Automatic cueing to reduce drooling: a long-term follow-up with two mentally handicapped persons

Drooling outcome measures in paediatric disability: a systematic review

Drooling, or sialorrhea, is a common condition in patients with cerebral palsy, rare diseases, and neurodevelopmental disorders. The goal of this review was to identify the different properties of sialorrhea outcome measures in children. Four databases were analysed in search of sialorrhea measurement tools, and the review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. The COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist was used for quality appraisal of the outcome measures. The initial search yielded 891 articles, 430 of which were duplicates. Thus, 461 full-text articles were evaluated. Among these, 21 met the inclusion criteria, reporting 19 different outcome measures that encompassed both quantitative measures and parent/proxy questionnaires.   Conclusions: Among the outcome measures found through this review, the 5-min Drooling Quotient can objectively discriminate sialorrhea frequency in patients with developmental disabilities. The Drooling Impact Scale can be used to evaluate changes after treatment. The modified drooling questionnaire can measure sialorrhea severity and its social acceptability. To date, the tests proposed in this review are the only tools displaying adequate measurement properties. The acquisition of new data about reliability, validity, and responsiveness of these tests will confirm our findings. What is Known: • Although sialorrhea is a recognized problem in children with disabilities, especially those with cerebral palsy (CP), there is a lack of confidence among physicians in measuring sialorrhea. What is New: • Few sialorrhea measures are available for clinicians that may guide decision-making and at the same time have strong evidence to provide confidence in the results. • A combination of both quantitative measures and parent/proxy questionnaires might provide an adequate measurement of sialorrhea in children.

Exploring treatments for drooling in children with neurological disorders

Introduction: Drooling represents a major problem in the every-day life of pediatric patients with neurological disorders. The significant burden, both physical and socio-psychological, of the disorder requires adequate clinical evaluation and proper management. However, treating drooling remains a challenge for clinicians. This is a review of the most up-to-date therapeutic options for the treatment of drooling in the pediatric population, hence both conservative, pharmacological, and surgical approaches are discussed. Areas covered: Randomized clinical trials (RCTs), structured reviews, and case reports are included. Special focus is paid on the methods used to evaluate the efficacy and safety outcomes in the selected RCTs, trying to promote the use of more validated scales to assess drooling in the future. Expert opinion: The lack of reliable metrics to assess efficacy and safety outcomes in drooling limits researchers from identifying the best patient-suitable treatment. The relatively small number of clinical trials carried out over the last two decades is also due to the difficulty in assessing drooling using subjective scales. A key enabler for new efficient therapies stands in the introduction of accurate and robust metrics to measure treatment effectiveness on drooling.

Behavioral Treatment of Drooling

Many children with mental retardation and developmental disabilities suffer from the consequences of chronic drooling. Behavioral treatment for drooling should be considered before other, more intrusive treatments such as medication and surgery are implemented. However, empirical studies on behavioral procedures are scarce. This article reviews 19 behavioral studies published since 1970. Treatment procedures are (a) instruction, prompting, and positive reinforcement; (b) negative social reinforcement and declarative procedures; (c) cueing techniques; and (d) self-management procedures. Although these procedures yield positive results, critical examination of experimental methodology of the studies reveals several methodological shortcomings. Guidelines for clinical use of behavioral treatment for drooling are presented, and recommendations are given for future research in this area.

Prevalence and predictors of drooling in 7- to 14-year-old children with cerebral palsy: a population study

AIM

To establish a prevalence estimate for drooling and explore factors associated with drooling in a population sample of children with cerebral palsy (CP) aged 7 to 14 years living in Victoria, Australia.

METHOD

A self-report questionnaire was used to collect data on drooling from parents of children born between 1996 and 2001, and registered with the Victorian Cerebral Palsy Register.

RESULTS

A total of 385 children (231 males, 154 females; mean age 10y 9mo [SD 1y 7mo], range 8-14y) were studied. The clinical type and distribution of CP were spastic (341), ataxic (16), dyskinetic (17), hypotonic (10), and unknown (1). Distribution in Gross Motor Function Classification System (GMFCS) levels was I (103), II (98), III (52), IV (63), V (61), and unknown (8). After adjustment for topographical pattern of motor impairment and GMFCS level, 40% were reported to have experienced drooling between 4 years of age and the time of completing the questionnaire. A significantly higher prevalence of drooling was found in children with poor gross motor function and in those with more severe presentations of CP, including poor head control, difficulty with eating, and inability to sustain lip closure (p<0.001 for each). Drooling was shown to be significantly associated with both intellectual disability and epilepsy in this group of children (p<0.001 for both).

INTERPRETATION

With a prevalence of 40%, drooling is an important comorbidity in CP. It was considered severe in 15% of children. Poor oromotor function was associated with drooling and could be the target of interventions for this under-researched problem.

Promoting mouth drying to reduce the effects of drooling in a woman with multiple disabilities: a new evaluation of microswitch-programme conditions

OBJECTIVE

Extending the use of microswitch-based programmes to (a) establish mouth-drying responses and reduce the effects of drooling, (b) assess the possibility of widening inter-response intervals and (c) determine whether different microswitch solutions would impact the accuracy/effectiveness of mouth drying.

METHOD

During the intervention phases of the study, the participant (woman) performed mouth-drying responses via a special napkin. Such napkin contained two pressure sensors/microswitches, a microprocessor and an MP3 serving to monitor responses and ensure stimulation contingent on them.

RESULTS

The participant (a) learned to dry her mouth and reduce her chin wetness, (b) stabilized her responding at lower frequencies (i.e. when the stimulation period was extended) and (c) produced more accurate/effective responses when she was required to trigger both sensors of the napkin.

CONCLUSION

Microswitch-based programmes may promote practically sustainable and effective mouth drying to reduce drooling effects in persons with multiple disabilities.

Promoting mouth-drying responses to reduce drooling effects by persons with intellectual and multiple disabilities: a study of two cases

This study assessed the use of microswitch technology to promote mouth-drying responses and thereby reduce the effects of drooling by two adults with severe intellectual and multiple disabilities. Mouth-drying responses were performed via a special napkin that contained pressure sensors, a microprocessor and an MP3 to monitor the responses and ensure positive stimulation contingent on them. Initially, the responses produced 10 or 15 s of preferred stimulation. Subsequently, preferred stimulation was supplemented with matching periods of lower-grade stimulation to extend the inter-response intervals. Results showed that both participants (a) learned to dry their mouth consistently and reduce their chin wetness during the intervention, (b) stabilized their responding at lower frequencies as the lower-grade stimulation was added to the preferred stimulation, and (c) maintained the latter levels at a 3-month follow-up. Procedure and response conditions and outcome implications are discussed.

Two persons with multiple disabilities use a mouth-drying response to reduce the effects of their drooling

These two studies involved a boy and a man with multiple disabilities, who were taught to use a mouth-drying response to reduce the effects of their drooling. Both studies relied on microswitch technology to monitor the drying response and follow it with positive stimulation (i.e., during intervention). In Study I, the boy performed the drying response via a special napkin. The microswitch technology consisted of touch/pressure sensors and a radio transmitter hidden inside the napkin. Drying responses led the boy to 8s of preferred stimulation. In Study II, the man performed the drying response via a handkerchief. The microswitch technology consisted of an optic sensor and a radio transmitter at the man's chest. Drying responses led the man to 8-10s of preferred stimulation. The stimulation time/conditions were subsequently modified to promote a reduction in the man's response frequency. The experimental design involved an ABAB sequence (Study I) or an ABABB(1)B(2) sequence (Study II), with the second B or the B(1)B(2) combination spreading over periods of about 3 months. The results indicated vast increases in drying responses and decreases in chin wetness during the intervention phases. The frequencies of the drying response remained consistent for the boy and stabilized at a lower level (i.e., in line with the manipulation of the stimulation conditions) for the man. Implications of the findings and limitations of the studies are discussed.

Upgraded technology for contingent stimulation of mouth wiping by two persons with drooling and profound developmental disabilities

Many persons with developmental and physical disabilities experience drooling (i.e., loss of saliva from the mouth). Technology was recently developed to help two of these persons reduce the negative effects of drooling by increasing mouth-wiping responses. This study upgraded our initial approach and tested it with the two persons who we previously treated. Upgrading ensured that all technology components, including the stimulation sources, were on the participant's body and that stimulation for mouth wiping caused no (or limited) environmental disturbance. We also conducted a social validation assessment of the new technology and its effects, employing university students as social raters. Evidence showed that the participants used the upgraded technology successfully in settings attended by varieties of other persons. The university students involved in the social validation viewed the use of the technology as enjoyable, beneficial, and environmentally acceptable, and they largely supported it.

Surgical treatment of dysphagia

The role of surgery in the management of dysphagia is clear in some areas and controversial in others. Evaluation for the causes of dysphagia can elucidate conditions in which surgery can improve safety, quality of life, or both. Surgical therapy, when indicated, is safe and effective for many causes of dysphagia. This article includes a general overview of the causes of dysphagia that can be addressed successfully with surgery as well as a discussion of why surgery may be less appropriate for other conditions associated with dysphagia.

Use of a Mouth-Wiping Response to Reduce Drooling by Two Persons With Profound Developmental Disabilities

Two men with profound developmental disabilities used a mouth-wiping response instrumental to reduce drooling via a micro-switch-based program (i.e., a program in which the response was automatically monitored and followed by positive stimulation). The wiping response was performed via a napkin or a handkerchief placed inside a belt pocket. The micro-switch technology consisted of two mini-tilt sensors and a radio transmitter hidden inside the napkin, or an optic sensor and a radio transmitter fixed inside the belt pocket. The study was carried out according to a multiple baseline across participants and included a 3-month postintervention check. During the baseline, the participants' mean frequencies of mouth wiping were near zero, and mean percentages of wet chin intervals were about 45 and 50. During the intervention, the mean wiping frequencies increased to 1.6 and 1.9 per min, whereas the mean percentages of wet-chin intervals were mostly below 10. These values were maintained at the postintervention check. Implications of the findings and limitations of the study are discussed.

A descriptive analysis of studies on behavioural treatment of drooling (1970-2005)

A descriptive analysis was conducted on studies on the behavioural treatment of drooling (published between 1970 and 2005). The 17 articles that met the inclusion criteria described 53 participants (mean age 14y 7mo, [SD 4y 9mo]; range 6-28y). Sex of 87% of the participants was reported: 28 male, 18 female. For 60% of the participants the degree of learning disability was reported, varying from severe/profound (n=24, 75%), moderate (n=4, 13%), to mild (n=2, 6%), while two participants (6%) had no learning disabilities. Forty-two participants (79%) were diagnosed with cerebral palsy. Behavioural procedures included instruction, positive and negative reinforcement, overcorrection and restitution, verbal and automatic cueing, and/or self-management. Effective behavioural procedures are reported in children with and without learning disability and/or motor impairment. Even participants with profound learning disability may benefit from behavioural intervention. However, the evidence base in terms of number of studies in this area is limited. Fifteen studies used a single participant design; two studies implemented an experimental-comparison group design. Some of these studies were poorly designed and methodological flaws were identified. Therefore, conclusions about efficacy of behaviour therapy for drooling and/or best practice cannot be drawn, although our analysis suggests that this approach is promising. However, future research on this topic is needed. After years of research focused on medical treatment, the option of behavioural treatment to reduce drooling should be reconsidered in relation to the medical management of this problem.

Management of drooling for children with neurological problems in Hong Kong

OBJECTIVES

To share our experience in the management of drooling in Hong Kong, to describe the clinical profile of children with this problem, and to report the clinical outcome of oro-motor training.

METHODS

Children attending the Drooling Clinic of Alice Ho Miu Ling Nethersole Hospital, Hong Kong between January 2000 and June 2003 were included. Multidisciplinary assessment was performed to ascertain the medical condition, functional status and oro-motor difficulties of each child. Intervention might include optimization of medical condition, oro-motor training and surgery. Severity of drooling was rated by a 10-point visual analogue scale (VAS). The outcome of oro-motor training was assessed by the change in VAS from baseline.

RESULTS

Eight children, with a mean age of 11.9 years, were included. Six children suffered from cerebral palsy and two had syndromal diagnoses. All had moderate or severe mental retardation. Poor lip closure, inadequate jaw control and delay in swallowing were common oro-motor difficulties. All children received oro-motor training. The mean duration of follow-up for seven children was 17 months. The mean baseline VAS was 7.1. When compared with the baseline, VAS rating during the training period decreased with a mean difference of 3.0. The difference remained at 1.9 at 4 months after training had stopped. Other functional gains, such as improved sucking and swallowing, were identified. Six caregivers declined surgery. One child improved and did not require surgery.

CONCLUSIONS

Short-term follow-up of oro-motor training suggested beneficial outcome.

Children with sialorrhoea in the absence of neurological abnormalities

OBJECTIVE

To study the outcome of 21 typically developing children who had been referred to the Saliva Control Clinic at the Royal Children's Hospital, Melbourne.

METHOD

Information was collected on various aspects of the child's health, oromotor function and severity of drooling. A follow-up telephone survey was completed by the parents of these children after a mean period of 3.4 years. Information was gathered regarding their child's drooling, current health, oromotor status and the usefulness of the clinic.

RESULTS

There was a statistically significant improvement (P < 0.01) in the saliva control measures analysed on follow-up. Thirteen children ceased to drool, three still drooled occasionally, and five continued to drool. The recommendations, mainly advice and referrals to other health professionals, were generally reported to be helpful by the parents.

CONCLUSIONS

This cohort of children was established retrospectively, and the study is therefore limited in both numbers and design. The results indicate that some typically developing children may be delayed in the development of saliva control. Parents and professionals can be reassured that this problem is likely to resolve.

A portable visual-feedback device for reducing excessive vocal loudness in persons with mental retardation

A simple portable device was employed to reduce excessive vocal loudness in two adults who functioned within the moderate mental retardation range (one in the lower and one in the upper half). The device provided these adults visual feedback when the voice exceeded a preset level of loudness. Data showed that the device was useful in helping both adults reduce excessive vocal loudness across different daily situations. Characteristics and applicability of the device are discussed.