• Parents, teachers, anyone working or living with a child with ASD

Introduction
Suzie, age 5, has a diagnosis of autism spectrum disorder. She has a limited diet, preferring crunchy foods, such as pretzels, that are quick and easy to chew. Suzie rejects slimy foods, such as canned peaches, meats, foods with lumps, and most fruits and vegetables. She is a very messy eater and often stuffs her mouth with food. Her parents dread brushing her teeth because of the way she fights them. She sometimes gags when they approach with her toothbrush. Suzie spontaneously produces some single words and phrases but does not consistently imitate words and phrases after her parents and teachers. She produces a limited variety of speech sounds. Suzie will continue to have difficulty imitating words and phrases, expanding the variety of speech sounds, accepting new foods, and tolerating tactile input from others until this aversion to tactile input is addressed through oral-motor treatment.

Evaluation of oral-motor skills has often been overlooked in treatment programs for children with autism spectrum disorders (ASD), partly due to a general lack of considering the development of the whole child. Thus, programs have often encouraged verbal imitation without focusing on the child's ability to process the sensory information and then produce the components of movements needed to produce a sound or a syllable. In the case of Suzie, this child is hypersensitive to tactile input inside the mouth. Suzie does not want to move the tongue vertically to the top of the mouth to produce a /d/ or an /n/ sound because it does not feel good to make contact with the palate or roof of the mouth. In fact, as we saw in the vignette, she may even gag when her tongue makes contact there. Oral-motor development is part of normal development and must be considered when looking at the child and her treatment program. They are the components that form the foundation of the sensory motor pat-terns that are practiced during the development of the simple as well as complex skills used while eating and speaking. Children with ASD, to varying degrees, are unable to register and modulate sensory information in one or more of the sensory systems (Ayers, 1979; Henry & Myles, 2007; Yack, Aquilla, & Sutton, 2002). This interferes with the ability to initiate movements, to plan movements, to sequence movements, and to develop a feedback system. All of these inhibit the development of oral-motor skills, in turn affecting eating, speech production, and communication.

Brief Overview of Sensory Processing and Oral-Motor Skills
Ayers, in her book Sensory Integration and the Child (1979), documents the symptoms of poor sensory processing that can affect oral-motor development in children with ASD. The number of sensory systems that are not registering and modulating information affects the level of severity of the child's dysfunction. For example, the child who is able to process information through her proprioceptive, tactile, and visual systems but not through the auditory system will present a different level of functioning from the child who is not processing information well from any of these systems.

The first child would have a sense of where his body is in space, accept being approached by others, and possibly gain information by reading. But he would be unable to follow verbal directions, need frequent repetition of verbal language, and possibly be using scripted language to communicate. The second child would easily become overstimulated by information, causing him to over-react or under-react and become defensive. This child would present with a more severe level of dysfunction, given his oral-motor, eating, and speech production.

Children with Differing Needs
Ayers (1979) cites three areas where children with autism have poor sensory processing - registering sensory information, modulating sensory input, and initiating movement. Each area is briefly described in the following.

Registering Sensory Information
Thomas, 7 years old, was attending to a siren from a fire engine in the distance and not to his teacher leading a lesson. A hand on his shoulder from his teacher assistant and the use of a microphone by the teacher to amplify her voice brought his attention back to the lesson.

Children with ASD often do not pay attention to information that is important, such as speech sounds. For example, instead of attending to speech, the child may attend to a background noise, such as the humming of a fan, not noticed by others around her. According to Ayers (1979), in such cases, the part of the brain that "decides" which information to attend to and what to do about that information is not "registering well." Emily, a 5-year-old girl with a diagnosis of ASD, had difficulty registering touch sensations. She never felt drool on her chin or food on her face. Emily also stuffed food in her mouth with no awareness that her mouth was already full. Emily's mother wondered why she had to constantly tell her daughter to wipe her face or take small bites and swallow.

This is commonly seen in children with ASD, but in varying degrees. In-deed, the ability to take in and respond to information is inconsistent with-in and across individuals. Motivation, strong sensations, and firm input are needed in order for these children to respond optimally to sensory input.

Modulating Sensory Input
Terry, an 8-year-old boy with a diagnosis of ASD, had difficulty modulating touch input. He could not tolerate the way his clothes felt against his skin. He spent a lot of his time pulling and tugging at his clothes. He frequently stood up and pulled his pants up at the waist. Instead of filtering out this touch sensation, all he could think about was how his clothes felt at that moment. This made it difficult to attend to another child trying to talk with him or to his teacher during a lesson (Yack et al., 2002).

The brains of many children with ASD are unable to control sensory input, causing them to receive too much input or not enough. In other words, the child is unable to balance the sensory input (Henry & Myles, 2007). In the first situation, the child is bombarded by input from one or more sensory systems. In the second, the child is not getting enough stimulation and, therefore, may crave input from one or more sensory systems.

Another example involving the tactile system (touch) is the child who needs strong, firm touch in order to register input but then quickly becomes overloaded and reacts defensively. This child is unable to regulate and integrate this input into his body awareness and make sense of the input once it is registered. This can result in oral-motor planning problems. An example is the child who has difficulty moving her mouth when requested to do so. She cannot stick out her tongue when asked or when given a visual model. However, the child can be seen to stick out her tongue while automatically licking a lollipop. It is difficult to plan movements when you do not have a good sense of your body. Further, when the child cannot organize and plan simple movements, he has trouble developing more complex behaviors such as speech production. In brief, the ability to plan movements depends, in part, on the accuracy of the child's touch system.