Question
How do you treat a student with low cognitive functioning who has tongue thrust? He is 4 years old. His tongue hangs out in between his front teeth in regards to resting posture. He has no difficulty eating or keeping food from falling out of his mouth.
Answer
I would first teach this child the typical tongue resting position, which is for the tongue tip to be on the upper alveolar ridge, just behind - but not touching- the upper central incisors. I have provided tactile cues with a tongue blade, swizzle stick, coffee stirrer, straw, etc. Sometimes a taste cue, such as toothpaste, pudding, jelly, peanut butter (just be cautious of allergies) may be helpful for these younger children.
In addition to teaching the placement, you may have to determine if this child is really able to maintain this position. I would have the child place his tongue on the "SPOT" and close his mouth and breathe gently through his nose for as long as he can. I usually time my patients for 60 seconds. If he can maintain the proper tongue position for that long, then he may just need some behavioral cues to encourage this typical rest posture more frequently throughout the day. If he is not able to maintain this position for the minute, you will have to determine if this is due to cognitive issues or if there might be some sort of an upper airway issue that is causing this child to maintain an open mouth position. Some children will exhibit this open mouth position due to enlarged tonsils and/or adenoids or allergy issues. If you have concerns about the upper airway, I usually suggest a referral to an ENT and/or an allergist. If I suspect allergist, from the parental report, I will request that the patient be seen by a board certified allergist who will perform allergy tests, not the primary care physician. I certainly have great respect for the primary care physicians, however if medications are a possible solution to the child's problems, I personally would rather the child be placed on medications that are specific for the allergies that they present, rather than a "general" medication, which could be used to treat a vast array of allergy symptoms. If a board certified allergist is not available, then certainly the primary care physician could manage the allergy symptoms. If the child is positive for allergies and/or has an upper airway disturbance, then I would wait for a few weeks to begin to help the child in learning the typical resting position, after any medical intervention - medication or surgical.
If allergy symptoms or nasal breathing are not of concern, the child's age and low cognitive functioning may make it difficult for this child to maintain the typical rest posture for more than a few seconds or to remember to put his tongue back after talking, yawning, laughing, etc. Many individuals, regardless of age or cognitive status, have difficulty initially in getting used to the feel of this new tongue position. Caregivers and educators should all incorporate the use of a cuing sign and/or phrase to help remind the child, as frequently as needed, in a positive manner to put his tongue back on his "SPOT". A reward system may need to be used for this child, as a motivator to continue to comply with this request. The reward system and verbal or sign cue should be weaned from use, as the child is able to perform the task more independently.
Marsha Lee-White, MA, CCC-SLP is a speech-language pathologist at the Cincinnati Children's Hospital Medical Center, providing services at the Outpatient Mason satellite. She is a certified orofacial myologist through the International Association of Orofacial Myology, and a certified member of the American Speech-Language-Hearing Association (ASHA). She has been providing clinical services to patients with orofacial myofunctional disorders/tongue thrust for approximately 15 years and has presented at the local and state level on this topic.