From an oral-motor viewpoint, there are a number of areas that can be focused on.

While the primary focus is on improving oral-motor skills, there will be a knock-on
effect in relation to feeding and speech development. Be aware of your child’s level
of development and consult with your speech & language therapist, physiotherapist
and occupational therapist, to ensure you select an appropriate starting point. To
minimise tongue protrusion, your child needs to develop some or all of the following:
• Stable, central base (i.e. control over the trunk, head, etc.)
• Increased oral/facial muscle tone
• Increased oral sensitivity
• Improved lip movements
• Improved jaw movements
• Improved tongue movements

As you can see, tongue protrusion may occur for a number of reasons. Many children
with Down Syndrome may simply be exhibiting a generalised delay in their
development, of which tongue protrusion is one feature. It is important therefore,
that a full assessment is carried out, to ensure that the correct remediation path is
chosen. It would be inappropriate to focus on skills that the child is unable to achieve.
In normal development, these oral motor patterns are generally established by the
age of 24 months, but your child may have a developmental delay and difficulties
with low tone, so starting any activities at this age may be inappropriate. Every child
presents a different picture, therefore every therapy plan should be tailor-made. It is
essential that you consult with a speech and language therapist, occupational
therapist and physiotherapist to get an overall picture of your child’s physical,
sensory and oral-motor development and discuss the value of working on this area.
These are the professionals qualified to guide you through the process.
Without the possibility of meeting therapists, you could try some of the suggestions
below. Eliminate any medical reasons (e.g. enlarged adenoids/tonsils, teething,
throat/respiratory infections, etc.). Select one or two exercises to try, but be aware
that doing them all at the same time could be harmful. Adults can often become
overenthusiastic and if the child is unable to co-operate with the exercises, they may
become resistant to any form of intervention in the longer term. It is vital therefore
that you are aware of your child’s strengths and difficulties and give them lots of
praise for any attempt that they make. They may require many opportunities to
practice and will need you to demonstrate it clearly, in a way that they will
understand. Observe your child and take note of the times their tongue protrudes,
what they are doing at the time, how long it persists, if they correct it themselves,
etc.
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Be patient and be prepared to repeat the activity over and over again. It may take
some time before the skill is achieved. Most of all, make it fun!
Practical ideas for developing oral sensitivity and muscle tone:
• Don’t do all the activities at the same time.

• These activities should not be done at mealtimes as this could lead to aversive
behaviours around food.
• These exercises should be dome for short periods of time.
• Talk through what you are doing, each step of the way.
• Ensure you are both positioned in a relaxed, comfortable position.
• Ensure your child is in a stable, supported position.
• Minimise distractions e.g. TV, radio, other people etc.
• Pause to allow time to swallow any saliva that may have accumulated.
• These exercises can be done throughout the day – washing / drying at bathtime
(using a towel, sponge, facecloth, etc).
• Don’t attempt this if your child has a cold.
• Stop if your child becomes distressed at any time.
o If your child is sensitive around their face, prepare them before you approach their
face. Use slow, firm strokes over the hands, arms, shoulders, body and neck with
a rough texture (e.g. towel, etc.)
o Using firm strokes/touch with a rough texture (e.g. towel, etc.) start at the sides of
the face / forehead / chin and gradually work towards the centre of the face.
o Massage the cheeks using circular movements, particularly around the mouth.
o Use 2 fingers to press the top and bottom lips firmly together. Hold for a couple of
minutes and release.
o Stroke firmly downwards on the area between the nose and top lip while using
your finger to push the bottom lip upwards.
o Using your thumb and index finger, pull the top lip down, starting under the nose
and working towards the top of the lip (without touching the lip itself). Do the

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same for the bottom lip, working from the chin to the lip. Support the jaw if
necessary.
o Press the lips together by pressing one index finger below the nose and the other
below the bottom lip – rotate the fingers towards the lips.
o Gradually introduce stronger flavours at mealtimes:
- curry / Chinese sauces / garlic
- chips: vinegar / garlic mayonnaise dip / brown sauce / ketchup / etc
- tangy or bitter flavoured fruits and yoghurts: kiwi / lemon / forest fruits /
grapefruit / cranberry / etc
o Extremes of temperature:
- ice-cream
- ice-pops
o Sensory toys:
- “Bumble Balls”
- Teethers that are textured / vibrate / etc.

Practical ideas for developing jaw and tongue movements

• When spoon-feeding your child, place the food centrally on the tongue and apply
firm downward pressure. This will reduce tongue protrusion that occurs during
swallowing.
• As the protrusion reduces, place the food at the sides of the mouth, between the
teeth. This will encourage munching and sidewards tongue movements.
• To stimulate biting, munching and sidewards tongue movements.
- Initially, do this at times when your child is relaxed.
- Initially, these activities should not be done at mealtimes.
- Use items such as teethers (ridged etc.), foods that do not break up (bite &
stay firm foods - Dried fruit: bananas / peaches / apricots, Liquorice sticks,
etc.)

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 - Place the item in the mouth, between the teeth, along the line of the jaw and
ensure that it is not placed so as to stretch the lips. Do not place too far
back in case your child gags.
- Place on the best side initially, than move to the other side.
- If the child is not munching, pull the item out slightly and gently or press
down.
- When you feel your child is confident about their biting skills, introduce food
items. Initially use bite-and-dissolve foods (Boudoir biscuits, meringues,
Skips/Snax, etc.).
- If the child is not biting off the food, break it off for them while they are biting
down on it. Do not force your child to take foods that their mouth is not
ready to handle.
- Over time, gradually introduce chewier foods in the same way.

Practical ideas for developing lip movements

• Using a mirror, make “oo” sounds (e.g. a ghost/owl/ monkey/wind etc.) and “ee”
sounds (e.g. mouse, E-I-E-I-O, etc.) using exaggerated lip movements. You might
need to gently push the lips from a tight stretched position (smile shape) to the
round position (kiss shape).
• Practice kissing. You might need to gently push the lips from a tight stretched
position (smile shape) to the round position (kiss shape). Put on some lip stick or
face paint and make kiss marks on a mirror, tissue, paper etc.
• Sucking through a straw. Make a tight lip seal around the straw.
• Blowing bubbles, blowing cotton wool balls across the table, blowing whistles/party
blowers, blowing bubbles in water with a straw, etc.

Tongue Exercises

12 May 09

The tongue is composed entirely of muscle and is moved and shaped

by two types of muscles: (i) The intrinsic muscles are contained within
the tongue and are responsible for the refined movements of widening,
flattening, elongating, shortening, narrowing, thickening and
lateralising the tongue. These muscles lift the sides, raise and depress
the tip as well as change the shape and contour of the tongue. (ii) The
extrinsic muscles are responsible for changes in the tongue position in
the mouth. These muscles elevate, depress, protrude and retract the
tongue and are important in the processes of eating, drinking and
talking.

Children with Down syndrome often exhibit low muscle tone in the
tongue. Their tongues may appear thick, bunched and slightly larger in
size. Children with low muscle tone in the tongue generally exhibit
imprecise pronunciation of speech sounds secondary to concerns with
intrinsic tongue muscle function. Without the support of the intrinsic
musculature, the extrinsic tongue muscles are unable to stabilise the
tongue, thus creating further difficulties with eating, drinking and
talking.

When targeting oral-motor skills, it is very important to remember the

developmental hierarchy of oral motor tasks. Starting at 18-24 months
(in children with normal muscle tone), children will be able to imitate
the following oral motor tasks:

1. Sticking out their tongue or tongue protrusion.

2. Pulling their tongue back or tongue retraction.

From 24-36 months, children will be able to move their tongue from
side to side or imitate tongue lateralisation. Only from 36-48 months
are children able to lift up their tongue tip or perform tongue tip
elevation tasks.

What activities can I do to develop tongue strength and mobility?

Activities to develop controlled tongue protrusion (sticking

your tongue out):

• Show your child how to push his/her tongue against objects, e.g.
clean bubble wand, cheerios on a plate, tongue depressor.

• Show your child how to balance a cheerio on the tip of his tongue.

• Poke your tongue in and out like a lizard in a slow rhythm. Do for 5
seconds.

• Encourage your child to lick foods from a plate (not at dinner of

course!), e.g. Nutella chocolate hazelnut spread, 100’s and 1000’s.
Encourage your child to use their tongue and not their lips.
• Encourage your child to lick food substances from a spatula or
spoon (small measuring spoons are a great idea!).

• Encourage your child to lick lollies and ice blocks.

• Place food tastes around your child’s lips and encourage them to
lick their lips.

Tongue retraction (pulling your tongue back):

• Difficult or strong blowing, e.g. difficult-to-blow whistles, party

horns.

• Sustained blowing, e.g. bubbles.

• Straw-drinking with long, thin straws and thickened liquids, e.g.

smoothies, milkshakes.

Tongue lateralisation or moving your tongue from side-to-side:

• Licking sticky foods from the corners of your lips, e.g. peanut
butter, honey, chocolate spread.

• Put small bits of melt-in-the-mouth foods into your child’s cheeks.

These can include chocolate buttons, meringue, prawn crackers, skips,
etc.

• Show your child how to use their molars to bite and chew crunchy
and chewy foods, e.g. carrot sticks, liquorice sticks, pretzels, and
breadsticks.

Tongue-tip elevation or lifting the tip of your tongue:

• Get your child to lick large lick-and-stick stickers.

• Dab a long line of peanut butter on a tongue depressor and get

your child to lick it all the way up, using only his/her tongue and not
his/her head.

• Tongue lifts – pretend you are a weight-lifter having to lift cheerios

on your tongue up and down.
(These exercises are to help increase control of the tongue. Use a
mirror when you first do the exercises, so that your child can see what
s/he is doing.)

• Open your mouth. Move your tongue from side to side in a slow
rhythm. Try not to move your head – only your tongue. Touch the
corners of your mouth with the tip of your tongue. Do this for about 5
seconds.

• Open your mouth a little. Slowly lick around your lips in a circle.
Then go the other way around your lips.

• Try to reach your nose with the tip of your tongue. Try to touch
your chin with the tip of your tongue. Then put these two movements
together and move your tongue up and down for 5 seconds.

• Poke your tongue into your left cheek, then the right cheek. Do this
3 times on each side.

• Clean around your teeth with your tongue.

• Pull faces in the mirror - ask your child to copy you - moving their
tongue up and down and side to side