The MORE concept developed from observing Philip, a three-year-old little boy with Down’s syndrome. He was a genius in terms of self-knowledge and innate drive to work his suck/swallow/breathe synchrony into a muscle synergy. He showed he could then use that synergy to enhance more typical development in oral motor skills for self-regulation, eating, and communication (verbal and nonverbal).
This was clearly effective for him, but to understand why required a search of the literature about the suck/swallow/breathe (SSB) synchrony. Phillip’s intuitive behavior was supported in the literature and led to the discovery of methods of treatment that would support more typical patterns of development that are dependent on the shift between the primitive SSB synchrony and the more mature, elaborate SSB synergy.
Anatomically, neurologically, and biomechanically, the functions of the SSB synchrony/synergy have direct and indirect influences on many aspects of life and human development. As the developmental model above illustrates, the influences are neither linear nor mutually exclusive. The interrelationships also indicate that we can influence the cycle by addressing the SSB and/or its specific components. Bringing arousal into optimal range, for example, while developing strategies for self-regulation (i.e. sucking on a straw or pen top) may allow better coordination of the SSB synchrony/synergy for eating and communication with facial expressions, voice, and articulation.
Initiating a swallow requires a suck with a seal that creates a vacuum. Through use of the suck/seal/vacuum musculature and neural components that also attach at points facilitating swallow and rib cage mobility, the SSB synchrony evolves rapidly into a synergy that then sets up change and variation of respiratory rate & depth. As each component develops and refines, that refinement contributes to the development and elaboration of other components. Early in development, suck and gnaw, cry and voice on breath are the only oral motor/respiratory skills that can influence the synergy. Later, bite, crunch, chew, and lick followed by suck, seal, vacuum, and swallow, become additional ways to access and activate the synergy.
Seal and Vacuum
The balance of stability and mobility between the back of the tongue and the jaw first produce a seal and vacuum between the tongue and roof of the mouth. As development proceeds proximal to distal, muscle control proceeds towards the front third of the tongue and from jaw to cheeks to lips. In treatment it is extremely important to remember to begin where the child can create the best seal and vacuum. Develop strength and endurance there and development forward will naturally emerge. As the child begins to move toward distal oral motor activities, challenging those actions help strengthen and master them. Being able to switch rapidly from back to front to middle to back of the mouth is critical for building oral motor self-regulatory strategies, producing facial expressions, managing voice for volume, prosody (the rhythmic quality of speech), emotionality, etc., to produce speech sounds and longer and longer utterances.
While this muscle development is proceeding, so are the outcomes of:
° coordinated binocular vision at various focal lengths;
° development of head/neck control, shoulder girdle stability/mobility and separation from the head;
° rib cage stability/mobility, connection of shoulder girdle to pelvic girdle with separation
° development of upper extremity control with hand development.
As the eye/hand/mouth is repeatedly used and postural control is developing, the outcomes for social interaction, communication, and motor skills begin to rapidly emerge.
Treatment Using the MORE Concepts
Originally MORE was the acronym used to grade oral motor activities for use in treatment. Over the years therapeutic culture has generalized the theory and treatment principles to MORE.
M for motor aspects of the activities
O for oral aspects of the activities
R for respiratory aspects of the activities
E for eyes or the visual aspects of the activities
MORE concepts and strategies are meant to be incorporated into the child's treatment program along with many other appropriate techniques for improving sensory motor processing and development. Oral motor activity can be incorporated into meals and snacks and with the toys and items that children and adults frequently put in their mouth for oral motor input. Major components of these items are:
Motor: Suck, gnaw, blow, bite, munch, crunch, chew, and lick
Sensory: Taste, temperature, texture, and quantity
Spatial Modalities: Shape, form, and size
Using these components in treatment or home programs will work toward more functional synergy of SSB elements and their related performance outcomes as seen in the model. A general guideline to follow in selecting materials and activities is to observe rhythm (novelty vs repetition), frequency, intensity, and duration of the oral sensory motor experiences the child is seeking and creating.
Observations of oral motor preferences coupled with previously obtained information from a thorough sensory history analysis which includes sensory defensiveness, food preferences and oral self-regulatory strategies, will create the menu for therapeutic opportunities and growth. A wide variety of activities and materials should be available with special consideration given to intensity in the categories of motor and sensory input.
Oral motor skills are naturally complex, and rapid variations and combinations of skills are endless. For this reason children normally only spend a short amount of time on each activity, be it a whistle; biting and tugging on a piece of tubing, jerky, or licorice; chewing gum; or sucking a piece of hard candy. It is the quick changes and combinations of performance requirements in the activities that promote integration, gradation, and functional oral motor skills, and then provide support to other layers of the model.
Although these concepts are developmental in nature, they are a lifelong necessity to support both simple and complex performance. Note sometimes your actions or the actions of the people around you in a meeting or during any activities that demand attention, skill, or strength. Mouth, jaw, tongue, and respiratory control are very active in these situations.
Submitted by Patricia Oetter, MA, OTR/L, FAOTA, Co-author of MORE: Integrating the Mouth with Sensory and Postural Functions, and Co-Instructor of the MORE Course.