Habitual Tongue-Clicking in Low-Functioning Client

By Pam Marshalla

An SLP wrote about a 12-year-old client with cerebral palsy who constantly makes sucking noises with her tongue. The therapist was seeking information about how to eliminate the habitual sucking that was distracting in the classroom.

More information about this client was gained through email exchange. The additional information and my responses are offered here.

The client has a cognitive age of 6 months

With a cognitive level of 6 months this client is functioning just above the reflex level, and automatic sucking often is part of this. Reflexes typically dominate from birth to four months of age. But your client has a neuromuscular deficit, therefore her primitive reflexes will dominate longer, perhaps for years. The reflex will fade if and when her cognitive and motor levels advance.

The client eats mostly purees, and she can drink from a sippy cup

This is more evidence that she is functioning just like a six-month-old, more evidence that she probably will not be able to stop this oral habit voluntarily. A typical six-month-old would not be able to stop this voluntarily, and neither will she.

Food is her greatest motivator

Naturally. She is functioning like a baby. Food, movement, and human contact will be her greatest motivators.

The sucking usually occurs during group activities. We think she is bored.

Yes. I would agree. She probably is entertaining herself by sucking. Sucking occupies her unoccupied mind. She needs more to do that sit in a group where she cannot possible follow what is going on.

The problem we have in the public schools today is that we are taking kids who are functioning at infantile levels, and we are trying to make them function like they are toddlers or preschoolers. To put it bluntly, this is insanity. One cannot make a child function at a higher cognitive level. This is the fault of the school system as it functions today.

I think it is time to re-think our approach to these kids. Decades ago, these children were kept at home and they attended special day schools, or they were institutionalized. Now I am not in favor of institutionalization — I used to work in one and it was quite oppressive. But I also am not in favor of pretending that a student isn’t exactly what she is. This student functions like an infant. Period.

More attention needs to be paid to what she can and is doing, and most of her school day needs to center around that. Imagine taking a typical six-month-old and placing her in a small group setting. What do parents have to do to keep babies quiet and occupied during times like this? She needs a toy with which to fiddle, a toy on which to suck and chew, a cuddle toy, someone to cuddle her while she sits, someone to gently tickle her arms or legs during the activity, someone to gently bounce her, someone to pat her back, and so forth. Babies are not entertained by talking. They are entertained by tactile and proprioceptive input.

The fact that she is using her tongue to make noises is encouraging to me as an SLP, but not to the classroom teacher who dislikes the distraction.

Yes, it is good that your client is moving her tongue. However remember that this is reflexive tongue movement, stimulated out of boredom, and becoming a strong habit. It is not the type of oral exploratory play one would expect in a typical child functioning at six months of age. A typical six-month-old would be moving the oral mechanism in many ways, would be exploring many objects with the mouth, and would be vocalizing simultaneously. A wide variety of pre-speech vocalizations would be heard as a result. Your client is locking in on a sound that does not contribute to speech learning. She needs to be stimulated with a greater variety of oral play activities.

We have tried oral stimulation using a press-release technique around her lips, inside cheeks, tongue, and roof of her mouth. She tolerated that for a few sessions and now she refuses to let anything in her mouth other than a spoon. We have tried chewy tubes/chew toys, but she refuses them.

Your client may be hypersensitive, or she simply may again be functioning like a 6-month-old. Have you ever tried to wipe the face of a typical 6-month-old? They don’t like it. You need to engage a process of increasing oral exploration in ways that are tolerable to her.

A solid plan to normalize oral-tactile sensitivity will be highly individualistic to the client. Pat-release and sticking chewy tubes in a kid’s mouth is not the answer just because they are a popular methods. Find out what the client tolerates and do that. Then do more of it and change it just a little bit. For example, try using other baby chew toys, especially those with a vanilla flavor. And try giving her chew toys that make noises, and ones that are dipped in her favorite purees. She may like that the best.

The solution for an oral habit like this is a plan with several elements including activities to normalize oral-tactile sensitivity, to increase oral exploration, to develop more advanced feeding skills, to stimulate cognition, and to develop social interaction.

Keep in mind that this child is not developmentally delayed, and she will not “catch up” just because she is in special education. She functions like a six-month-old, and she may always function like a six-month-old. This is not because of the cerebral palsy, which is a motor disability. This is because she has impaired cognition. We used to call this mental retardation and I personally believe that we still should. By facing the fact that a child like this has a cognitive deficit, that she functions more like a baby, that she is mentally handicapped, we can design a program that is more suited to her, that will help her be the best she can be. If we stop denying who these children really are, and if we stop pretending that they can benefit from activities that are far too advanced for them, we may begin to help these children reduce the inappropriate oral habits they develop because they are soooooooo bored.

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