Autism and drooling

Today’s answer is by behavior analyst Kara Reagon, former Autism Speaks associate director for dissemination science.

Our 3-year-old was recently diagnosed with autism. He has made progress and is now talking, requesting and labeling. But he drools all the time, and we have to wipe his face constantly. How can we help him not drool?

Everybody drools – at least to start. Typically developing infants start to gain control of their swallowing and mouth muscles between 18 and 24 months of age. But it’s common for children with developmental disorders to drool excessively and for longer than is typical with other children. This includes children with autism, many of whom have delays and difficulties with muscle control and sensitivity.

What causes excessive drooling?

Typically, drooling involves low muscle tone, a lack of sensitivity around the lips and face, difficulty swallowing and/or excessive production of saliva. A variety of neurological and attention deficits can contribute to these issues – as is often the case among children – and sometimes adults – who have autism.

You are right to be concerned. Drooling becomes socially stigmatizing when it continues beyond infancy. It’s also unhygienic – an important issue as your son enters group settings such as preschool.

That said, drooling in some situations – for instance, while sleeping – is generally harmless unless it’s so excessive that your child is inhaling saliva.

So let’s focus on your son’s tendency to drool during the day.

Evaluation and treatment options

First, it’s important to discuss your son’s drooling with his pediatrician or a pediatric ear-nose-throat specialist to address or rule out serious underlying medical conditions. This will likely involve an examination of his tonsils, sinuses, and salivary glands. Also, certain medications can worsen drooling – another issue to discuss with your son’s doctor. In addition, the doctor should evaluate whether your son’s drooling is resulting in his inhaling saliva into his lungs – putting him at risk for pneumonia.

Treatment options should be tailored to your son’s needs and may require further evaluation – for instance by a speech-language pathologist or occupational therapist experienced in oral-sensitivity and muscle tone issues.  

Speech and occupational therapists can help your son improve his oral muscle tone, lip closure and swallowing. In some cases, the therapist may suggest a dental appliance or chin cup to assist in lip closure, tongue positioning and swallowing.

It may also help to reduce the amount of acidic foods your son is eating – as they can trigger the production of excessive saliva. But it’s important to work with a dietician before introducing any significant change to your son’s diet – particularly if he’s already a picky eater.

The goals of therapy

Drooling can be addressed through occupational and/or speech therapy that focuses on the following:

1. Develop good posture and positioning. Sometimes, poor muscle control of the trunk, neck and head results in the head tilting downward. In this position, saliva tends to pool at the front of the mouth and spill from parted lips. The therapist can help you position your child in ways that encourage proper trunk control and head support.
2. Build oral muscle strength and control. Therapists use a variety of playful oral-motor exercises to help children build muscle tone around the mouth. For instance, the therapist may have your son practice closing his lips around a straw, spoon or a piece of food and/or practice pronouncing closed-lip speech sounds such as “p,” “b” and “m.” The therapist will show you how to continue these exercises at home, with lots of encouragement in the form of praise and/or small rewards.
3. Increase oral sensitivity. Similarly, therapists have a variety of tactile exercises that can help your child develop sensitivity in the lips, tongue, mouth and chin. This includes building awareness of dryness versus wetness – so your child becomes aware when he’s drooling. Playful oral-sensitivity exercises can include blowing bubbles, making exaggerated sounds involving the lips such as “oooo,” “eeee” and “puh-puh-puh.” Again the therapist will give you guidance on how to practice these exercises at home.
4. Practice proper chewing and swallowing. Does your child drool excessively while eating? If so, you and the therapist can work with your child to master the steps of proper chewing and swallowing. It’s helpful to practice these exercises when your child is hungry enough to enjoy a snack but not ravenous. In general, the therapist will show you how to model, or exaggerate, appropriate chewing motions (closing the teeth and then the lips, etc.) and encourage your child to do the same. It can help to give your son a hand-held mirror so he can watch himself perform these steps. As always, remember to encourage and praise, as in: “That’s great. You’re chewing your cracker. Awesome, you swallowed the cracker! Good eating.”
5. Practice wiping with a napkin or handkerchief. While your child is learning to become aware of wetness on his face, it’s important to encourage the socially appropriate practice of wiping with a napkin or handkerchief. For mealtimes, I suggest teaching him the habit of “wipe, wipe, swallow” – wiping one side of the mouth and then the other before swallowing. Consider attaching the napkin to a wristband during meals to encourage this habit. You mention that your son drools continuously. So you’ll also want to teach him the habit of wiping with a handkerchief when not at the dinner table. This includes helping him learn to keep a clean handkerchief handy in a pocket. Another option is have your son wear wrist sweatbands and encourage him to use them to wipe each side of his face regularly. Both at the dinner table and away, you’ll want to cue your child – perhaps by properly wiping your own mouth – when you see him drooling.
6. Put it all together with rewards. Be sure to create a reward system to reinforce each step your child takes with chewing, swallowing, wiping and most importantly keeping a clean, dry face. At age 3, you may want to keep this simple – with lots of praise and small rewards. But your son may be old enough to enjoy a token system that involves earning larger rewards such as a favorite activity with you.

Editor’s note: The above information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional.