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Straws As Therapy Tools

By Sara Rosenfeld-Johnson, M.S., CCC-SLP
Published in ADVANCE Magazine April 19, 1999
Copyright © 1999 Sara Rosenfeld-Johnson, M.S., CCC-SLP

Film writers and novelists know that one translation of this tactile information has to take
quick path into a storyline is through the reliable place in the mouth; that therapists must put
dramatic tool: food. Oral motor therapists are no something into their client's mouths that is going to
different. This article is the first of a two-part series increase their client's awareness of their mouth and
that explores the use of simple tools to facilitate that will, in a series of measured progressions,
therapy for a variety of speech disorders. The first strengthen the target muscle groups. This oral
tool - straws - can be used by many clients. The muscular development and control is an important
primary goal of the use of straws is to address prerequisite which then enables the clinician to use
insufficient tongue retraction. This treatment traditional articulation therapy.
encourages increased speech clarity whether the Let's review some basics. In English, in
client has an inter-dental lisp or other varieties of order to have connected speech (co-articulation)
phoneme distortions. Therapeutic straws have also and speech clarity we have to stabilize the back of
been found to be useful when working with our tongue on the back of the palate. Then,
velopharyngeal insufficiency or a client that is whatever else our tongue is required to do, it moves
recovering from a cerebral vascular accident (CVA). from that position of stability. The tongue elements
In these instances and numerous others, specially work with four basic movement components: 1)
gradated straws are used in a hierarchical retraction/protrusion, 2) back elevation/depression,
succession to work on a specific component of oral 3) tip elevation/ depression, and 4) the ability to
movement. spread the sides of the tongue. When babies are
The use of straws in speech therapy is not born they have approximately a 50% back and 50%
uncommon. For many years straws have been an forward movement from the resting position called a
important utensil in feeding and lip rounding suckle. As the child gets older and begins spoon and
exercises. On the client's level the straws cup-feeding they achieve about a 75% retraction
themselves are viewed as fun and the food is and 25% protrusion. They do not stick their tongues
experienced as a reward. At the therapeutic level out during feeding. Those who do frequently present
straws have the promise of addressing a multiple with feeding problems. Straws have been prescribed
array of disorders and muscle groups far beyond routinely for these occurrences because, at the very
traditional practice. A little over twelve years ago, least, through straw feeding, the client can return to
when I was initially using straws for feeding or lip- the 50%/50% suckle. But there is no reason to stop
rounding goals, I was struck by the improved tongue there, and, I would argue that allowing clients to
retraction (and therefore speech clarity) that was its suckle straws is therapeutically wrong IF treatment
side-effect. Since then straws have become one of stops there. Suckling can actually exacerbate
my most important therapy tools. protrusion of the tongue. (It should be mentioned
Traditional therapy methods start with the that sippy-cups, a popular feeding tool, encourage
assumption of adequate tongue muscle function. suckling, once again falling short of the preferred
The premise of traditional therapy would follow that if 75%/25% retraction/protrusion goal.)
you listen to me when I say "ball" (auditory stimuli), By continuing to use a progressive series of
and you look at a ball when I say it (visual stimuli), increasingly more complex straws and thicker liquids
and if you hold the ball (tactile stimuli) when I say it, we can teach the tongue muscle to retract. The goal
then through this multi-sensory approach you will is to achieve close to a 75% retraction; to achieve
acquire the ability to say "ball". Oral motor therapy that position of stability. The back of the tongue in
(OMT) does not work like that, particularly with our stabilized retraction allows the tip of the tongue to
special education clients who have reduced visual or move side-to-side to alternating back molars; the
auditory capabilities. OMT asserts that the

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 Straws As Therapy Tools
By Sara Rosenfeld-Johnson, M.S.,CCC-SLP
Published in ADVANCE Magazine April 19, 1999
2

very movement that is needed to chew food care-givers for low-tone children who may not be
effectively. At this milestone we have clients who able to pull liquids up on their own initially can gently
attain more eating independence and improved squeeze the liquid up to assist.
nutrition, both very important for children that have Exactly what is straw drinking? Normal straw
not progressed well with cups or spoons. drinking requires complex movement from the jaw,
How do therapeutic straws address speech lips and tongue. Through the coordination of these
clarity goals? Children or adults with interdental lisps movements a vacuum draw is created. Each of our
are missing this important component of stabilized speech sounds are made with a different
tongue retraction. Clients who stabilize their tongue combination of these graded movements.
at the front of their mouth between their teeth rather Over many years I developed a
than in the retracted position of stability are said to successional group of straws with each individual
be fronting their sounds. If a client is using an straw working on a specific part of those graded
interdental production on /t/, /d/ or /n/, which are the movements. After initial experiments with ordinary
first stable retracted sounds in the developmental straws, which offer such limited results as to be
scale, the mastery of these sounds must occur therapeutically unusable, I located every
before attempting to master /s/ or /z/. If a conceivable type of straw produced and jury-rigged
developmentally normal three-year-old them when necessary. Ultimately I was compelled to
interdentalizes on /n/ there is already a problem. In persuade straw manufacturers to custom-produce a
fact, any three-year-old with an interdental few of the straws for the specific attributes that I
production on /t/, /d/ or /n/ needs help to retract the needed.
tongue, and further, any child with an identified This hierarchy of straws progresses through
speech problem who suckles, whether its a bottle, a matrix that advances from multiple sips to single
cup or straw, is maintaining their speech errors if sips and then from thin liquids to thickened liquids
they are secondary to interdental tongue placement. while varying the straw's diameter, overall length
(If a developmentally normal four-year-old does not and the structural complexity via elbows, curves,
interdentalize on /t/, /d/ or /n/, has correct tongue twists and placement of a lip block.
blade retraction, but lisps on /s/ it is possible that the How would therapy begin? At the outset -
lisp is secondary to a developmental delay and may making sure that the client is sitting up straight in a
not need therapeutic intervention.) stable position receptive to drinking - I give them a
How do we get clients on therapeutic straws simple, straight, regular-diameter straw to see how
and at what age or point in therapy? Muscles can be they will use it, allowing them to drink from it like
toned at any age; one or one hundred. These they normally would. I place my finger at the point
techniques will work anytime but the younger the where the straw is entering the mouth so that I can
client the easier. then take the straw out and measure the length from
Young children with an identified dysfunction the entry point to the tip of the straw that is inside
can often be started as early as one-year-old. Many the mouth. There are several things to watch for at
of our clients with Down syndrome are started this this stage. Is the straw more than 1/4 - 1/2 of an inch
early because we are working on the concept of inside their mouth? If so, then they are either
retraction as a critical oral motor skill that then suckling it or biting it. Is the client biting the straw? If
cascades into other oral motor benefits. Other so, that could be an indication of jaw instability. The
clients with a low tone diagnosis also benefit from correct position for the therapeutic use of the straw
this early intervention. Many of these children are is with jaw stability, tongue retraction and lip
still on a bottle at ages two, three or four; suckling. In rounding to fully enable drawing.
virtually all cases, by the age of two, straw therapy The first straw in my hierarchy is cut to the
can be successfully undertaken. Some children length that I measured above. The straw has a lip
need an assisted transition. I use a squeezable block which encourages sealing and rounding. Over
"honey bear", emptied, cleaned, filled with slightly a succession of visits as the client exhibits
thickened liquid and retrofitted with a straw. The proficiency I surreptitiously reduce the length from
child can still clutch the "honey bear" bottle while the lip block to the internal tip until the client has
learning to draw liquid up through the straw. The achieved primary retraction and at least minimal lip

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 Straws As Therapy Tools
By Sara Rosenfeld-Johnson, M.S.,CCC-SLP
Published in ADVANCE Magazine April 19, 1999
3

rounding. At this point the client is said to be

therapeutically drinking from a straw and I am free to
move through the remainder of my hierarchy. Clients
are taking these straws home and using them daily
for drinking all thin liquids. As they progress,
thickened liquids and purees are introduced using
specifically identified straws in the hierarchy. The
clients use these straws to drink 3-4 ounces once a
day. As each straw is mastered or seems to be too
easy, I move onto the next. For some clients this
may be as frequently as one new a straw a week, as
it might be in the case of a developmentally normal
child with an interdental lisp. For this client a full,
successful course of treatment may last as short as
four months.
Other clients, depending on the diagnosis,
for example cerebral palsy, the therapy, while still
effective, may continue for a longer period of time. A
client with Down syndrome may complete the full
treatment in one to two years and we often find that
this type of therapy reduces the duration of speech
therapy as they get older. Clinicians who are
targeting specific sounds in therapies with their
clients will find that therapeutic straw treatments
have proven to be effective with the standard
production of /t, d, l, n, k, g, s, z, ch, sh, j, & r/.
Clients with velopharyngeal insufficiency are
another population that benefit from straw drinking.
For them it increases tongue retraction, changes
resonation and elevation of the velum. Clients
recovering from Cerebral Vascular Accidents (CVA)
often exhibit lip asymmetry. Therapeutic straw
drinking works to bring their lips to symmetrical
midline thereby improving speech clarity.
An extra advantage of treatment through
therapeutic straw drinking is that it can be equally
effective with clients irrespective of cognitive
abilities. That is the therapeutic results, (tongue
retraction and tongue grading), for a client with
severe cognitive impairment and limited or no
language skills can be almost the same as with a
developmentally normal child or adult. This adds to
its promise as an important tool in the arsenal of all
oral motor and speech pathologists.

Email: [email protected] Website: www.talktools.net