Q: In a few of your blogs you mention that sometimes we have to teach a client to suppress his gag reflex. Why would you need to suppress the gag, and how does one go about doing it?

The gag needs to be suppressed only if it is interfering with oral motor learning for speech and/or feeding.

Severe Cases

In the most severe of these cases, excessive gagging causes children to be unwilling to move and explore with the mouth.  These clients often have severe speech-language delay, cognitive impairment, and neuromuscular involvement.  They often avoid the types of feeding, mouthing, and vocal play activities that normally stimulate oral movement in infancy.

Method for Severe Cases

We help these clients learn to suppress the gag so they can eat a greater variety of foods, so that can engage in an increased variety of mouthing and oral play activities, so they can handle oral hygiene procedures (face washing, tooth brushing, dental visits, etc.), and so they can explore more widely with their sound-making apparatus. Treatment to normalize the gag response includes their feeding program activities, mouthing play, oral hygiene routines, hands-on oral-motor techniques, and vocal play activities.  The best resource for this information is Morris and Klein (2000).

Mild Cases

In the mildest of cases, we teach a client to suppress his gag in order to learn tongue-back elevation for K, G, Ng, and R.  These children typically have a normal gag response.  We teach them to suppress their gag so that they can tolerate the tactile-proprioceptive stimulation techniques we want to use that are designed to teach the back of the tongue to rise to the velum.  This is just like learning to suppress the gag during dental visits.

Method for Mild Cases

I have been working with high-functioning clients in this way for the better part of four decades. I first developed this method while working with adults in acute care, but I have since used it with uncounted scores of children who had specific articulation deficit.  The method is simple and direct, and it has worked for me every time with willing clients.  Place a metal spoon in ice water and engage in the following:

LIPS:  Have the client place the bowl of the spoon on his lips. Tell him to hold it there fore a 3-count (3 seconds). Then have him place the spoon back in the ice water. Reward him for holding the spoon on his lips without gagging (choking).  Say, “You didn’t choke!”

TONGUE TIP: Have the client place the bowl of the spoon face down on the tip of his tongue. Tell him to hold it there fore a 3-count (3 seconds). Then have him place the spoon back in the ice water. Reward him for holding the spoon on his tongue-tip without gagging (choking). Say, “You didn’t choke again!”

TONGUE MIDDLE: Have the client place the bowl of the spoon face down on the middle of his tongue. Tell him to hold it there fore a 3-count (3 seconds). Then have him place the spoon back in the ice water. Reward him for holding the spoon on the middle of his tongue without gagging (choking). Say, “You didn’t choke this time either!  Very nice.”

TONGUE BACK: Have the client place the bowl of the spoon face down on the back of his tongue. Tell him to hold it there fore a 3-count (3 seconds). Then have him place the spoon back in the ice water. Reward him for holding the spoon on the back of his tongue without gagging (choking). Say, “You didn’t choke again! Excellent. You are learning to hold your choking back.”

Try this procedure on yourself so you can experience first hand how it works.

At each point, teach the child to breath or pant gently through his mouth and over the spoon. This will calm him and help him hold the gag in check.

At each point, tell him, “Don’t choke” and “Don’t let yourself choke.”  Teach him that he can hold his gag back, that he can suppress it.  He can do this because everyone can.

The client will gag at one of these points.  Then say, “Oh! You Choked! I hate those chokes…”  Give him a moment to recover, and then say, “Do it again….” Start in the front again, at the lips, and have him move back step-by-step one more time.

You are teaching your client to tolerate tactile stimulation to the tongue, from tip to back.  You are teaching him to suppress his gag, to avoid his gag, to hold his gag back.  Once the client can suppress his gag, you then can apply your method to stimulate the back of the tongue to rise for the phoneme you are teaching.  Teach him to hold his gag back as you employ your phoneme stimulation method.

Reference

• Morris, S. E., & Klein, M. D. (2000, 1983). Pre-feeding skills: A Comprehensive Resource for Mealtime Development. Austin: Pro-Ed.  [Chapter 17. Specifics of Oral-Motor Treatment, section called “Sensory Issues”]

Also See…

• Marshalla, P. (1995) Oral-Motor Techniques in Articulation and Phonological Therapy.  Mill Creek: Marshalla Speech and Language.  [Chapter 3. The Tactile and Proprioceptive Systems]