Feeding and Oral Motor Skill development in typical children and management in children with developmental disabilities

Feeding is the first essential function which everyone is concerned about in all new born and young children. Infants and toddlers who are at the risk for developmental difficulties or who have been diagnosed with abnormalities, however, may also have dysfunction in their feeding abilities. This problem can include  poor intake, excessive time needed to feed, unusual feeding characteristics (e.g., abnormal oral-motor patterns or inappropriate progression of feeding skills), and physiological compromises associated with feeding.

Feeding  provides an opportunity for early bonding, and its success strengthens maternal confidence.  Conversely, feeding dysfunction can erode maternal confidence, causing stress that can alter the mother child relationship and interference with bonding.

Occupational therapist working in early intervention programs have the knowledge and skill to make unique contributions to the treatment and management of feeding dysfunction in infants and young children, particularly within the context of the family unit. A background in neuromotor control, in the medical aspects of disease and disability, and in general, child development must be combined with a solid foundation in human interaction and behaviour to effectively manage feeding problems in the population.

Anatomical maturation:

          With growth, changes occur in the size and anatomic relationship of the oral, pharyngeal, and laryngeal structures. These changes are rapid during the first 12-18 months of life, then progress slows  throughout the remainder of childhood period. As the infant matures, the oral cavity enlarges and elongates, and the fatty tissue diminishes. Postural stability, through muscular contraction and the development of more rigid connective tissue, develops to provide the stability for the highly specialized movements of the lips, cheeks, tongue, and jaw, which are involved in the chewing or in sipping from cup.

          As the infant grows, the oral cavity enlarges and there is a downward elongation of the pharyngeal region. The larger oral cavity allows greater mobility of the lips, tongue, and cheeks, which allows the emergence of a wider variety of oral and speech skills. As the pharynx elongates, the hyoid must develop greater mobility to achieve continued protection of the airway. This occurs around 4-6 months of age.

          Infants must have split-second timing between sucking, swallowing, and breathing for safe and efficient feeding. In the sequence of feeding events, the infant takes one to two sucks and then must swallow, suppressing respiration for 0.5-1.0second. The infant then takes a breath, which is typically overlapped with sucking, and the sequence is repeated.  The coordination of breathing with swallowing during feeding continues to play an important role in spoon feeding, sipping from cup, and more matured eating skills.

          Deficits in oral-motor control are common in children with neurologic deficits and can lead to illtimed release of food into the pharynx or release of the bolus in a piecemeal fashion. If food is present in the pharynx before the swallow is triggered, there is the risk of aspiration during nonfeeding times. Children with cerebral palsy have a higher respiratory rate, less regularity to breathing, lower volume per breath, and more difficulty holding their breath than typical children. During eating, children with cerebral palsy also have difficulty in sustaining respiration and timing the integration of swallowing into the respiratory cycle. Coordination of oral skills, swallowing, and breathing remains important for children. Incoordination of these functions can lead to longer feeding times, feeding  inefficiency, physiologic compromise, aspiration, or any combination of these factors.

Sucking:

Sucking develops at 15-18 weeks of gestation.  The well-coordinated, efficient sucking needed for feeding does not generally develop until around 34 weeks of gestation. Infants who are good feeders tend to have sucking patterns that are fast and strong, as well as stable and rhythmic.

 Nutritive and non-nutritive sucking

Characteristics	Nutritive sucking	Non-nutritive sucking
Rate	One suck per second during the sucking burst	Two suck per second
Burst and pause pattern	Initial continuous sucking gradually increasing pauses toward end of feeding	Stable number of sucks per burst (4-13 sucks) and duration of pauses (3-10 seconds)
Suck-to-swallow ratio	1:1 at start of feeding 2-3:1 towards end of feeding	Multiple sucks to one swallow

Normal versus abnormal functions must be considered in the context of the following areas of performances:

1.     Neuromotor performance, including the influence of muscle tone, reflex activity, and motor control on overall posture, position, and oral-motor skills

2.     Sensory responses

3.     Swallowing ability

4.     Physiologic support for feeding

5.     Structural integrity

6.     Behaviour and interaction during feeding.

Neuromotor dysfunction can have a significant impact on the feeding posture. The characteristics of typical feeding posture include:

·        Neutral alignment of the head and neck (or slight neck flexion)

·        Midline orientation

·        Symmetric trunk position

·        Hip flexion (degree varies with the child’s age)

·        Symmetric arm position with the shoulders relaxed and forward

        The body angle during feeding depends on the level of head and trunk control present. Infants with limited head, neck, and trunk control are fed in a semireclined position. Older children who have adequate postural control are fed in an upright position.

Oral-motor control:

          The assessment of oral-motor control includes facial muscle tone, oral reflex activity, and functional oral-motor skills. Oral reflex are often evaluated for their presence or absence. It is highly important to consider their contribution or interference with feeding function.

          The child’s skill in complex activities, such as sucking or chewing, is based on the movement characteristics of each oral structures (i.e., the tongue, jaw, lips , and cheeks), as well as their coordinated function. Both the resting position and movement patterns of each structure must be evaluated. The expectations of movement vary based on developmental age and feeding activity (e.g., cup versus spoon) and are most effectively observed during the feeding time.

Atypical development and functional problems:

-         Hypertonic Muscle Tone

-         Hypotonic Muscle Tone

-         Tongue Retraction

-         Tongue Tip Elevation

-         Tongue Thrust

-         Tonic Biting

-         Jaw Thrust

-         Jaw Instability

-         Lip Retraction

-         Lip and Cheek Instability

-         Lip and Cheek Immobility

Guiding principles of treatment:

1.     Alignment: Proper alignment of the body and the head are crucial to optimal feeding performance. Abnormal alignment of body structures can influence the function of all the oral structures. For example, neck and head extension can lead to tongue retraction or thrusting during feeding.

2.     Proximal stability: Controlled extremity movement requires a stable base. The movements of the tongue and lips for feeding are distal movements, requiring stability of many proximal structures, particularly the jaw. For the mandible to be stable, head and neck stability built on trunk stability is mandatory.

3.     Appropriate movement patterns. Once proper alignment and stability have been achieved, the therapist or caregiver can facilitate appropriate oral movement patterns. Simultaneous application of inhibitory and facilitative techniques elicits the desired movement patterns.

        To achieve proper alignment, stability and appropriate movement patterns, preparation of the child using neurodevelopmental handling techniques before feeding may be beneficial.

What are stereotypes? What is the cause and management?

A stereotypy is a repetitive or ritualistic movement, posture, or utterance that occurs for no obvious goal or purpose. A behavior is defined as stereotypy when it fits the requisite form, which involves repetition, rigidity, and invariance, as well as a tendency to be inappropriate in nature.

Stereotypes are common to individuals with sensory processing disorder, intellectual, or developmental disabilities. They are intensively found in people with mental retardation and autism spectrum disorders.  Restricted, repetitive, and stereotyped patterns of behavior are one of three core diagnostic features of autistic disorder and are a frequent target of behavioral interventions for children with autism. 

Stereotypic behaviors are highly heterogeneous in presentation. Behaviors may be verbal or nonverbal, fine or gross motor-oriented, as well as simple or complex. Additionally, they may occur with or without objects. Some forms involve stereotyped and repetitive motor mannerisms or use of language. Common examples of stereotypy are hand flapping, body rocking, spinning objects, sniffing, immediate and delayed echolalia, and running objects across one’s peripheral vision. Other forms involve more complex behaviors, such as restricted and stereotyped patterns of interest or the demand for sameness. These forms may involve a persistent fixation on parts of objects or an inflexible adherence to specific, nonfunctional routines or rituals. For example, a child engaging in stereotypic behavior may attend only to specific parts of objects (e.g., car wheels, doll eyes). Alternatively, a child may insist on playing with his or her toys in a very specific fashion (e.g., lining blocks up in identical rows repetitively).

There are several possible explanations for stereotypy, and different stereotyped behaviors may have different explanations. A popular explanation is stimming, which hypothesizes that a particular stereotyped behavior has a function related to sensory input. Other explanations include hypotheses that stereotypy discharges tension or expresses frustration, that it communicates a need for attention or reinforcement or sensory stimulation, that it is learned or neuropathological or some combination of the two, or that it is normal behavior with no particular explanation needed.

          First, stereotypy is socially stigmatizing. Because of the existing obvious bizarre movements, the child’s involvement in the community, peer and adult interactions, or typical education settings may become severely restricted. Second, stereotypic behaviors interfere with learning to a large extent. Obsession to repetitive play or behavior will block the child’s access to matured play and learning through exploring the environment. This in turn will obstruct the child’s overall psychosocial development.

Stereotype Vs sensory demand

The most common cause of stereotypic behavior is found to be a strong need or aversion towards one or more sensory input. The subcategory of stereotypy, commonly referred to as self-stimulatory behavior (SSB), is a behavior, which is maintained automatically by the reinforcing sensory stimuli that it produces. Automatic reinforcement infers that the reinforcer and the behavior are one and the same. Self-stimulatory behavior, arguably a primary reinforcer, is resistant to social consequences. Although the particular sensory function being stimulated may not always be visually apparent to an observer, stereotypies often provide an obvious source of sensory input (e.g., visual, auditory, tactile, Proprioceptive, vestibular, taste, or smell). Also a stereotype of a specific sensory back ground is presented in order to mask or overcome the acceptance of one or more of other sensory stimulation. For example a child might engage in monotonous singing to overcome the noise of a spinning fan or child might flap hands at times of excitement to seek proprioceptive input which is expected to give a calming effect.

Stereotypes Vs Play

Apart from sensory background, stereotypes must also be viewed from a cognitive strategy’s point. Inadequate cognitive abilities to explore and manipulate toys and materials in an environment will also account for repetitive behaviors. A specific way of manipulating a toy, done accidently, can provide a sensory input or meaning to the child according to his/her level of play or cognition. This will result in repetitive or restricted pattern of play which is considered to be stereotypic. In such case, the child will not be able to stop this pattern of behavior and engage in purposeful play or behavior until the cognitive inadequacies are filled.

Stereotype Vs reinforcement/stress

Sometimes stereotypes which have begun due to a sensory need or lack of play skills may turn out to be a behavior that is controlled by external reinforcers. The most commonly environmental contingencies include social positive reinforcement (e.g., praise, attention), social negative reinforcement (e.g., escape or avoidance), non-social positive reinforcement (e.g., demand for a material or a tangible), non-social negative reinforcement (e.g., removal of or escape from a task or aversive physical stimulus), or some combination of social and non-social reinforcement. Here, stereotypes are increased or decreased depending upon the variables in the reinforcers. Forms of self-injurious behavior and stereotypes that increase with increase in stress/ demand can be grouped under this category. Careful analysis of social and nonsocial reinforcers and monitoring the level of stress is necessary to intervene in such case.

Example

Repeated banging/throwing/tapping/spinning or lining up if rings from a stacking ring set can be analyzed in terms of the above mentioned causes.

Lining up/ spinning/ tapping the rings might give visual, auditory or proprioceptive input to the child which might serve as a means to meet the sensory demands of the child. Providing adequate visual, auditory and proprioceptive stimulation through a sensory diet and providing alternative sources of matched stimulation through toys in a socially accepted manner will be useful in reducing stereotypes.

Note: Detailed explanation on sensory diet is given in sensory integration page in this blog.

The same pattern of behavior like lining up or tapping can also be because of the lack of the concept of size and shape that is required to stack the rings on the stand. This makes the child to be less successful in age appropriate use of the given toy. Here, adequate training of perceptual skills and concepts is the key to management.

The child may also throw, spin, bang or tap a ring to escape from or avoid a demand or stress. A previous incident of positive or negative, social or non social reinforcement would be a common cause that makes the child to attempt the same behaviors in these situations. Managing demands according to the child’s level of performance and controlling the immediate positive or negative reinforcements to the stereotypes will result in marked decrease in such behaviors.

Soft neurological signs observed in children with Learning Disability

ü Choreiform movements: Jerky , rapid, irregular movements usually involving the face and distal extremities.

ü Dysdiadochokinesia: Impaired ability to perform rapidly and smoothly repeated alternating movements.

ü Finger Agnosia: Inability to name, recognize, or select one’s fingers.

ü Mild dysphasias: Mild inability to process language.

ü Ocular aprxaia: Inability to perform purposeful voluntary ocular movements to command when comprehension and sensorimotor skills are present.

ü Strabismus : Deviation of the eye.

ü End –point nystagmus: Involuntary rapid movement of the eye ball.

ü Exaggerated associated movements: Involuntary movements or reflexive increase of tone.

ü Tremor

ü Motor awkwardness

ü Fine motor incoordination

ü Awkward gait

ü Papillary inequalities

ü Mixed laterality

ü Right –left discrimination confusion

ü Unilateral Winking defect

ü Avoidance response to outstretched hands

ü Extinction to double tactile stimulation

ü Borderline hyperreflexia and reflex asymmetries

SOCIAL STORIES FOR AUTISM

 Social stories were developed to help improve social interactions in children with autism by giving simple and clear descriptions of social cues and appropriate behaviors. A social story is a simple description of an everyday social situation, written from a child's perspective.  Social stories can be used in different situations. For example, social stories can help a child prepare for upcoming changes in routine, or learn appropriate social interactions for situations that they encounter. The idea is that the child rehearses the story ahead of time, with an adult. Then, when the situation actually happens, the child can use the story to help guide his or her behavior.

Learners with autism often have difficulty understanding expectations in social situations. Over the past decade, social stories have become increasingly popular as an intervention strategy for learners with ASD. Social stories are brief descriptions of expectations that are explained in the context of a “story” created on an individual basis to describe a specific scenario the learner will encounter. Typically, the story is written from the perspective of the learner, in a meaningful format for people with ASD. A social story is created specifically for the student it is intended to help. Practitioners can create stories that are supplemented with pictorial cues or photos in addition to textual information. The use of stories to explain social rules and contingencies has been shown to be beneficial for learners with autism.

There are several ways that social stories may help improve a child's theory of mind. One is that, by giving examples of specific social cues and behaviors, social stories may improve social problem-solving in general. Social stories may also help organize social ides and cues that were previously disorganized. Moreover, by using print, audio, video, or pictures to replace in-person teaching, social stories may take away some of the anxiety of social relationships. In this way, autistic children can concentrate on what is being said rather than their relationship with the person who is saying it.

Suggestions for developing effective social stories. There are currently seven recognized sentence types used to create social stories:

 - Descriptive: (De) give who, what, where, and why details about the situation so the child can recognize when that situation actually occurs, Sentences that provide factual information.

 - Perspective: (P) describe one of the child's possible feelings or responses Sentences that provide insight regarding the thoughts, feelings, and behaviors of others.

-Affirmative: (A) often refer to a law or a rule or are a commonly shared opinion Sentences that are used to reassure the learner.

- Directive: (Di) tell the child the appropriate social responses in that situation.  Sentences that tell the learner what behaviors are expected.

 - Control:  (Cn) are created by the child, to help remember strategies that work for him or her. Sentences that use analogies to explain situations.

 - Cooperative: (Co) describe how other people will help out in a given situation. Sentences that tell the learners who can assist them in different situations.

 - Consequence: Sentences that tell what will happen as a result of the actions.

For example, a social story using sentence types is:

When we go to the shoe store, there will be many shoes to choose from. (De)

I might not know which shoes I like. (P)

That is okay with everyone. (A)

I can hold onto my string while I decide. (Cn)

When I decide about the shoes, I will tell the grown-up. (Di)

The grown-up will go get the shoes for me. (Co)

The two options for how to construct social stories using the different types of sentences: the basic social story ratio and the complete social story ratio.

In the basic social story ratio, should be using 2–5 descriptive, perspective, and/or affirmative sentences for each directive sentence.

The complete social story ratio includes the addition of control and cooperative sentences. For each control or cooperative sentence, 2–5 descriptive, perspective, affirmative, and/or directive sentences are recommended.

The objective of the social story is to describe rather than direct. The assumption is that changes in behavior may be a result of a greater understanding of expectations and events in their environment. Social stories reported in the literature are primarily composed of descriptive, directive, consequence, and perspective sentences. Social stories can be used to both increase and decrease behavior. For example, social stories can be used to explain the actions required to deposit a check at the bank or to explain the contingencies required to access a desired reinforcer (e.g., to access a trip to the park, they must not engage in any aggressive behavior). Social stories are often used for multi-element situations (which change on a frequent basis), fear situations, and to reduce challenging behaviors.

Often, social stories are used in combination with other treatments, as part of a packaged social skills intervention. In fact, when part of packaged interventions, some gains have been noted. However, multiple treatments limit the extent to which treatment effects can be attributed to social stories.

Development of the stories is highly variable. There are few guidelines for how to use the social story and when to curtail its usage. Two commonly used, but empirically unsupported, strategies to fade the use of a social story are to reduce the number of times the story is read each week and systematically removing sentences from the story, specifically the directive ones.

Social stories are written in the first person, in the present tense, and from the child's point of view. The parent, teacher, therapist, or counselor should write the story to match the child's vocabulary and comprehension level. The story is written and put into booklet format. Once it is ready, an adult should read the story with the child at least twice, even if the child is capable of reading it. The adult then checks to make sure the child understands the important elements, either using a checklist or role-playing the situation ("Let's pretend we're at the shoe store. What happens next?") After that, the child reviews the story each day. For children who cannot read, audio tapes, videotapes, or picture books of the story can be made for the child to review each day. Finally, the effectiveness of each story should be monitored, with the story being faded out when the behavior has been learned. 

The literature describes a variety of strategies to implement the social story. They include having the teacher or parent read to the child, having the child read, listening to or watching the story on a computer or TV, and listening to the story embedded in a song.

It may be that social stories enhance parent and teacher attention to targeted behaviors, which may make it more likely that desirable behaviors are prompted and reinforced. There also appears to be a discrepancy between the perceived effects of treatment and the future use of the social stories. Studies were unsure if the social stories had an effect on the target behaviors, but planned to continue using them and even create new stories for other skills. Investment may come from face-validity or natural quality of approach for parents (e.g., all parents read to kids). Teachers liked using social stories and found their outcomes to be favorable, but did not continue to use the stories beyond the scope of the research study. The time consuming nature of reading a social story before an activity may have not made it feasible for teachers with large groups of students. To maintain the behavior, the stories would need to be a part of the lesson planning and become integrated into the classroom routine. Even in studies that have shown promising treatment effects using social stories, there is a lack of knowledge about the critical components. By developing more effective methods for evaluating social stories, improvements in creating and implementing them can be made.

It is possible that their effectiveness may be a result of other elements of the packaged interventions. In general, it is clinically wise to use social stories in combination with direct behavior change procedures.

Recent research studies show that social stories can help reduce problem behaviors, increase social awareness, and/or teach new skills. In some cases, the new behaviors were maintained and generalized to other situations, even after the story was faded out. Social stories are most useful for children who have basic language skills

From an autistic point of view

 I liked the sound of flowing water and enjoyed pouring water back and forth between orange juice cans; whereas another child may avoid the sound of flowing water. I liked the visual stimulation of watching automatic sliding doors; whereas another child might run and scream when he or she sees an automatic sliding door. ....................................          

                            Says Temple Grandin,  A 64 year old  autistic person, Doctor of animal science and a professor in Colorado state University, USA.  In her articles she explains about the sensory, language, social communication and learning issues that she experienced as a person with autism.. It would provide a good insight to parents and professionals about the struggles or voices of autistic children... For a better understanding, follow the link...

http://legacy.autism.com/families/grandin_articles.htm

SUCCESS ON AUTISM

              As a part of celebration of World’s autism day, here is a message to parents and professionals who dedicate their lives in the development of children with autism.

Success on autism depends on

·        Early intervention

·        Space for environmental stimulation

·        Consistency in treatment/Parental support

Early Intervention

                      Early intervention is a method of finding out the risk of disability or delay in children and treating them at very young age. Symptoms of Autism usually start at 18 months of age. Mere observation of the child speech and play behavior, and if a difference is observed, undergoing a screening test for autism will usually give a better hope to maximize the positive impact of intervention. As infant brains are quite malleable, therapy as early as possible will help to boost up the potentials of learning that the brain has in order to limit the deleterious effects of autism. Another practical reason is, young children will not have any obligations like schools or any other classes and the whole day can be effectively spent for therapy and it is always easy to handle and shape the negative behaviors of a 2 year old when compared to 12 year old! 

Space for environmental stimulation

               A common strategy that is seen behind almost all of the children with autism is the lack of environmental opportunities for typical development. Due to the change in culture and work and lifestyle pressure, the parents and family members are failing in providing productive play opportunities for children. Most of the parents live in nuclear family, where the father or sometimes both the parents go for work and the child is left alone with the mother or in the maid’s hands. This blocks the child’s access for social interaction and masks the chance of observational / imitational learning, through which a child normally begins social/emotional development. The child might have been provided with lots of toys but no access of peer groups will only push the child towards social withdrawal which is the key feature of autism. Hence parents attention towards creating an environment, where the child has adequate opportunities for mingling with lots of children and adults and exposure to all sorts of play, will help in minimizing the effect of core features of Autism.

Consistency in treatment and parental support

               As Autism is considered as a developmental disorder, its management would also be developmental. Once the diagnosis for the Autism Spectrum Disorder is made, every second there on should be planned and directed towards intensive therapy. As a child with autism will show deficits in the areas of sensory motor, speech and social behavior, treatment strategies should be focused at the development of all these areas. Key to success lies in choosing and learning the effective treatment techniques and applying them consistently on all areas like home, school/work and society.  Since development happens at a wide range of time, parents should be motivated to provide the therapy opportunities and emotional support to the child, lifelong. Therapy for autism can never be given a fixed period say 1 year or 5 years. It must continue till the child or person with autism is able to lead a life independently.

Proper understanding of these concepts and continuous management with professional guidance will definitely help parents and individuals with autism to reach for the heights of success and happiness. On this special day, we wish all children with the spectrum to overcome their difficulties with a warm support from the society.