. Alright, so kids who have under responsive probe, tactile systems, there, they have an under reaction to tactile input, the nerve isn't getting all the way to the muscle. So it takes a lot of sensory input to feel things. So they may have trouble with eating because they don't really feel the food and can't tell where it is in his mat in their mouth. Touch may not get a lot of information from just touching a muscle and saying Move Move your lip, move your lip, move your lip, and then taste they may need more taste on their food to get more movement. So for example, I might see a child eat a banana, and they kind of mash and then they forget it's there and maybe pocket it in their in their cheek. But then I give them a banana with some honey on it or a little cinnamon, or I put it in the freezer and make it really cold and then I give them the banana. And now I see they chew chew chew and they swallow. Well that in that added sensory information, help them feel it. And so it tells told them that their muscles and their brain keep going keep going keep going and finish what you started. Over responsive systems have an overreacted reaction to tactile input so they might avoid touch taste and foods that have too much sensation. So with Mobius we know that certain parts of their face are more than likely under responsive where we don't see the movement, but they may have increased sensation and other areas because of a variety of reasons. And it's really what we call more of a mixed sensitivity that we see within Moebius. And that can be disorganizing to the motor system because we are, our motor system is, is is pretty much a symmetrical thing, it moves equally on each side, we might move our tongue to the right to chew. But we need that sensation to be equal. So if I can't really feel things over here, and I feel things over here, but I can't figure out what to do with it, it just it, it can make things difficult. So we, we look at that. And if they have over responsiveness in some places, then we have to work to try and calm that down and desensitize it. We also see kids who have fluctuating tactile sensitivity. And that's where things change over time. So if your child has a diagnosis of a sensory modulation disorder, or sensory processing disorder, or is on the autism spectrum, there's a possibility there's fluctuate. So one day, it might be one way and the next day, it's another and we just have to kind of have to follow things. And it can make things really challenging. And then we also have kids who become tactile defensiveness, and this is where they learn to respond negatively to tactile input. And it really has nothing to do with my mouth is sensitive, but maybe they've had a lot of doctors that have been messing with their face and putting things on their mouth. And they just don't want us to do anything. Even if it's something as simple as just chew on this, that becomes a versiv. And so they become defensive. And so we have to kind of work through that. And be careful not to create defensiveness by forcing a lot of this type of therapy for somebody who's not quite ready for it. So it can be a tricky area as well, and all things that we think about and work through in our therapy. So let's get into the therapy part so that you can kind of see some of the things that we do to help to help. So the first thing is always beginning with a sensory motor program, okay, and I say sensory motor, because the sensory input that we give them, is to create a movement that's specific to our goal, if you can kind of follow that. So for example, if I want your upper lip to move, I want to put sensory information in that upper lip so that you have more awareness of that lip, and then I'm going to ask you to do something while I'm doing it. So we have a tool called a the top tools vibrator into that. It's a, it's a spinner.

Unknown Speaker  47:52  
And we put a tooth head in it. Okay. And I'll tell you, if you decide to try this, break your tooth that in half, okay, and then you put it in the top of the spinner. And then we're going to put it in the muscles that we want to move. So some of the places that we commonly are using this are under the lips,

Unknown Speaker  48:14  
under here,

Unknown Speaker  48:17  
inside the cheeks, because we want the cheeks to move, and then the sides of the tongue, because we want the tongue to move side to side. Okay, so we will write a program or a protocol for providing more sensation. So this tooth that is real scratchy, I'm going to dip it in ice water to make it really cold. And I'm going to press the button to add vibration. And now instead of just saying Move, move, move, move, move and stretching and trying to get input that way, I'm going to add extra extra input underneath that muscle, whichever muscle I'm trying to get to move. And as same time I'm going to tell them to move that muscle. So if I'm working under their legs, I want to tell them, squeeze your lips, squeeze your left. Okay, now I squeeze really fast because it doesn't take much for me to move our people, our clients with Mobius we're gonna tell them squeeze and nothing looks like it's happening. Right? But we're gonna keep telling them to squeeze because we want them thinking about what squeeze your lip, they can feel their lip a little bit more. And sometimes, depending on the client, we'll start to see some squeezing. Or we'll remove the tool and we'll start to see a twitch in the muscle. Okay, so there's two things we're looking for. We're looking for an actual movement, or we're looking for a twitch or some kind of some kind of attempt to move whatever muscle it is. I think this is a little video here. Here he is, okay. So what I want you to watch for here, I'm gonna rewind it is we're going to do use the vibration and the tooth that under his lip, and we're going to pull it and I want you to watch for where the, if you see a little Twitch, I can't remember which side it was. And I wish I'd watched this before, I've seen this a million times, but there's a little twitchy movement in his upper lip.

Unknown Speaker  50:37  
I think it's gonna be on his left side, because I'm focusing their little twitch right there. Okay, and go back and let you watch it one more time. So look for the little twitch right here in the corner of his lips. And this is a little boy who does not move his lips at all.

Unknown Speaker  51:11  
Okay, so just that teeny, little Twitch, that little Twitch is huge for a child with Mobius. And we're looking for that one twitch to become to twitches to become three twitches to eventually becoming some movement with them. So sensory input is your best friend on a motor speech program, and the motor feeding program, excuse me, and we go back to that we go back to that vibration a lot in our session. So if you're already in therapy, and you have a, you're doing some sensory work with them, if you're doing a sensory warm up, I'm going to use my vibration or do whatever it is before my beginning of my session, and then we do all our work. That's not as effective for people with Mobius. As do a little sensory work, try and get a little movement, go back to your sensory work, come back and work on a little bit movement. And I can use that vibrator and to fit in different parts of the mouth 10 1520 times in a session with people with Mobius. So we we use that a lot more than we do with some other people who have motor function deficits. Here's my little slide about stability. So we want to make sure that when we're working with our clients that they have the ability to sit with 90 degrees in their hips, I hope you can see my pointer, 90 degrees in the knees and 90 degrees in the feet. Okay, so when when we're working with our young ones, we're working in some type of highchair that has a foot rest, and there's all different kinds on the market. This is the one talk tools has just as an example. And as this baby grows, this foot rest can can go down so it can grow with her, or this little girl. She's got fairly decent motor skills. But when she tries to use her mouth, she tends to do a lot of moving around. So we have her in a good stable chair too. But it's more just like a regular toddler chair. So it's short to the ground. I don't can't really see where her feet are. But she can sit where her her back is against the back of the chair. And her feet are way down here on on the ground. So the the one thing to think about is if you work with if you're working with little people, you don't want to see it in big people chairs, we wouldn't we need to have little people in little chairs. And then as you get bigger, you can get bigger and that will just allow her to be able to focus on and use those muscles better without compensating and trying to recruit other muscles in their body. Okay, so let's talk a little bit about nutrition. We've got sensory, we've got our body posture now what are we going to do in eating.

Unknown Speaker  54:06  
Um, so just some comments and some things about breast and bottle feeding. And honestly, when we start to really talk about feeding, if you are having problems in feeding difficulties, you really need to have a hands on evaluation with a therapist who's trained to work on feeding. But some of the things that we often see problematic with Mobius is breast feeding can be difficult. A lot of them can learn how to do it, but it can be difficult because the upper lip and the cheeks don't activate the way they're supposed to. But with tactile support, and I'll show you a photo in just a minute by giving them some cheap support and pulling forward while they're breastfeeding. We can a lot of times help with some of those difficulties there. Bye Giving them giving them the movement a little bit that they're not getting on their own. bottle feeding can sometimes be harder. Choosing the right bottle will be important, we often will use a bottle with a liner that we can help squeeze to give them the nutrition while we're working on trying to get more motor function from the mouth. So in order to get bottle and breastfeeding to work, we have to have suction. And if the upper lip isn't working and the cheeks aren't contracting, you're not going to get that suction, they're going to be using their jaw. So you might feel a lot of biting. And they might be trying to use their tongue, but they can't get that pressure to draw. And so we can help, we can help with that by squeezing our bottle. So think about this, like a baby bottle. This is a straw cup, but if this was the nipple that's that's in the child's mouth, I'm helping support their jaw, and I'm just squeezing so they don't have to work so hard. And that that becomes one of the problems a lot of times some kids can kind of get it. But they're working so hard, they burn more calories than they're getting. And we have growth issues. So we have things we can do with that. The skill may not develop if the child is older and compensatory strategies may be necessary to ensure adequate nutritional intake. So if they are, you know, 567 months old, and that suck reflex hasn't turned into some type of function and we can't adapt, we may be moving into some other alternatives. Sometimes that's tube feedings, but sometimes it can also be let's move into a cup or let's move into a straw where we can do more assistance, let's go ahead and move into purees that don't require that same suction. And they might, they might be able to get it. Our goal when we're doing feeding in any of these capacities, is trying to keep the ear above the mouth, which if you look at this picture here, okay, and here, that allows that keeps milk from going into the mouth too quickly. And going into the inner ear. inner ear infections, infants with motor difficulties is much higher than kids who have normal feeding skills with bottle and breastfeeding. And so if we position them with their ears higher than gravity is going to help us bring it down and not not into the ears. Okay, so some possible support, we might be giving john cheek support like you see, with this bottle here, we might be supporting the lower lip, we might just be helping with elevating the bottle, all kinds of things and doing some sensory input to those upper facial muscles that aren't moving first. And then feeding can also make a big difference. And even if you're not seeing a lot of movement, you might see a better seal. So we're always exploring all of those options. And then Haberman feeders are meant to be adaptive to help some of our more challenging feeders as well and keep them keep them off the tube if we can. Okay, um, when we are moving into older skills, were thinking about moving into straw drinking as one of them, we will use, we have motor goals that we're trying to help facilitate. And this is why we want to teach them to drink from the straw correctly. If they're sucking with their tongue, then we're not getting upper lip closure, cheat contraction, tongue retraction, and they might be swallowing okay, but it it might not be helping them with that swallow. So we have a system of starting with a syringe.

Unknown Speaker  59:08  
I'll just show you this real quick. I have a feeling I'm taking longer than I need to but I'm just going to keep going. I get to talking. We take a syringe and we put whatever they're eating, it could be breast milk, it could be puree, and we squeeze into the back cheek to try and teach them to swallow with their tongue back. We can use a syringe to try and teach them to suction and slurp. The by putting it in the back they'll feel it and that will help create that give them that cue to say suck. We will do that with the honeybear as well and put it into the corner. I'm going to show you a video in just a second and our honeybear allows us to squeeze The liquid and until they can learn to suck it so that we can place and squeeze. They can slurp and swallow and then eventually, they can use that slurp that will help them start to draw it up. And then we're going to work on moving that stroke to midline until you see this bottom picture where the young man is using one of our our straw hierarchy straws and he is now even without fully closing his lips. He's drawing liquid Up, up the straw suction is one of the best ways to try and get lip and cheek movement if we can teach that. So we have a systematic approach to doing that. And kids will start at all different levels. And things sometimes are adapted based on on what we're seeing. But here's a little video this is this little guys first time learning to drink from the straw.

Unknown Speaker  1:01:00  
I'm squeezing. I always act surprised but it's it's amazing. It's awesome every time it happens when when it when it works the way it's supposed to. But he's doing those little, those little slurp sounds you heard at the end. So just modeling letting him hear it letting him feel it and he did it automatically. And that's going to help him learn to suck with his tongue back rather than forward. And you'll see a lot of times when you're trying to teach suction as kids get older, that their tongue will be forward. And we need to teach them to pull their tongue back. So that's the goal initially is trying to get that tongue retraction there. Okay, spoon feeding some things that we work on with spoon feeding, we're working on upper lip closure, and we're trying to work on jaw grading and tongue retraction. And so we have two possible in positions and sets for infants and toddlers. But honestly, we use this with adults as well. Side placement of a spoon is when a child is a person, infant or child hasn't or adult has no lip closure. And we're going to tilt the spoon up to touch the lip to give them some feel input kinesthetic feedback that's feeling it. And since this particular presentation, and I haven't been able to use it with anybody with Mobius because these came out after COVID started, we have top tools has come up with a new tool called the Cincy repair. But it has it has four levels of vibration. And we have created spoon tips and byte tips and tongue tips and all of these things to help us add more sensory input to our tools to get our movement. And so we have a an infant spoon tip that looks like this. And you can see it has like a piece here and here that help us give pressure to the corner. So see what happens to my lip. When I push my top lip comes down. Okay, that helps them to start get the start to get the feel. And if I tilt it, as I'm doing that, now it's touching their upper lip, it's vibrating, it's giving sensory input, I might be getting some twitches of movement that then can become a little bit of an upper lip movement. And we have to let me just stop for one second because I get this question. A lot of times upper lip movement for people with Mobius if especially if it's bilaterally effective does not look like my lip closure. pulling my lips. upper lip closure for people with Mobius is very minimal. We don't see a lot of movement. So all of these exercises aren't going to all of a sudden get a lot of excessive movement, but it's going to get that lip in place where it needs to be. So that we can get a better rest posture so that we can get mom Instead of mom, because the upper lip is up here, it's to get that lip to be active and down, not necessarily that you're going to get tightness. So I hope that makes a little bit of sense. And that's that that's good information for you as parents, but great information for therapists who are not familiar with Mobius, who don't know what to expect as a result, because a lot of times, we think it's not working, because we're not seeing what we are used to seeing when we do when we do these kinds of exercises. So we can do a side placement and help get the movement and then we can go to front placement so that they can get some lip closure without physically helping,

Unknown Speaker  1:05:44  
then we start to work here at midline, and start to try and get as much movement and pressure as we can, versus what they what we wind up seeing with some of her adults is a scrape to get food off because that that muscle is way up here and not down here. Alright, some activities for teaching, chewing, okay. Now, these are activities that can be done. Starting at birth, and you'll you see here ABCDE it's a progression from easy and the least invasive and kind of the most natural to things that we use to try and get more movement, more contraction, more compression, as as they get stronger. So we wouldn't expect a baby to be able to bite on a bite tube and compress yet because they don't have that kind of muscle. So we will progress as we go. So a gloved finger simply using my my hands inside their mouth. And having them chew on my finger helps work on that jaw muscle and there's a bite reflex when babies are born. And so that bite reflex, and sometimes that bite bite reflex is affected by Mobius. But not always. So if they if we can put our finger in and they they can bite or we can move our finger around and they start to bite then that's good, we want to do that. We will use something called an infant. I don't have one in front of me right here. But this is what it looks like. And that is protects your finger if they start to bite a little harder. And it also adds some sensory input. So it has these little these little fuzzy things on it little bumps. And so now they have, they can feel things a little bit more. And that can help continue to get our movement. Our Cincy tool has lots of different tips for chewing. So we have a small one that we call a weak chewy, it's really little a narrow for our babies, and then we have the bigger bite surface. As if kids are a little bit older, and we use this a lot when teeth come in. Or if we need to add a step to add sensory input. So if my glove, they're not really biting, and I feel like they have a really low sensation, I'll use some vibration with that. And then my chewy tubes. This is when I'm starting to really teach choo choo. So I'm trying to get him to really bite hard and bite repetitively, getting them ready for chewing harder solids like fruit and vegetables and meat and, and those kinds of things. So all of these can help us build up our jaw muscles. And then that's going to help me with my speech movement later. Okay. When I think about introducing solids, here's just some guidelines and things to think about. Start with soft solids, okay, um, think about the normal progression that you might have done with your other children. And if you're not, if this is your first child, I'm reading just some basic information about where we normally start. We start with soft things. We start with egg we start with mashed avocado, we start with

Unknown Speaker  1:09:09  
Gerber puffs, things that melt in their mouth, all those kinds of things. But we are number two aware of sensory preferences. So sometimes the soft solids can be really bland, especially if they are packaged baby foods, they tend to be on the blander side. So we might think about looking to add more sensory input which is usually flavor and changing temperature a lot of times so we want to keep about think about those things texture, we might see they chew better with textures, textured foods. So we're looking at that. We're always placing them on the back molars for them to begin with, especially if they're having trouble with tongue control. Okay. Normally when we take a bite, we put it here You're in the front, we bite off and we use our tongue to move it to the back, if they can't move their tongue side to side, then they're not going to transfer. And that's where they're going to either chew incorrectly, or they're going to choke because they're not going to swallow correctly. So we're going to put it on the back molars for them, that's going to make sure it's getting in place to get good jaw activation. And that's going to help get our tongue over. And then we often will use our tools that were on the previous slide to practice chewing on a non food surface, and then transfer that to, to eating. So if I chew on my chewy tube back here, and then I give them a bite of banana, I use cocktail forks that are very flat and narrow, so that I can get it all the way to the back. And I'll have them bite on the same side that I practiced. Okay. All right, let's think about some speech things. Remembering that the muscles you use for feeding are the same ones you use for speech. If you do those feeding activities, you are preparing for later speech. But we do have things that as kids get older, we start thinking more specifically about isolated Speech Movement. And I'll just show you a couple of those thoughts here. jaw exercises, chewing on your best back molars best jaw exercise we have chewing on non food items. Best second option, if they're not able to eat solid foods just yet, or maybe they're they're not cleared for solids at all. We can use our tools to help facilitate that chewing, which is the first step. And then we have something called jaw grading bite blocks that we'll use. So these we will have them. This is a resistance exercise where he had them bite and hold and we pull to help them activate that jaw muscle that resistance helps activate. And then we work to encourage more lip and tongue movement. So I might have them hold a bite block and try and close your lips and get a little movement there. Or I might use a bigger one, move your tongue for kids who are using their jaw too much. And those are all kind of written specifically into our programs. But so just know bite blocks can be used for resistance for exercise, but they can also use be used to stabilize the job to get them to use those other muscles that they might not be using. Blowing is a big part of speech. And by blowing horns that go in the mouth, I just realized I forgot to get these out. I'm blowing a horn is one of our another one of our lip closure activities. And I feel like if I had to pick any that probably work the best if I can get movement, straw drinking and horn blowing are probably two of my favorites because there's not just close your lips and sit it's close your lips and do something else and so that do something else often kind of helps the lips do a little more work. So we we have horns that have different types of mouthpieces, this one I don't have to close my lips very much. Here, let's start here. You can start to work on that blowing, which can start working on getting a little bit of that lip contraction. I've done a little bit of sensory work under your lip, we use our vibration, I saw some Twitch, we go into a horn and now we've got a little a little extra movement. Then some of our horns have even flatter mouthpieces. So this is one that often has to be done. If they don't have lip closure, I don't want them doing this.

Unknown Speaker  1:14:01  
I want them using their lips. You don't have to close your lips much but some of our kids with Mobius can't close that much. So we'll wrap up medical tape to make the mouthpiece bigger. And then as their skill gets better, we make it smaller and smaller and smaller and smaller until we get and that that lip closure and then our horn hierarchy is going to make them close their lips harder and harder and harder. And I've seen some kids who've gone from zero lip closure to being able to close their lips on a very very small mouthpiece like you see if I can find out here we go.

Unknown Speaker  1:14:40  
Like this.

Unknown Speaker  1:14:43  
We'll see that and actually get some sound if you can get your lips hear. You're pretty good for an M sound and close to getting a B sound and those kinds of things. We might also work on our lip closure with our sins See tool. This picture here has, there's a Mickey Mouse tip that you can use that's a little wider. We also have a tongue depressor. So we can add vibration to this and, and work on closing your lips and touching here, we've got another one that we use a lot. This is a little, it's a happy face. But if I turn it this way, and I place here and you don't have a lot of movement, now you can feel something and you can practice, wah, wah, wah, for the child who's doing ma, ma, or Ma, Ma. Now they're feeling that M sound is my top lip and mata blut. Touching. Okay, so we're practicing our sounds and things with our tools as well. So here's a little, some other ones, we have something called sponge ball, some tongue depressor. This is in our manual. With all of our exercises, I can actually grab that because I'm in my office. It's called oral placement, therapy for speech, clarity and feeding. And there's, there's an exercise in there where we use a makeup sponge, and we cut it to the size of the opening that their lips are in to start with. And they hold a sponge that's big, and we start to make it smaller and smaller and smaller, and we work down to a tongue depressor. And then here's a picture I just took this week with a little boy just to show you the Cincy tool as well. So tongue depressors can really start to get that lip closure. Tongue exercises, so some things you can do for tongue. We already talked about straw drinking and horn blowing. Those work on tongue retraction. lateral movement of the tongue, chewing on your chewy tube gets tongue lateralization. And then we have something called a chewing hierarchy that Laurie overland our feeding specialists develop to help teach kids once they learned to bite on the back to then move their tongue with food. And there's a whole series of steps there that we use with non food items. And with food items. So we do with both. We have tools that have little balls on them that they can feel to help them work on lateral movement and elevation. So again, going back to that feel something to touch something to move. And then when we talk about tongue elevation, swallowing, using teaching them to put their tongue to the spot, and their spot is what is that resting place right behind their teeth where you say today, now that's what we call the spot. works on elevation suction, clicking your tongue, sucking your tongue gets that elevation, and then our tongue tip elevation tool. So all kinds of things to help us get those movements there. Okay, so takeaways, I have no idea how long I've been talking, but hopefully I'm in in the right time. And we're we're getting this piece. People with Mobius some things to think about, need more sensory input to achieve the movement. Okay, so we always want to be considering that are we giving them enough sensory input, they need this steps to be task analyze, to start where their skills are and work from there. So,

Unknown Speaker  1:18:27  
um,

Unknown Speaker  1:18:28  
might be my goal. But if I task analyze lip closure, I need adjustability, I need tongue retraction and I need my upper lip and my my top lip to be able to come together, then I can teach him. So that's an example of kind of a task analysis of a of a skill. People with Mobius will not develop lip closure by pulling their lips together for them or stretching alone. I work with lots of therapists who are doing everything they can. We have a technique called Deborah the Beckman stretches where we stretch to try and get blood flow to the muscle and get more movement and get resistance. That by itself, I have not seen been effective. I won't say it's not part of my program sometimes. But it will not be as effective as sensory input under the lip and on the lips. In my opinion, I think that tends to work a little bit better. prompt is a technique that I've seen used a lot with kids with Mobius, where we pull the lips together. And we have them practice that helps them get the feel, but it will not help create the movement on its own. So again, going back to that task analysis of why is their lip not closing first, and then if needed using some of those as transition techniques to help us get to our next step. People with Mobius are all different and they require different programs. So I get a lot of questions. Can you just send me a program for people with Mobius I wish I could but I can't, I need to be able to, to see what each person's problems are. And we start from there. There's basic consistencies, like we all need sensory input, everybody is going to have trouble with lip closure. But beyond that developing a program is really hard. Just hear you give this to your therapist. So just kind of keep that in mind benefits from starting early, even if their lips are already closed, because as you can kind of see when structure grows, that can impact things. So the more we work on getting that sensory input to those nerves to get as much movement as we can, we'll start to see that movement with growth. And the outcome can be a little bit different there. And people with Mobius can absolutely benefit from muscle based and myofunctional approaches, but they typically need to be adapted. So you know, a lot of people have said, Well, can I take a talk tools class and learn what to do? Yes, you can, you can learn the basics. But then you need to know the adaptations. And a lot of what is in this class. Now here is a lot of those adaptations and what I help out with a lot. So what I wanted to also leave you with is my email address, I am happy to speak with you, I'm happy to speak with your therapists. Because I know what it's like not knowing what to do. It's not fun. And yeah, there's just not enough kids with Moebius for many of these therapists to get good at one diagnosis that's so rare and has its its own unique challenges when we're talking about people with muscle based issues. So our goal is talk tools therapists who have been working with kids with Mobius. And it's not there's not just me, there's, there's several. We are always, always happy to help. So I want to address a few questions that I've already gotten. And then we will have time for any additional questions. For those of you who are watching. One of the questions that I got was my child failed in MBs study after previously passing previously, for pureed foods, what are the recommendations for oral stimulation and tell she's able to eat by mouth again. So for that one, all of the things that I was talking about that are non food movements that mimic the movements we need for feeding are what we're going to do with a child who's not eating. So that's what we're going to be doing with an infant. And then that's what we're going to be doing with a 15 year old who's on a feeding tube. So working on jaw movement with non food items, using sensation to try and create movement, teaching them to blow, teaching them to maybe manage saliva we might be working on slurp saliva if we get saliva build up. So there are there's a lot of things that we can do. We just do them in the non food side. And then once we get the clearing, even if it's for one food, maybe we get back to purees, then we have some things that we can transfer because we've already worked on them. So I hope that answers your question. If not, you can certainly email me for some more information. Second question, my son is four and a half. His speech is not very clear, what should I do to improve his speech? So

Unknown Speaker  1:23:25  
hopefully, I've given you a lot of things to think about. You know, if a lot of parents tell me kind of when they take these courses, when we talk about a specific thing, they say, yeah, that's, that's my child. So that's sometimes where we need to start. But the best case scenario is you you are able to have an evaluation by somebody who does muscle based therapy, and we can truly identify where the problems are. But again, muscle based work, getting those muscles to move better will often result in better speech all by itself, especially if they've already been working on speech. Another question was asking about different drinking tools for weaning from a bottle. So I'm hoping I covered that question for you. Um, a lot of kids who were trying to wean from a bottle, especially if they're older, we try and wean to a straw, even if it's a squeezable straw, and even teaching them to squeeze the straw if they're if they're capable, just to get them off that bottle because now we're in that, that period of time where it's not age appropriate anymore. But that would be one of my first attempts cup drinking can be challenging because we don't get the upper lip seal. We tend to see that even with assistance. We can get better delivery of liquid with a straw versus a cup a lot of times so that might be My recommendation to start there without knowing more about him or her. And then the last one, can you give me advice on reducing the use of fingers while chewing. So this is a good one, my my kids that choose to do a lot of using their fingers, I'm going to probably assume that there's not great tongue control along with difficulty with lip closure. So my chewing hierarchy that I mentioned earlier, and doing that with food. So here's a veggie stick, I'm going to start out by having them practice with just a little bit of food. While I'm holding their hands down, if I have to and telling them use your tongue, use your tongue use your tongue, I'm going to have done sensory work on that tongue I've gotten in the tooth that is just step one of about five or six different things I can do to work on tongue lateralization. So I'm going to work on that first, then I'm going to work on it with small pieces of food, no hands, and then work on bigger and sometimes just even that placement will help with not needing to use my hands. But there's also some behavioral techniques a lot of times where we have to teach them, hold your hands together, don't get and give them a lot of verbal instruction not to use their hands as well, but teaching them to chew on their back molars and making sure they have tongue lateralization. You can chew and swallow with no lip closure and have good control if you can get better, better tongue control. Okay, so that's the last of the questions. And I think we'll, I will stop sharing here and we'll take it back to having some time for questions.

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