Dyspraxia and the oral motor system

          "Apraxia" comes from the Greek word "praxis," which means action. Apraxia or Dyspraxia is defined as difficulty in motor planning of movement to achieve a predetermined idea or purpose, despite having the desire and the physical ability to perform the movements.  It is believed to be an immaturity of parts of the motor cortex (area of the brain) that prevents messages (ideas) from being properly transmitted to the body, which may affect any or all areas of development. It is inconsistent, and affects each child in different ways, at different stages of development and varies in severity.

Praxis is a largely cortical process that is highly dependent on subcortical processes such as sensory discrimination, body scheme/body awareness, and the ability to produce feed forward responses.  Praxis involves four major components.

 (a) Ideation - the ability to conceptualize and identify a motor goal and some idea of how to achieve the goal;

 (b) Motor planning - the ability to plan and organize a series of intentional motor actions in response to environmental demands;

(c) Motor coordination/execution - the ability to perform motor responses with precision;

(d) Feedback - the ability to recognize and respond to the motor act and its consequences.

Within occupational therapy practice, praxis represents performance skills and forms the foundation for developing performance patterns and occupations.

Oral Motor System

The primary oral motor mechanism is the suck/swallow/breath (SSB) synchrony. This involves the rhythmical, coordinated pattern of sucking, swallowing and breathing. An intact synchrony of SSB is critical to many elements of sensorimotor and cognitive development including speech and language development, postural control, feeding/eating behavior, eye/hand coordination, and sense of well being. Even a subtle disruption in any element of the SSB may have a far-reaching impact on development and function. The SSB synchrony often functions as an organizer for neuromotor behavior and can be used effectively in treatment to bring about more integrated behavior. Bite, crunch, chew, lick, suck, seal, vacuum, swallow, blowing and vocalization are ways to activate the SSB synergy. Suck, blow, bite, crunch, chew and lick are major components of oral motor activity, which can be incorporated into meals, snacks, and play activities. Use of these along with taste, temperature, texture, size and form will help improve SSB synergy and therefore influence sensorimotor and cognitive functioning.

Praxis related to oral motor system

Oral Dyspraxia - children are unable to reproduce mouth movements. Examples of this are the inability to put their tongue up to the roof of their mouth. A child with oral dyspraxia may not be able to perform these movements, even though they do this unconsciously.  Questioning for following movements in child may help to identify oral praxis problems in children.

·       Smile

·       Make jaw and lip movements that correspond to saying “aa”, “ee”, “oo”, “ae”, or “oh”.

·       Kiss, or make a kiss face

·       Stick out their tongue

·       Try to touch their tongue to their nose

·       Lick honey off from their upper, side, or lower lip

·       Imitate making a funny face

·       Blow out candles or blow bubbles

·       Bite their lips

·       Show various emotions in facial expressions

Verbal Dyspraxia - children have difficulty pronouncing sounds or saying words. Many words just do not sound right regardless of how hard they try to produce the sound or word correctly.In ideomotor apraxia, the execution of simple and complex, meaningful and meaningless movements with the orofacial musculature and/or with the limbs is impaired in distinct ways. The parapraxic distortions of movements occur when the movement is required out of context. The recognition of movements and gestures is intact. Ideomotor apraxia manifests itself as oral apraxia, bilateral limb apraxia, or unilateral limb apraxia. In ideational apraxia, in contrast, there is a disturbance in the conceptual organization of complex actions requiring the use of various objects. The syndrome is observed in the spontaneous behavior of the patients. There are indications that these patients are also impaired in the recognition of actions.

Oral Defensiveness – is an avoidance of certain textures of food and activities using the mouth in general (such as tooth brushing). Each child differs in the types or textures or activities they find offensive. Some common behaviors a child with Oral Defensiveness may exhibit:

·       Resist brushing his teeth or going to the dentist.

·       Be a picky eater and preferring only certain textures, dislike foods with unpredictable lumps, disliking sticky foods such as rice, jelly, banana, etc.

·       Refuse to eat hold or cold foods.

Activities to develop oral praxis

Few specific activities to develop the integrated and controlled movement of Jaw, lips and tongue along with those activities listed below to develop oral motor integration would help to develop good oral praxis which will in turn help in successful development of speech and oral skills.

Jaw Control  

·       Opening mouth wide to accommodate and hold balls of lemon size

·       Pull along strings by teeth from semi close boxes to develop clenching of Jaw as in saying “eee”

·       Holding and transferring straws or tubes in mouth with hands at the back to develop controlled jaw protrusion

Tongue control

·       Let the child put the tongue out of the mouth to lick honey or pickle.

·       Apply honey on ice cream stick and hold vertically to allow child to lick it from top to down and bottom to top.

·       Apply sweetened lipstick around the lips for licking.

·       Ask child to move beads from left to right and vice versa in a “U” shaped string

·       Stick magic pops or chewy candies at different area inside the mouth and let the child remove them out using tongue.

·       Draw different figures using ketch up or Jam on plate and let the child lick them in the same pattern

Lip control

·       Teach to purse lips by using straw or tube which is pulled unexpectedly when the child holds on it.

·       Teach upper and lower lip approximation in the same way as mentioned in lip pursing by using an ice cream stick placed horizontally between the lips.

·       Video model funny oral movements as in animal or vehicle sounds.

·       Incorporate other blowing activities as mentioned below.

Activities to Develop Oral Motor Integration

 Licking – Have the child lick stickers and place them in a book. They may also lick lollipops and Popsicles, or place sour drops or other foods on the child’s lips and have them lick it off. Licking helps on developing the tongue musculature.

 Sucking Activities – These work on developing the tongue, check, jaw, and lip musculature. They also facilitate concentration and help the child to do transition between activities.

1. Straw – Use straws for drinking liquids. There are a variety of straws that can be used which make it easier or more difficult for the child, such as using thick and thin straws to suck over thin and thick liquids. Using two straws together can also be done to make it more of a challenge for the child.

2. Washcloth Soaked in Juice – A washcloth may be soaked in a sour juice for the child to suck on.

3. Suck Foods Off Finger – The child can also suck foods off of his finger, such as peanut butter, honey, melted chocolates, etc.

4. Sucking In – Children may suck in on a piece of balloon, bubble gum over the lips, sucking on a lollipop, nipple, pacifier, or finger and creating a loud pop as it is pulled out.

5. Chew and suck – Sugar cane and drum stick can be given to initially chew well to bring out the juice and then suck to take the juice in.

Blowing Activities – These help develop the tongue, cheek, jaw and lip musculature; respiratory control (oral, pharyngeal, upper chest, and diaphragm); it opens up the rib cage;

1. Blowing Bubbles – The child may blow bubbles into a bathtub or sink with a few drops of liquid detergent in it r use a bubble dart.

2. with a straw or tubing: blowing cotton balls, crinkled up tissue paper, ping-pong balls, or other small and lightweight object to a given target.

3. Blow through a straw into a thick substance, such as milk shakes, porridge etc for increased resistance.

4. Blow Toys – Have the child play with toys such as whistles, party blowers, other musical instruments like flute, mouth organs, etc.

5. Blow up balloons.

Bite/Crunch/Chew – These activities are used for developing jaw and neck stability as well as upper thoracic stability. It also decreases oral defensiveness, hyperactive gage, and tongue thrust, jaw protrusion and retraction, and teeth grinding. In addition, it facilitates concentration. Crunchy foods are very alerting and chewy foods are organizing.

1. Chewy Foods – Such as dried fruit; jelly, and chewing gum.

2. Chewing Activities – Have child chew on objects such as a pacifier or teething ring, dog toys, tubing, etc.

3. Crunchy Foods – Such as chips, cookies, Pop corns, candies, frozen peas, corn nuts, Chocó sticks, wafers etc.

Tactile Experiences – Have the child experience a variety of textures, temperatures, and sensations. The following are types of foods that are alerting: cold foods (frozen fruit, ice, frozen teething rings, frozen toothbrush soaked in juice), Pop Rocks candy, sour drops (also encourages puckering), and hot tastes such as fireballs.  Chew-on toothbrush, water pick, electric toothbrush, etc., are also great tactile experiences.