Notes on oromotor control

If I had the detachment of another person who wasn’t Sacha’s dad, I would probably find something fascinating in what his difficulties might reveal. There is a lot that is profound in child development, and one sees that all the more clearly when it cannot proceed along the typical paths. One can see why Piaget and Merleau-Ponty thought there might be answers to philosophical problems here. While there is much to think about in this, the experience of struggling with these things is immensely painful when this struggle necessarily takes place through the daily interactions of a parent and a child. But laying out thoughts on a page for the possible consideration of others is an important exercise in self-clarification for people like me, so here are some thoughts derived from recent exercises in oromotor control.

I have been trying to get Sacha to lick his lips as a sensory and oromotor exercise. The difficulties getting him to do this seem quite illuminating. If I dab a bit of Nutella on his lip, Sacha is aware of this but doesn’t know how to get it into his mouth, other than by using his own finger to wipe it off and then sucking that finger. He doesn’t seem to be fully aware of, or in control of, his tongue for the purpose of movements like this. He can coordinate his tongue well enough for the purposes of everyday eating, when it is relatively unfocused or a spontaneous part of a broader action, but when it is specifically his tongue that needs to be isolated for an action, he finds this very difficult, near impossible.

For this reason, I decided to go right back to control of the tongue, and have spent a couple of sessions focusing on that. Both face-to-face and in front of a mirror, I have modelled the action by sticking my own tongue out, offering the dab of Nutella to go on Sacha’s tongue if he can stick his out too. Feeling something specific being asked of him, his avoidant behaviours kick in here: for some time, he will avoid looking at me and looking at himself in the mirror. But as is generally the case, one seems to be able to wait out this avoidance and get past it to some extent, and the chocolate means there is at least some motivation.

When more engaged, Sacha will reach for my hand and try to get the Nutella onto his own fingers in order to get it into his mouth, or he will grab my hand and try to insert my fingers into his mouth directly. When I insist that he sticks his tongue out, he is at a complete loss. He will stick his own hand into his mouth and feel his tongue, and he can even get his tongue to stick out if he touches it at the same time with his hand or holds it between his fingers, but there seems to be a complete block around large-scale voluntary movement of the tongue in isolation. He will spend a while apparently thinking about tongue movement, and managing smaller-scale movements, pushing it up against his teeth so that it pokes out a little, but he seems mostly unable to turn this into a larger voluntary movement.

He did, however, suddenly manage to stick his tongue out at points during the exercise, but these seemed to be at least semi-involuntary. After trying and failing for a long time, he would disengage and start to turn to something else. Suddenly the tongue would pop out! “Yay!”, I would say, and dab the Nutella on it. But since it had been involuntary, this came as a surprise to Sacha. He seemed puzzled that he had just suddenly done what I had been asking him to do for so long, but that this had been more or less accidental.

When Sacha was tiny, voluntary tongue movement was one of the first things he did: at age 5 months or so he would stick his tongue out at me and laugh, or blow rasperries this way. So in a sense it is a previous skill which has gone away. However, the actions of a 5 month old are of course not quite voluntary in the same way as those of a 3.5 year old. They are less self-conscious, and in this case might be related to things like the spontaneous workings of mirror neurons. In the 3.5 year old Sacha, these things are being mediated through social expectations, avoidant tendencies, his own self-consciousness and anxieties and so on. And it now seems as though it is easier to do this action involuntarily than voluntarily. As long as it is focused upon, it doesn’t happen; when the focus goes elsewhere, suddenly it happens.

One could describe this problem in terms of motor planning: Sacha is struggling to compose intended movements with his tongue. Proprioception also seems relevant, and probably gets at something more important: the fact that he can move the tongue better when he feels it with his fingers suggests that he needs this something extra to properly locate the tongue in space and within his body schema; until the tongue is “found” by an another limb which locates it externally, it can’t be controlled at will. But beyond the bounds of the body and the nervous system itself, I think there may be something social going on here: it seems to be specifically when I ask him to do this action that it becomes difficult.

When that demand is set aside by orienting to something else, beyond the immediate encounter with the asking person and a situation laden with explicit expectations, suddenly the action becomes possible (and indeed, later in the day, we noticed Sacha experimenting on his own with sticking his tongue out, clearly thinking about it). One might talk about this in terms of demand avoidance, but it has a different, much more profound quality to the cases of avoidant behaviour mentioned above, where Sacha will pointedly look away, disengage, shut off when something is asked of him. Here he seems to be participating, and he has a motivation to participate: he clearly wants the chocolate, as he is trying other means to get it. Yet as long as he tries directly to do the action that is asked of him, it is as if the relevant body part is paralysed. There is something paradoxical in this: the movement happens “voluntarily” when it is least intended. Yet this is precisely the point when Sacha is not obeying a demand, and so in a sense it really is more voluntary. It is perhaps active participation in actions where the terms are set explicitly by another person that is the real difficulty here.

I find it hard to see where the line is between a behavioural issue and what is probably a neurological issue here. Perhaps this line is objectively blurry.

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