Oral Apraxia and Apraxia of Speech

Oral Apraxia and Apraxia of Speech

Oral Movements and Language Development

By

Katie Alcock, Ph.D., Department of Psychology, Lancaster University

How are Language Development and Motor Development Linked?

People have been asking for a long time whether children who are good, or poor, at motor (movement) skills are likely to be good, or poor, at language skills. Here’s what we know so far. When you look at walking, running, jumping and other gross motor skills you don’t find any link between these and language – children who are slow or fast to walk are not necessarily slow or fast to talk. However there is a lot of evidence that hand gestures (including things like waving bye-bye and pointing – communicative gestures – and things like showing what you do with scissors or a comb, without having them in your hand – symbolic gestures) are linked to language abilities. Children who use hand gestures early are likely to be early talkers. Children who are late to use gestures are likely to be late talkers, and are more likely than children whose gestures are on schedule to remain delayed in their language use. There is also an association in older children between having disordered or delayed language development and having difficulties with control of limb movements – it is not just a link in early life.

So, we know a lot about how arm and hand movements are related to language development and language disorders. But most people speak with their mouths. What do we know about oral (mouth) movements – such as sticking out the tongue, licking the lips, and kissing in a grown-up way – and language development? In fact, very little. Here’s a short summary of what we do know:

Typical Oral Motor Development

We actually know very little about how typically developing children develop mouth movements. Most research so far has been on feeding in young infants, without relating this to language development or looking at how mouth movements develop in older children. What we do know is also a little contradictory: some research suggests that children do not learn how to control their mouth movements at an adult level until after they are about 14 years old, while other researchers suggest that there is no real change in children’s skills from a much younger age – maybe 5 years, maybe 8. This is something that my research group is looking into at the moment. We are testing children’s mouth movement skills from the age of 1 year to the age of 8 years to see how they develop.

Oral Motor Development in Children with Language Difficulties

Likewise, until recently we have known only a little about how mouth movements develop in children who have language problems for whatever reason. There are a wide variety of reasons for children to have language development difficulties but in many different syndromes we do see some oral motor difficulties. For example, nonfluent developmental dysphasia (a speech output difficulty without any associated learning disabilities or hearing/social difficulties) tends to be associated with oral dyspraxia (a diagnosed difficulty in coordinating oral movements). In children with specific language impairment (or SLI, a very similar problem where children have delayed or disordered language, without any difficulty in hearing, a general learning disability, or any social difficulties such as autism) the children who find the most difficulty with oral movements are the same children who find most difficulty with pronouncing new words.

Oral movements also tend to be difficult for children with other types of language difficulties – those due to autism and Down Syndrome, for example. Most of these studies tend to look at whether or not a child has a diagnosis of oral dyspraxia, however, and then see whether this diagnosis tends to coincide with a diagnosis of a language difficulty. Two studies that I have been involved in have taken a different approach: we wanted to see if language development could be associated with more subtle variation in oral motor skill, where the mouth movement abilities were not poor enough to be diagnosed as oral dyspraxia. In the first study we looked at a group of individuals who have a developmental language impairment and in the second we looked at a large group of children whose language was – as far as we know – developing in a typical fashion.

Oral Motor Abilities and Developmental Language Impairment

About 5% of children have a specific language impairment (SLI). Children with this disorder have difficulty in constructing sentences, learning new words, and/or speaking. This often runs in families and we studied a large family – which we’ll call the KE family – who had such a disorder. Half of the family members had the disorder and just as many boys as girls developed the disorder. When the family first agreed to take part in research, a paper was published by another research group which said that the family members had difficulties with forming sentences – in particular with regular grammatical endings such as “-ed” on “walked” – but not with any other speech and language skills, and also not with other, non-language skills.

When my research group first got to know members of the family we thought that something couldn’t be quite right about this, as many of the children and even the adults in the family struggle with their speech and are occasionally very hard to understand. I decided to see if, as I suspected, they also had difficulty with non-language skills such as mouth movements. Other people in the group also went on to look at a wide variety of language skills, too, and not just regular grammatical endings – affected family members turned out to have a problem with a wide range of language skills.

We tested family members’ mouth movement skills by looking at:

  • Simple mouth movements – such as opening the mouth
  • Complex mouth movements – such as whistling
  • Combinations of mouth movements – such as three in a sequence (first open your mouth, then put your lips tightly together, then stick out your tongue) or three at the same time (open your mouth, stick out your tongue and make a “h” sound in your throat)
  • Repeated movements – such as opening and closing the mouth again and again, as fast as possible.

We compared the abilities of family members who have the speech and language problem, with those who do not and some additional volunteers who were the same age as the family members with the speech and language problems. The mouth movements we asked them to do were first of all described to them, as above, and then shown to them to copy. We found that affected family members were poorer at performing most of the kinds of movements we gave them – but not all of them. They found the combinations of movements more difficult, but the simple movements on their own were not more difficult, and nor was performing repeated single movements quickly. So, it seems that these individuals have problems with coordinating several muscles in one movement, or coordinating several movements at the same time – which is exactly what you need to do when you are speaking. The other thing we found was that these types of movements were hard whether we showed the family members what to do, or described the movements. From this we could conclude that any difficulty with the movements was not due to a difficulty in understanding the instructions, which could easily hinder performance if someone has a language problem.

This finding was very interesting and it led us to ask what relationship there might be between mouth movement abilities and language abilities in children who are typically developing – who do not have any language difficulties.

Oral Motor Development in Children with Typically Developing Language

Most children develop language without any problems, but the rate at which children develop varies widely. Typically developing children mostly seem to start their language development slowly and then, at an average age of about 21 months, suddenly pick up speed and start to learn words much faster and also to combine words into baby sentences such as “doggie bark” or “more juice”. Because development is so fast at this stage, children can be very different from each other – so if we want to find out what it is that makes children different from each other, this is an ideal age to look at.

What Do We Already Know About Mouth Movements and Typically Developing Language?

Again, very little! There is a little bit of research with children who are just starting to speak to suggest that children who are good at coordinating simple feeding movements are not necessarily good at coordinating speech movements but then, we already know that very simple movements are not so closely related to speech movements. However, there is also some research suggesting that older children who have poorer mouth movements also have poorer speech abilities – even up to 10 years of age.

We decided to investigate this further. We looked at 60 children aged 21 months who we recruited through our local hospital when the children were born. As with the older children and adults we tested simple movements (opening the mouth), complex movements (licking the lips) and repeated movements. We also looked at children’s language abilities (by giving the parents a questionnaire to fill in with a list of words children might know at this age, as well as ways in which children can use words and put them together), and children’s cognitive or problem-solving abilities (again using a questionnaire that asks about children’s play skills).

What We Found

The main finding was that the higher a child’s vocabulary was (the more words they knew), the better their mouth movement skills were. We also found that both mouth movements and cognitive abilities were related to each other and to language – but after we removed the variability associated with the cognitive abilities, we still found that mouth movement ability was related to vocabulary. So children who are better at mouth movements are better at language – and it’s not just because they are the cleverer or more able children overall.

One particularly interesting finding was that children who were poor at mouth movements were almost invariably poor at language. Children who were good at mouth movements could however be either good or poor at language. What this suggests is that children need good oral motor skill to be good at language – but they need a lot of other skills too.

What We Concluded

Although the initial reports of the difficulties experienced by the KE family, and a lot of theories of language development, suggest that language is a separate skill that does not depend on other skills such as motor or cognitive skills, our research suggests that this is not true – language and oral movements are linked in both typical and atypical development, and this link is not due to some children being more advanced in all abilities.
There are a number of reasons this might be the case: children who are good at imitating one thing may simply be good at imitating, and therefore learning, new words. However when we looked at older children we found that those with language difficulties also had problems when the movements were explained to them. So this cannot be the only reason for the link we found.

Alternatively, children who are poorer at coordinating any movements of their mouths might, as a result of this, have problems both with carrying out the kinds of movements we gave them to do, and with carrying out speech movements. This would mean they had a hard time pronouncing words and therefore demonstrating what they knew in the way of vocabulary to parents and others. We didn’t find as strong a link between children’s comprehension of words and their mouth movements, which suggests this might be the reason.

However, it is true that children who talk more practice using their mouth more – since that’s how they talk! So we can’t rule out that the link might be the other way round – children who have had more practice in talking have, on the whole, had more of a chance to exercise their mouths, so they would be better at the non-speech mouth movements we gave them.

So, where do we go from here? Well, one thing people ask is whether practicing mouth movements can help children who have speech and language problems. It is fair to say we don’t have enough evidence to conclude that – if children have a basic problem with mouth movement control that applies both to speech and non-speech movements, then helping them with their non-speech movements may or may not help them with their speech movements. If however they lack practice with speech movements and this means they then find non-speech movements difficult, then practicing the non-speech movements is probably not going to help.


About the author: Dr. Katie Alcock combined her early interests in languages and in how the brain works by doing a Ph.D. at Oxford University looking at developmental language disorders and comparing them to those that follow a stroke. Since then she has carried out research in Tanzania (investigating the impact of ill health on cognitive development) and La Jolla (researching the cognitive psychology of language) and is currently a Lecturer at Lancaster University, where she continues research on language development, developmental language disorders, and the impact of health and poverty on language and cognitive development, with current projects in Kenya and Indonesia. To LEARN MORE about Dr. Alcock’s research go to http://www.psych.lancs.ac.uk/people/KatieAlcock.html.

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (Apraxia Kids)
www.apraxia-kids.org

What Does the Research Say Regarding Oral Motor Exercises and the Treatment of Speech Sound Disorders

By

Gregory L. Lof, Ph.D., CCC-SLP

The vast majority of the legitimate research shows no changes in speech sound productions because of non-speech oral motor exercises. However, many clinicians have strong opinions about their efficacy by stating clinical anecdotes, or they will cite non-peer reviewed publications and CEU events that claim there are speech benefits of these exercises.

Literature searches of the available information on this topic yield six treatment studies. The participants in these studies range in age from 4 to 8;11 years. Some of the studies include children with Childhood Apraxia of Speech (CAS) who had treatments of varying duration using a variety of treatment approaches. Almost all studies were some type of a single-subject research design. Of these six studies, five showed no treatment effects for changing speech sound productions. Only one study reported any positive effects of oral motor exercise; however, this study contained many fatal flaws that invalidated the findings (e.g., non-equivalent groups, severity of involvement was not controlled, different sounds were treated for each subject, etc.).

The primary reasons that these exercises do not change speech sound productions are:

  1. task specificity that makes these exercises ineffective; and
  2. oral motor exercises do not increase strength for speech as many clinicians claim.

Task specificity is a reason why these exercises almost certainly will not affect speech. In order for there to be positive transfer of one behavior (i.e., the exercise) to another behavior (i.e., speaking) the task must be identical. But most oral motor exercises are NOT identical to the movements required for speech; no English speech sounds involve tongue wagging, whistling, tongue clicks or curls, etc. The relevancy of the task is important because context is crucial. Here are two non-speech examples that may illustrate this:

  1. A piano teacher would not ask her students to practice finger movements on a tabletop instead of on actual piano keys because there would be no transfer of this irrelevant table pounding to the integrated needs of piano performance;
  2. A basketball coach would not have student athletes learn to dribble a basketball by just “pretending” that they have a ball in their hands; irrelevant hand flapping will not lead to better ball handling. These examples are directly related to the question because non-speech oral motor exercises also lack relevancy and they disintegrate the highly integrated task of speaking. For example, repeated elevation of the tongue tip to the alveolar ridge will not establish /l/ production because it lacks relevancy.

In addition, in the neurology literature, scientists have demonstrated how speech movement control is mediated at different nervous system locations than are non-speech movements. The training of irrelevant non-speech movements will not transfer to speaking because they are controlled by entirely different parts of the brain. Some examples of this are:

  1. A person can have dysphagia (i.e., a swallowing disorder) without having a speaking problem (the same structures are used for speaking and for swallowing but they have different speech and non-speech functions);
  2. People can strengthen the velopharyngeal complex by performing blowing exercises, but the speech will remain nasalized (same structures, but different functions, which shows task specificity).

Oral motor exercises do not increase strength for speech. In order to increase strength, all exercises must be done consistently, against resistance, and typically until failure (the same way you strengthen muscles when you go to the gym). Regardless of the fact that strength is not all that important for speaking (the strength needs for talking are very minimal), these exercises usually do not strengthen the necessary muscles anyway. For example, how many clinicians actually have their clients perform tongue wagging until there is failure? And is there always a resistive force used during the exercises? I doubt it. Therefore, the children are probably not strengthening these muscles. In addition, very few clinicians objectively measure oral muscle strength pre- and post-treatment, so strength improvements cannot actually be evaluated. One other thing about strength: for CAS and other speech sound disorders, oral motor strength is not impaired. In cases where strength is impaired, the child should probably be diagnosed with dysarthria. But most of the dysarthria literature also reports a lack of speech improvements using oral motor exercises.

Some clinicians use these exercises as “warm up” drills or use them in the hopes that it will lay a foundation for speech. But there is no evidence to support the use of these drills even for awareness purposes; the transfer of these “meta” skills to speaking has not been empirically demonstrated. There is research that shows that non-speech behaviors are NOT a precursor to later speech learning, so these exercises cannot effectively establish speech productions. Therefore, “warm up” exercises will not carry over to speech nor will the exercises build a speaking foundation.

The bottom line is that if clinicians want the speech productions of children to change, then they must work on speech and not on tasks that only superficially appear to be speech-like movements. The current available literature is clear that non-speech oral motor exercises will not produce speech changes. Clinicians who use these procedures in the hopes of changing speech productions must be very cautious in making claims of the treatment efficacy of such tasks. All practitioners need to use current research evidence to guide their clinical practice.

References

(*Research on treatment efficacy of non-speech oral motor exercises)

*Abrahamsen, E, P., & Flack, L. (Nov., 2002).
Do Sensory and Motor Techniques Improve Accurate Phoneme Production?
Paper presented at the National Convention of the American Speech-Language-Hearing Association, Atlanta, GA.

*Christensen, M., & Hanson, M. (1981).
An Investigation of the Efficacy of Oral Myofunctional Therapy as a Precursor to Articulation Therapy for Pre-First-Grade Children.
Journal of Speech and Hearing Disorders, 46, 160-167.

*Colone, E., & Forrest, K. (Nov., 2000).
Comparison of Treatment Efficacy for Persistent Speech Sound Disorders. Poster presented at the National Convention of the American Speech-Language-Hearing Association, Washington, D.C.

*Fields, D., & Polmanteer, K. (Nov., 2002).
Effectiveness of Oral Motor Techniques in Articulation and Phonology Treatment.
Poster presented at the National Convention of the American Speech-Language-Hearing Association, Atlanta, GA.

Forrest, K. (2002).
Are Oral-Motor Exercises Useful in the Treatment of Phonological/Articulation Disorders?
Seminars in Speech and Language, 23 (1), 15-25.

*Forrest, K., & Peabody, E. (2003).
Comparison of Treatment Efficacy in Childhood Apraxia of Speech.
Manuscript submitted for publication.

*Guisti, M.A. (2002).
The Efficacy of Oral Motor Therapy for Children with Articulation Disorders.
Unpublished Master’s Thesis, Southern Connecticut State University, New Haven, CT.

Hodge, M. M. (2002).
Nonspeech Oral Motor Treatment Approaches for Dysarthria: Perspectives on a Controversial Clinical Practice.
Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 12 (4), 22-28.

Lof, G. L. (2003).
Oral Motor Exercises and Treatment Outcomes.
Perspectives on Language Learning and Education, 10 (1), 7-11.

Moore, C, & Ruark, J (1996).
Does Speech Emerge from Earlier Appearing Oral Motor Behavior?
Journal of Speech and Hearing Research, 39, 1034-1047.

*Occhino, C., & McCann, J. (Nov., 2001).
Do Oral Motor Exercises Affect Articulation?
Poster presented at the National Convention of the American Speech-Language-Hearing Association, New Orleans, LA.


(Gregory L. Lof, Ph.D., CCC-SLP, is an Assistant Professor and the Associate Director in the Graduate Program in Communication Sciences and Disorders at the MGH Institute of Health Professions, an academic affiliate of the Massachusetts General Hospital in Boston. He received his Ph.D. from the University of Wisconsin-Madison in 1994. He has taught and served as a clinical supervisor at universities in Minnesota, South Dakota, Wisconsin, and Massachusetts. His research, teaching and clinical interests primarily are with children with articulation/phonological disorders as well as interests in professional issues. Dr. Lof is the 2004 Topic Coordinator for articulation/phonology for the ASHA convention and he has served on the 1995, 1998, and 2002 ASHA Convention Program Committee for phonology. He is an editorial consultant for the journals Journal of Speech, Language, Hearing Research, American Journal of Speech-Language Pathology, Contemporary Issues in Communication Sciences and Disorders, and Language, Speech, and Hearing Services in Schools. He has presented workshops at ASHA conventions, at local universities, in school districts, and at numerous state conventions.)

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (Apraxia Kids)
www.apraxia-kids.org

Logic, Theory, and Evidence Against the Use of Non-Speech Oral Motor Exercises to Change Speech Sound Production

By

Gregory Lof, Ph.D., CCC-SLP

[Read the text below or Download this PDF file of the handout from Dr. Lof’s invited presentation at the 2006 ASHA Convention. Reprinted with permission from the author.]

Introduction

Non-Speech Oral Motor Exercises (NS-OME) Defined

  • Any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities (Lof & Watson, 2004; In press).
  • A collection of nonspeech methods and procedures that claim to influence tongue, lip, and jaw resting postures, increase strength, improve muscle tone, facilitate range of motion, and develop muscle control (Ruscello, In Press).

Do SLPs use NS-OME? Nationwide survey of 537 SLPs by Lof & Watson (2004; In press)

  • 85% use NS-OME to change speech sound productions.
  • Hodge, Salonka, & Kollias (2005): Nationwide survey of 535 SLPs in Canada found that 85% use NS-OME to change speech sound productions, the same result as in the USA!
  • Clinicians report being “Very Familiar” with the research that has examined the efficacy of NS-OME and the theoretical basis for using them.
  • 61% of the clinicians agree with this statement: “The literature I have read strongly encourages the use of NS-OME.”
  • 87% of the clinicians learned to use NS-OME from non peer-reviewed CEU offerings, workshops, and in-services.
  • Most frequently used exercises (in rank order): Blowing; Tongue Push-Ups; Pucker-Smile; Tongue Wags; Big Smile; Tongue-to-Nose-to-Chin; Cheek Puffing; Blowing Kisses; Tongue Curling.
  • Reported benefits (in rank order): Tongue Elevation; Awareness of Articulators; Tongue Strength; Lip Strength; Lateral Tongue Movements; Jaw Stabilization; Lip/Tongue Protrusion; Drooling Control; VP Competence; Sucking Ability.
  • These exercises are used for children with (in rank order): Dysarthria; Apraxia of Speech (CAS); Structural Anomalies; Down Syndrome; Enrollment in Early Intervention; “Late Talker” Diagnosis; Phonological Impairment; Hearing Impairment; Functional Mis-articulations.

Evidence-Based Practice

  • Defined: The conscientious, explicit, and unbiased use of current best research results in making decisions about the care of individual clients (Sackett et al., 1996). Treatment decisions should be administered in practice only when there is a justified (evidence-based) expectation of benefit.
  • No Child Left Behind places an emphasis on scientifically-based methods, calling on clinicians to use scientific, research-based interventions
  • 2006 IDEA Part B Regulations: “Special education and related services…must now be based on peer-reviewed research to the extent practicable.”
  • The goal is to use the literature in a savvy process that draws on a number of different factors in which evidence plays a key role.
  • Dollaghan (2004) reminds clinicians that when using the EBP paradigm, valid and reliable evidence needs to be given more credence than intuition, anecdote and expert authority. Evidence must come from works that are independent and peer-reviewed.
  • Opinions and clinician’s own clinical experiences can be useful, but they can also be biased and even wrong!
  • Therapist Bias: Halo effect and Rosenthal effect (see Damico, 1988).

Logic

  • Clinical experience cautions: Finn, Bothe, and Bramlett (2005) provided criteria for distinguishing science from pseudoscience: (1) Treatments remain unchanged even with evidence against its effectiveness because disconfirming evidence is ignored; (2) Anecdotal evidence and personal experience are given extraordinary credence; (3) Inadequate evidence is accepted; (4) Peer review is avoided; (5) Methodology is disconnected from established scientific models; (6) Use of new terms that are not scientific nor conventional; (7) Grandiose outcomes are proclaimed; (8) Claims of success only within a holistic framework.
  • Many claims are made about NS-OME effectiveness in catalogs selling therapy materials, non-peer reviewed publications, CEU events, etc. But no evidence of effectiveness is provided.
  • Some claims of effectiveness are outrageous and are actually illogical when carefully examined.

Theory

Part-Whole Training and Transfer

  • Basic questions: Does training on a smaller portion of the articulatory gesture transfer over to the whole gesture? Is it more efficient with better learning by first training just part of the movement and not the whole movement?
  • Tasks that comprise highly organized or integrated movements (such as speaking) will not be enhanced by learning the constituent parts of the movement alone; training on just the parts of these well-organized behaviors can actually diminish learning. Highly organized tasks require learning the information processing demands, as well as learning time-sharing and other inter-component skills.
  • “Fractionating a behavior that is composed of interrelated parts is not likely to provide relevant information for the appropriate development of neural substrates” (Forrest, 2002).
  • Some clinician-researchers believe that it can be more effective to “Train the Whole” (Ingram & Ingram, 2001) and to use “Whole-Word Phonology and Templates” (Velleman & Vihman, 2002) rather than breaking up the gesture into small parts.

Strengthening the Articulatory Structures

  • Basic questions: Is strength necessary for speaking? If so, how much? Are the articulators actually strengthened by using NS-OME? How do SLPs objectively document weakness of articulators and also objectively document supposed increases in strength after NS-OME?
  • Articulatory strength needs are VERY low for speech and the speaking strength needs do not come anywhere close to maximum strength abilities of the articulators. For example, lip muscle force for speaking is only about 10-20% of the maximal capabilities for lip force, and the jaw uses only about 11-15% of the available amount of force that can be produced (see also Bunton & Weismer, 1994).
  • Agility and fine articulatory movements, rather than strong articulators, are required for the ballistic movements of speaking. NS-OME encourage gross and exaggerated ranges of motion, not small, coordinated movements that are required for talking.
  • NS-OME may not actually increase articulator strength. To strengthen muscle, the exercise must be done with multiple repetitions, against resistance, until failure…and then done again and again. Most NS-OME do not follow this basic strength training paradigm so there are probably no actual strength gains occurring due to these exercises.
  • Articulators can be strengthened (e.g., the tongue for oral phase of swallowing or the VP complex) but these strengthened articulators will not help with the production of speech.
  • Measurements of strength are usually highly subjective (e.g., feeling the force of the tongue pushing against a tongue depressor or against the cheek or just “observing” weakness), so clinicians cannot initially verify that strength is actually diminished and then they cannot report increased strength following NS-OME. Only objective measures (e.g., tongue force transducers) can corroborate statements of strength needs and improvement. Without such objective measurements, testimonials of articulator strength gains must be considered suspect.
  • See Chi-Fishman and Pfaizer (2003) for information on tongue anatomy, physiology, and strengthening principles

Relevancy of NS-OME to Speech

  • Relevancy is the only way to get changes in the neural system; the context in which a skill is learned is crucial. In order to obtain transfer from one skill to another, the learned skills must be relevant to the other skills. “…muscle fibers are selectively recruited to perform specific tasks, so static non-speech tasks do not account for the precise and coordinated activity needed during speech” (Hodge & Wellman, 1999).
  • For sensory motor stimulation to improve articulation, the stimulation must be done with relevant behaviors, with a defined end goal, using integration of skills. “The PURPOSE of a motor behavior has a profound influence on the manner in which the relevant neural topography is marshaled and controlled” (Weismer, 2006).
  • Most NS-OME dis-integrate the highly integrated task of speaking (e.g., practicing tongue elevation to the alveolar ridge with the desire that this isolated task will improve production of the lingual-alveolar sound /s/). For example, a motor task (e.g., shooting a free throw using a basketball) must be learned in the context of the actual performance goal. By analogy, no one would teach a ballplayer to pretend to hold a ball and then pretend to throw it toward a non-existent hoop with the eventual hope of improving free throwing ability. Breaking down basketball shooting or the speaking task into smaller, unrelated chunks that are irrelevant to the actual performance is not effective.
  • Another non-speaking example would be the illogical finger pounding on a tabletop to simulate playing on a piano. Learning and improving piano playing must be practiced on a piano, not on a tabletop. Likewise, learning and improving speaking ability must be practiced in the context of speaking. To improve speaking, children must practice speaking, rather than using tasks that only superficially appear to be like speaking.
  • Because isolated movements of the tongue, lips and other articulators are not the actual gestures used for the production of any sounds in English, their value for improving production of speech sounds is doubtful. That is, no speech sound requires the tongue tip to be elevated toward the nose; no sound is produced by puffing out the cheeks; no sound is produced in the same way as blowing is produced. Oral movements that are irrelevant to speech movements will not be effective as speech therapy techniques.

Task Specificity

  • Three related concepts: 1. same structures but different functions, 2. task specificity, 3. domain specific.
  • The same structures used for speaking and other “mouth tasks” (e.g., feeding, swallowing, sucking, breathing, etc.) function in different ways depending on the task and each task is mediated by different parts of the brain. The organization of movements within the nervous system is not the same for speech and nonspeech gestures. Although identical structures are used, these structures function differently for speech and for nonspeech activities.
  • Weismer (2006): The control of motor behavior is task (speaking) specific, not effector (muscle or organ) specific. There is strong evidence against the “shared control” for speech and nonspeech. “Motor control processes are tied to the unique goals, sources of information (e.g., feedback), and characteristics of varying motor acts, even when those share the same effectors and some neural tissue.”
  • Some examples of task specificity: Babbling and early nonspeech oral behaviors are not related (e.g., Moore & Ruark, 1996); Patients can have dysphagia with and without speech problems (i.e., “double dissociations”; Ziegler, 2003); It is well documented that the VP mechanism can be strengthened, however, reduction of speech nasality does not occur (e.g., Kuehn & Moon, 1994); Breathing for speech is different than breathing at rest or during other activities (e.g., Moore, Caulfield, & Green, 2001). See Weismer (2006) for summary of 11 studies that show that speech and nonspeech are different for a wide variety of structures, including facial muscles, jaw motion, jaw operating space, jaw coordination, lingual movement, lip motions, leavator veli palatini, and mandibular control.

Warm-Up/Awareness/Metamouth

  • Warm-up has a physiological purpose during muscle exercise: to increase blood circulation so muscle viscosity drops, thus allowing for smoother and more elastic muscle contractions (Safran, Seaber, & Garrett, 1989).
  • Warm-up of muscles may be appropriate (Pollock et al., 1998) when a person is about to initiate an exercise regimen that will maximally tax the system (e.g., distance running or weight training). However, muscle warm-up is not required for tasks that are below the maximum (e.g., walking or lifting a spoon-to-mouth). Because speaking does not require anywhere near the oral muscular maximum, warm-up is not necessary.
  • If clinicians are not using the term warm-up to identify a physiological task to “wake up the mouth,” then perhaps they believe that they are providing some form of “metamouth” knowledge about the articulators’ movement and placement.
  • Awareness and its role in therapy is always questioned. It is well known that young children have difficulty with various metaphonological awareness tasks (Kamhi & Catts, 2005). For articulation awareness, Klein, Lederer and Cortese (1991) reported that children age 5 and 6 years had very little consciousness of how speech sounds were made; 7 year olds were not very proficient with this either. According to Koegel, Keogel, and Ingham (1986), some children older than 7 years were successful during a metalinguistic speech intervention program, but only when they have the “…cognitive maturity required to understand the concept of a sound…”
  • It appears that young children cannot take advantage of the non-speech mouth-cues provided during NS-OME that can be transferred to speaking tasks. More research is needed to determine the minimum cognitive, linguistic, and motor abilities of children that are necessary for such “meta” skills.

Childhood Apraxia of Speech (CAS)

  • Children with CAS have adequate oral structure movements for nonspeech activities but not for volitional speech (Caruso & Strand, 1999), so this would preclude the use of NS-OME because non-speech is not the problem.
  • There is no muscle weakness for children with CAS, so there is no need to do strengthening exercises. If there is weakness, then the correct diagnosis is dysarthria, not apraxia.
  • “Non-speech therapy activities will not improve a child’s (with CAS) speech. Activities that address speech directly are critical for that purpose” (Velleman, 2003).
  • See the quote by Davis & Velleman (2000) below.

NS-OME for Non-Motor Speech Disorders

  • Some may believe that motor exercises can help children with motor production speech problems, such as functional misarticulators (phonetic/articulatory problems) or children with structural problems; however the evidence does not support this.
  • It makes no sense that motor exercises could help improve the speech of children who have non-motor problems such as language/phonemic/phonological problems like children in Early Intervention diagnosed as late talkers.

Cleft Lip/Palate

  • The VP mechanism can be strengthened through exercise (many studies have demonstrated this since the 1960s), but added strength will not improve speech productions.
  • See the quotes by Peterson-Falzone, Trost-Cardamone, Karnell, Hardin-Jones (2006) below.

Evidence

There are 10 studies evaluating the effectiveness of NS-OME: 9 show no benefits, 1 shows benefits (but it has many methodological flaws).

  1. Christensen & Hanson (1981). Ten children aged 5;8 to 6;9 years underwent 14 weeks of treatment, with half of the children receiving only articulation therapy and the other half receiving articulation and neuromuscular facilitation techniques. Both groups made equal speech improvements; the exercises did not help for better speech sound production BUT they were effective in remediating tongue-thrusting (probably due to task specificity).
  2. Gommerman & Hodge (1995). Single Subject Design (A-B-C) with a 16-year-old girl with tongue thrust and sibilant distortions. Therapy was baseline (A phase), myofunctional therapy (B phase), then articulation therapy (C phase). Tongue thrust was eliminated with myofunctional therapy but speech did not change until speech therapy was initiated.
  3. Colone & Forrest (2000). Monozygotic twin boys age 8;11 years old took part in a motor treatment for Twin 1 and phonological treatment for Twin 2. No improvements with motor training occurred but there were improvements using a phonological approach; when Twin 1 received phonological treatment, there were the same improvements as for Twin 2.
  4.  Occhino & McCane (2001). Single Subject Design (A-B-C-B-C) with a 5-year-old child. Oral motor exercises alone produced no improvement in the articulation of one of two phonemes and also no improvements in oral motor skills. Oral motor exercises prior to or along with articulation therapy did not have an additive or facilitative effect but productions did improve with articulation therapy.
  5. Abrahamsen & Flack (2002). Single Subject Design with a 4-year-old child for 10 hours of individual treatment using blowing, licking, and oral stimulation. There was no evidence of effectiveness in changing speech sound productions after this treatment.
  6. Bush, Steger, Mann-Kahris, & Insalaco (2004). Single Subject Design (ABAB Withdrawal) with a 9-year-old boy. OME added to articulation treatment, then removed, then re-added for the sounds /r/,/s/,/z/,/l/. “Oral motor treatment did not improve or reduce treatment’s success.”
  7. Roehrig, Suiter, & Pierce (2004). AB or BA Single Subject Design with six 3;6 to 6;0 year old boys and girls for 15 weeks of therapy: (A) Tradition, production-based therapy twice a week for ½ hour; (B) Passive OME and traditional therapy twice a week for ½ hour. “The addition of OME to the traditional articulation therapy approach did not add to participant’s overall progress; improvement following therapy with OME was not different from improvements following articulation therapy alone.”
  8. Guisti & Cascella (2005). Single Subject Design using two boys and two girls in first grade. Therapy followed Easy Does it for Articulation: An Oral Motor Approach for 15 one-half hour individual treatment sessions. No evidence of effectiveness in changing speech-sound productions.
  9. Hayes et al. (In submission). Six 4-year-olds, five boys and one girl who all had “functional misarticulations” were studied in a counterbalanced intervention design where children were randomly assigned to a specific order for an oral motor approach and traditional articulation approach. The traditional treatment resulted in significant speech sound changes but there was no support for oral motor therapy bringing about any changes. There was some evidence that NS-OME actually hindered learning.
  10. Fields & Polmanteer (2002). Eight 3- to 6-year-old children were randomly assigned to one of two groups: four children received 10 minutes of oral motor treatment and 10 minutes of speech therapy and four children received 20 minutes of only speech therapy. Fewer errors at the end of 6-weeks of treatment for the children who received the combination of treatments. But there were many methodological and statistical issues that may invalidate this finding, such as: the children in the speech-only group were more severe; there was an unequal gender distribution; and there was no report of what the treated sounds were so there can be no evaluation as to how difficult it was to treat certain sounds.

Combining Treatment Approaches

  • Most SLPs use a combination of treatment approaches so it is difficult to “tease apart” which approach is providing therapeutic benefit. Additionally, whenever intervention approaches are combined, it is unknown if and how they actually work in conjunction with each other to enhance performance.
  • There is much evidence that the NS-OME portion of combined treatments is irrelevant to speech improvements (see above).
  • NS-OME probably do not harm the child when used in combination with traditional approaches (however, Hayes et al. [2006] found that some children may be negatively affected by a combination approach).
  • It seems reasonable that if there is no speech improvement using combined approaches, then clinicians should eliminate the approach that is not effective (i.e., the NS-OME) so as to not waste valuable therapy time with an ineffectual technique.

In Conclusion

  • If clinicians want speech to improve, they must work on speech, and not on things that LOOK like they are working on speech.
  • Phonetic placement cues that have been used in traditional speech therapy are NOT the same as NS-OME.
  • NS-OME is a procedure not a goal. The goal of speech therapy is NOT to produce a tongue wag, to have strong articulators, to puff out the cheeks, etc. Rather, the goal is to produce intelligible speech.
  • We have been burned before. In the 1990s many SLPs inappropriately embraced Facilitated Communication (FC) as a treatment approach because they thought they observed that it worked. Once it was tested using scientific methodology, it was found to not work. Pseudoscientific methodologies can persuade clinicians to provide the wrong treatment.
  • Speech is special and unlike other motor movements.
  • Following the guidelines of Evidence-Based Practice, evidence needs to guild treatment decisions. Parents need to be informed that NS-OME have not been shown to be effective and their use must be considered experimental.
  • Just remember: Same structures, different functions. Same structures, different functions.

Relevant Quotes

  • Weismer, G. (2006). “…oromotor nonverbal tasks are unlikely to contribute to an understanding of normal and disordered speech production.”
  • Gerratt et al. (1991). “Preference for nonspeech maneuvers is surprising since so little research exists on the relations of these measures to speech…”
  • Davis & Velleman (2000): “There is presently no research available to support the efficacy of oral-motor therapy for improvement of speech productions skills. Thus, it is appropriate to work with children with DAS (Developmental Apraxia of Speech) on nonspeech oral-motor skills themselves, but improvement in speech should not be expected as a result.”
  • Peterson-Falzone, Trost-Cardamone, Karnell, & Hardin-Jones (2006):
    • “Do not invest time or advise a parent to invest time and money addressing a muscle strength problem that may not (and probably does not) exist. It is very frustrating to see clinicians working on “exercises” to strengthen the lips and tongue tip when bilabial and lingua-alveolar sounds are already evident in babble, or when bilabial and lingual/lingua-alveolar functions are completely intact for feeding and other nonspeech motor behaviors.”
    •  “Having a repaired cleft does not mean a child will lack the muscle strength needed to produce consonant sounds adequately. The presence of a cleft palate (repaired or unrepaired) has no bearing on tongue strength or function (why would it?). The majority of children who demonstrate VPI do so because their palate is too short to achieve VP closure. Muscle strength or lack thereof is not a primary causal factor associated with phonological delays in this population.”
    •  “…blowing should never be used to “strengthen” labial or soft palate musculature; it does not work. Children who appear to improve over time in therapy when using these tools are likely demonstrating improvement related to maturation and to learning correct motor speech patterns. Had therapy focused only on speech sound development, these children probably would have shown progress much sooner.”
  • Love, R.J. (2000):
    •  “…recently the profession has rejected the concept of a direct correlation between oral movements and speech and eating behavior.”
    •  “…speech movement control was mediated at a different level in the nervous system than was nonspeech movement control.”
    •  “…it is clear that the infantile reflexes involved in chewing and swallowing behavior are mediated at brain-stem levels, not at the cortical level of oral-motor control as is speech.”
    •  “…improvement of infantile chewing and swallowing behavior in no way contributes to the development of neural networks for speech production.”
    •  “…oral reflexes and chewing and swallowing behavior are relatively independent of speech production mechanisms.”
    •  “…recent studies of the development of mandibular action in normal children suggests that motor coordination for speech activities is clearly different than it is for nonspeech activities…”
    •  “…[there is] doubt that muscle weakness or pathological muscle imbalance of oral and mandibular muscles is critical for speech movements.”
  • Hodson, B.W. (1997):“…research data supporting efficacy of oral-motor exercises for unintelligible children as a whole are lacking.”
  • Tyler, A. (2005). “I strongly advise against the use of oral-motor exercises for children with phonological-articulatory disorders…”
  • National Joint Committee for the Communication Needs of Persons with Severe Disabilities (2006): “There are different types of oral-motor exercises. Typically, oral-motor treatment consists of three types of activities: active exercise, passive exercise, and external stimulation. Active exercise involves strength training and muscle stretching. Passive exercise involves clinician assistance and may involve massage, stroking, or tapping parts of the oral musculature. Clinicians also may use external stimulation, which includes hot and cold application, vibration, or electrical stimulation to the muscles involved in speech and swallowing. At this time, there is limited data-based evidence to support the use of oral-motor activities to help with speech production. Available evidence is based primarily on expert opinion; randomized clinical trials with a randomized control group, the highest level of evidence, have not been conducted. Data are available on the effectiveness of speech (articulatory and phonological) treatment. Thus, use of oral-motor treatment techniques may take time away from treatment approaches that are known to be effective, such as teaching the correct way to position the tongue to produce a correct speech sound. Some researchers suggest that speech and language treatment should be task specific. That means that treatment techniques should be related to the desired outcomes. If improved speech is the goal, it follows that treatment techniques should be speech-specific. Oral-motor treatment techniques are sometimes applied based on the assumption that oral motor problems contribute to speech problems. However, this may not be an accurate assumption, particularly when no muscle weakness is apparent in the oral mechanism.”
  • Smith (2006). “Infants do not start life with language and motor mappings in place; many years of learning must occur. The speaker must develop a set of maps that include language, motor, and auditory networks.”

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Oral Apraxia and Apraxia of Speech

Oral Movements and Language Development

By

Katie Alcock, Ph.D., Department of Psychology, Lancaster University

How are Language Development and Motor Development Linked?

People have been asking for a long time whether children who are good, or poor, at motor (movement) skills are likely to be good, or poor, at language skills. Here’s what we know so far. When you look at walking, running, jumping and other gross motor skills you don’t find any link between these and language – children who are slow or fast to walk are not necessarily slow or fast to talk. However there is a lot of evidence that hand gestures (including things like waving bye-bye and pointing – communicative gestures – and things like showing what you do with scissors or a comb, without having them in your hand – symbolic gestures) are linked to language abilities. Children who use hand gestures early are likely to be early talkers. Children who are late to use gestures are likely to be late talkers, and are more likely than children whose gestures are on schedule to remain delayed in their language use. There is also an association in older children between having disordered or delayed language development and having difficulties with control of limb movements – it is not just a link in early life.

So, we know a lot about how arm and hand movements are related to language development and language disorders. But most people speak with their mouths. What do we know about oral (mouth) movements – such as sticking out the tongue, licking the lips, and kissing in a grown-up way – and language development? In fact, very little. Here’s a short summary of what we do know:

Typical Oral Motor Development

We actually know very little about how typically developing children develop mouth movements. Most research so far has been on feeding in young infants, without relating this to language development or looking at how mouth movements develop in older children. What we do know is also a little contradictory: some research suggests that children do not learn how to control their mouth movements at an adult level until after they are about 14 years old, while other researchers suggest that there is no real change in children’s skills from a much younger age – maybe 5 years, maybe 8. This is something that my research group is looking into at the moment. We are testing children’s mouth movement skills from the age of 1 year to the age of 8 years to see how they develop.

Oral Motor Development in Children with Language Difficulties

Likewise, until recently we have known only a little about how mouth movements develop in children who have language problems for whatever reason. There are a wide variety of reasons for children to have language development difficulties but in many different syndromes we do see some oral motor difficulties. For example, nonfluent developmental dysphasia (a speech output difficulty without any associated learning disabilities or hearing/social difficulties) tends to be associated with oral dyspraxia (a diagnosed difficulty in coordinating oral movements). In children with specific language impairment (or SLI, a very similar problem where children have delayed or disordered language, without any difficulty in hearing, a general learning disability, or any social difficulties such as autism) the children who find the most difficulty with oral movements are the same children who find most difficulty with pronouncing new words.

Oral movements also tend to be difficult for children with other types of language difficulties – those due to autism and Down Syndrome, for example. Most of these studies tend to look at whether or not a child has a diagnosis of oral dyspraxia, however, and then see whether this diagnosis tends to coincide with a diagnosis of a language difficulty. Two studies that I have been involved in have taken a different approach: we wanted to see if language development could be associated with more subtle variation in oral motor skill, where the mouth movement abilities were not poor enough to be diagnosed as oral dyspraxia. In the first study we looked at a group of individuals who have a developmental language impairment and in the second we looked at a large group of children whose language was – as far as we know – developing in a typical fashion.

Oral Motor Abilities and Developmental Language Impairment

About 5% of children have a specific language impairment (SLI). Children with this disorder have difficulty in constructing sentences, learning new words, and/or speaking. This often runs in families and we studied a large family – which we’ll call the KE family – who had such a disorder. Half of the family members had the disorder and just as many boys as girls developed the disorder. When the family first agreed to take part in research, a paper was published by another research group which said that the family members had difficulties with forming sentences – in particular with regular grammatical endings such as “-ed” on “walked” – but not with any other speech and language skills, and also not with other, non-language skills.

When my research group first got to know members of the family we thought that something couldn’t be quite right about this, as many of the children and even the adults in the family struggle with their speech and are occasionally very hard to understand. I decided to see if, as I suspected, they also had difficulty with non-language skills such as mouth movements. Other people in the group also went on to look at a wide variety of language skills, too, and not just regular grammatical endings – affected family members turned out to have a problem with a wide range of language skills.

We tested family members’ mouth movement skills by looking at:

  • Simple mouth movements – such as opening the mouth
  • Complex mouth movements – such as whistling
  • Combinations of mouth movements – such as three in a sequence (first open your mouth, then put your lips tightly together, then stick out your tongue) or three at the same time (open your mouth, stick out your tongue and make a “h” sound in your throat)
  • Repeated movements – such as opening and closing the mouth again and again, as fast as possible.

We compared the abilities of family members who have the speech and language problem, with those who do not and some additional volunteers who were the same age as the family members with the speech and language problems. The mouth movements we asked them to do were first of all described to them, as above, and then shown to them to copy. We found that affected family members were poorer at performing most of the kinds of movements we gave them – but not all of them. They found the combinations of movements more difficult, but the simple movements on their own were not more difficult, and nor was performing repeated single movements quickly. So, it seems that these individuals have problems with coordinating several muscles in one movement, or coordinating several movements at the same time – which is exactly what you need to do when you are speaking. The other thing we found was that these types of movements were hard whether we showed the family members what to do, or described the movements. From this we could conclude that any difficulty with the movements was not due to a difficulty in understanding the instructions, which could easily hinder performance if someone has a language problem.

This finding was very interesting and it led us to ask what relationship there might be between mouth movement abilities and language abilities in children who are typically developing – who do not have any language difficulties.

Oral Motor Development in Children with Typically Developing Language

Most children develop language without any problems, but the rate at which children develop varies widely. Typically developing children mostly seem to start their language development slowly and then, at an average age of about 21 months, suddenly pick up speed and start to learn words much faster and also to combine words into baby sentences such as “doggie bark” or “more juice”. Because development is so fast at this stage, children can be very different from each other – so if we want to find out what it is that makes children different from each other, this is an ideal age to look at.

What Do We Already Know About Mouth Movements and Typically Developing Language?

Again, very little! There is a little bit of research with children who are just starting to speak to suggest that children who are good at coordinating simple feeding movements are not necessarily good at coordinating speech movements but then, we already know that very simple movements are not so closely related to speech movements. However, there is also some research suggesting that older children who have poorer mouth movements also have poorer speech abilities – even up to 10 years of age.

We decided to investigate this further. We looked at 60 children aged 21 months who we recruited through our local hospital when the children were born. As with the older children and adults we tested simple movements (opening the mouth), complex movements (licking the lips) and repeated movements. We also looked at children’s language abilities (by giving the parents a questionnaire to fill in with a list of words children might know at this age, as well as ways in which children can use words and put them together), and children’s cognitive or problem-solving abilities (again using a questionnaire that asks about children’s play skills).

What We Found

The main finding was that the higher a child’s vocabulary was (the more words they knew), the better their mouth movement skills were. We also found that both mouth movements and cognitive abilities were related to each other and to language – but after we removed the variability associated with the cognitive abilities, we still found that mouth movement ability was related to vocabulary. So children who are better at mouth movements are better at language – and it’s not just because they are the cleverer or more able children overall.

One particularly interesting finding was that children who were poor at mouth movements were almost invariably poor at language. Children who were good at mouth movements could however be either good or poor at language. What this suggests is that children need good oral motor skill to be good at language – but they need a lot of other skills too.

What We Concluded

Although the initial reports of the difficulties experienced by the KE family, and a lot of theories of language development, suggest that language is a separate skill that does not depend on other skills such as motor or cognitive skills, our research suggests that this is not true – language and oral movements are linked in both typical and atypical development, and this link is not due to some children being more advanced in all abilities.
There are a number of reasons this might be the case: children who are good at imitating one thing may simply be good at imitating, and therefore learning, new words. However when we looked at older children we found that those with language difficulties also had problems when the movements were explained to them. So this cannot be the only reason for the link we found.

Alternatively, children who are poorer at coordinating any movements of their mouths might, as a result of this, have problems both with carrying out the kinds of movements we gave them to do, and with carrying out speech movements. This would mean they had a hard time pronouncing words and therefore demonstrating what they knew in the way of vocabulary to parents and others. We didn’t find as strong a link between children’s comprehension of words and their mouth movements, which suggests this might be the reason.

However, it is true that children who talk more practice using their mouth more – since that’s how they talk! So we can’t rule out that the link might be the other way round – children who have had more practice in talking have, on the whole, had more of a chance to exercise their mouths, so they would be better at the non-speech mouth movements we gave them.

So, where do we go from here? Well, one thing people ask is whether practicing mouth movements can help children who have speech and language problems. It is fair to say we don’t have enough evidence to conclude that – if children have a basic problem with mouth movement control that applies both to speech and non-speech movements, then helping them with their non-speech movements may or may not help them with their speech movements. If however they lack practice with speech movements and this means they then find non-speech movements difficult, then practicing the non-speech movements is probably not going to help.


About the author: Dr. Katie Alcock combined her early interests in languages and in how the brain works by doing a Ph.D. at Oxford University looking at developmental language disorders and comparing them to those that follow a stroke. Since then she has carried out research in Tanzania (investigating the impact of ill health on cognitive development) and La Jolla (researching the cognitive psychology of language) and is currently a Lecturer at Lancaster University, where she continues research on language development, developmental language disorders, and the impact of health and poverty on language and cognitive development, with current projects in Kenya and Indonesia. To LEARN MORE about Dr. Alcock’s research go to http://www.psych.lancs.ac.uk/people/KatieAlcock.html.

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (Apraxia Kids)
www.apraxia-kids.org

What Does the Research Say Regarding Oral Motor Exercises and the Treatment of Speech Sound Disorders

By

Gregory L. Lof, Ph.D., CCC-SLP

The vast majority of the legitimate research shows no changes in speech sound productions because of non-speech oral motor exercises. However, many clinicians have strong opinions about their efficacy by stating clinical anecdotes, or they will cite non-peer reviewed publications and CEU events that claim there are speech benefits of these exercises.

Literature searches of the available information on this topic yield six treatment studies. The participants in these studies range in age from 4 to 8;11 years. Some of the studies include children with Childhood Apraxia of Speech (CAS) who had treatments of varying duration using a variety of treatment approaches. Almost all studies were some type of a single-subject research design. Of these six studies, five showed no treatment effects for changing speech sound productions. Only one study reported any positive effects of oral motor exercise; however, this study contained many fatal flaws that invalidated the findings (e.g., non-equivalent groups, severity of involvement was not controlled, different sounds were treated for each subject, etc.).

The primary reasons that these exercises do not change speech sound productions are:

  1. task specificity that makes these exercises ineffective; and
  2. oral motor exercises do not increase strength for speech as many clinicians claim.

Task specificity is a reason why these exercises almost certainly will not affect speech. In order for there to be positive transfer of one behavior (i.e., the exercise) to another behavior (i.e., speaking) the task must be identical. But most oral motor exercises are NOT identical to the movements required for speech; no English speech sounds involve tongue wagging, whistling, tongue clicks or curls, etc. The relevancy of the task is important because context is crucial. Here are two non-speech examples that may illustrate this:

  1. A piano teacher would not ask her students to practice finger movements on a tabletop instead of on actual piano keys because there would be no transfer of this irrelevant table pounding to the integrated needs of piano performance;
  2. A basketball coach would not have student athletes learn to dribble a basketball by just “pretending” that they have a ball in their hands; irrelevant hand flapping will not lead to better ball handling. These examples are directly related to the question because non-speech oral motor exercises also lack relevancy and they disintegrate the highly integrated task of speaking. For example, repeated elevation of the tongue tip to the alveolar ridge will not establish /l/ production because it lacks relevancy.

In addition, in the neurology literature, scientists have demonstrated how speech movement control is mediated at different nervous system locations than are non-speech movements. The training of irrelevant non-speech movements will not transfer to speaking because they are controlled by entirely different parts of the brain. Some examples of this are:

  1. A person can have dysphagia (i.e., a swallowing disorder) without having a speaking problem (the same structures are used for speaking and for swallowing but they have different speech and non-speech functions);
  2. People can strengthen the velopharyngeal complex by performing blowing exercises, but the speech will remain nasalized (same structures, but different functions, which shows task specificity).

Oral motor exercises do not increase strength for speech. In order to increase strength, all exercises must be done consistently, against resistance, and typically until failure (the same way you strengthen muscles when you go to the gym). Regardless of the fact that strength is not all that important for speaking (the strength needs for talking are very minimal), these exercises usually do not strengthen the necessary muscles anyway. For example, how many clinicians actually have their clients perform tongue wagging until there is failure? And is there always a resistive force used during the exercises? I doubt it. Therefore, the children are probably not strengthening these muscles. In addition, very few clinicians objectively measure oral muscle strength pre- and post-treatment, so strength improvements cannot actually be evaluated. One other thing about strength: for CAS and other speech sound disorders, oral motor strength is not impaired. In cases where strength is impaired, the child should probably be diagnosed with dysarthria. But most of the dysarthria literature also reports a lack of speech improvements using oral motor exercises.

Some clinicians use these exercises as “warm up” drills or use them in the hopes that it will lay a foundation for speech. But there is no evidence to support the use of these drills even for awareness purposes; the transfer of these “meta” skills to speaking has not been empirically demonstrated. There is research that shows that non-speech behaviors are NOT a precursor to later speech learning, so these exercises cannot effectively establish speech productions. Therefore, “warm up” exercises will not carry over to speech nor will the exercises build a speaking foundation.

The bottom line is that if clinicians want the speech productions of children to change, then they must work on speech and not on tasks that only superficially appear to be speech-like movements. The current available literature is clear that non-speech oral motor exercises will not produce speech changes. Clinicians who use these procedures in the hopes of changing speech productions must be very cautious in making claims of the treatment efficacy of such tasks. All practitioners need to use current research evidence to guide their clinical practice.

References

(*Research on treatment efficacy of non-speech oral motor exercises)

*Abrahamsen, E, P., & Flack, L. (Nov., 2002).
Do Sensory and Motor Techniques Improve Accurate Phoneme Production?
Paper presented at the National Convention of the American Speech-Language-Hearing Association, Atlanta, GA.

*Christensen, M., & Hanson, M. (1981).
An Investigation of the Efficacy of Oral Myofunctional Therapy as a Precursor to Articulation Therapy for Pre-First-Grade Children.
Journal of Speech and Hearing Disorders, 46, 160-167.

*Colone, E., & Forrest, K. (Nov., 2000).
Comparison of Treatment Efficacy for Persistent Speech Sound Disorders. Poster presented at the National Convention of the American Speech-Language-Hearing Association, Washington, D.C.

*Fields, D., & Polmanteer, K. (Nov., 2002).
Effectiveness of Oral Motor Techniques in Articulation and Phonology Treatment.
Poster presented at the National Convention of the American Speech-Language-Hearing Association, Atlanta, GA.

Forrest, K. (2002).
Are Oral-Motor Exercises Useful in the Treatment of Phonological/Articulation Disorders?
Seminars in Speech and Language, 23 (1), 15-25.

*Forrest, K., & Peabody, E. (2003).
Comparison of Treatment Efficacy in Childhood Apraxia of Speech.
Manuscript submitted for publication.

*Guisti, M.A. (2002).
The Efficacy of Oral Motor Therapy for Children with Articulation Disorders.
Unpublished Master’s Thesis, Southern Connecticut State University, New Haven, CT.

Hodge, M. M. (2002).
Nonspeech Oral Motor Treatment Approaches for Dysarthria: Perspectives on a Controversial Clinical Practice.
Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 12 (4), 22-28.

Lof, G. L. (2003).
Oral Motor Exercises and Treatment Outcomes.
Perspectives on Language Learning and Education, 10 (1), 7-11.

Moore, C, & Ruark, J (1996).
Does Speech Emerge from Earlier Appearing Oral Motor Behavior?
Journal of Speech and Hearing Research, 39, 1034-1047.

*Occhino, C., & McCann, J. (Nov., 2001).
Do Oral Motor Exercises Affect Articulation?
Poster presented at the National Convention of the American Speech-Language-Hearing Association, New Orleans, LA.


(Gregory L. Lof, Ph.D., CCC-SLP, is an Assistant Professor and the Associate Director in the Graduate Program in Communication Sciences and Disorders at the MGH Institute of Health Professions, an academic affiliate of the Massachusetts General Hospital in Boston. He received his Ph.D. from the University of Wisconsin-Madison in 1994. He has taught and served as a clinical supervisor at universities in Minnesota, South Dakota, Wisconsin, and Massachusetts. His research, teaching and clinical interests primarily are with children with articulation/phonological disorders as well as interests in professional issues. Dr. Lof is the 2004 Topic Coordinator for articulation/phonology for the ASHA convention and he has served on the 1995, 1998, and 2002 ASHA Convention Program Committee for phonology. He is an editorial consultant for the journals Journal of Speech, Language, Hearing Research, American Journal of Speech-Language Pathology, Contemporary Issues in Communication Sciences and Disorders, and Language, Speech, and Hearing Services in Schools. He has presented workshops at ASHA conventions, at local universities, in school districts, and at numerous state conventions.)

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (Apraxia Kids)
www.apraxia-kids.org

Logic, Theory, and Evidence Against the Use of Non-Speech Oral Motor Exercises to Change Speech Sound Production

By

Gregory Lof, Ph.D., CCC-SLP

[Read the text below or Download this PDF file of the handout from Dr. Lof’s invited presentation at the 2006 ASHA Convention. Reprinted with permission from the author.]

Introduction

Non-Speech Oral Motor Exercises (NS-OME) Defined

  • Any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities (Lof & Watson, 2004; In press).
  • A collection of nonspeech methods and procedures that claim to influence tongue, lip, and jaw resting postures, increase strength, improve muscle tone, facilitate range of motion, and develop muscle control (Ruscello, In Press).

Do SLPs use NS-OME? Nationwide survey of 537 SLPs by Lof & Watson (2004; In press)

  • 85% use NS-OME to change speech sound productions.
  • Hodge, Salonka, & Kollias (2005): Nationwide survey of 535 SLPs in Canada found that 85% use NS-OME to change speech sound productions, the same result as in the USA!
  • Clinicians report being “Very Familiar” with the research that has examined the efficacy of NS-OME and the theoretical basis for using them.
  • 61% of the clinicians agree with this statement: “The literature I have read strongly encourages the use of NS-OME.”
  • 87% of the clinicians learned to use NS-OME from non peer-reviewed CEU offerings, workshops, and in-services.
  • Most frequently used exercises (in rank order): Blowing; Tongue Push-Ups; Pucker-Smile; Tongue Wags; Big Smile; Tongue-to-Nose-to-Chin; Cheek Puffing; Blowing Kisses; Tongue Curling.
  • Reported benefits (in rank order): Tongue Elevation; Awareness of Articulators; Tongue Strength; Lip Strength; Lateral Tongue Movements; Jaw Stabilization; Lip/Tongue Protrusion; Drooling Control; VP Competence; Sucking Ability.
  • These exercises are used for children with (in rank order): Dysarthria; Apraxia of Speech (CAS); Structural Anomalies; Down Syndrome; Enrollment in Early Intervention; “Late Talker” Diagnosis; Phonological Impairment; Hearing Impairment; Functional Mis-articulations.

Evidence-Based Practice

  • Defined: The conscientious, explicit, and unbiased use of current best research results in making decisions about the care of individual clients (Sackett et al., 1996). Treatment decisions should be administered in practice only when there is a justified (evidence-based) expectation of benefit.
  • No Child Left Behind places an emphasis on scientifically-based methods, calling on clinicians to use scientific, research-based interventions
  • 2006 IDEA Part B Regulations: “Special education and related services…must now be based on peer-reviewed research to the extent practicable.”
  • The goal is to use the literature in a savvy process that draws on a number of different factors in which evidence plays a key role.
  • Dollaghan (2004) reminds clinicians that when using the EBP paradigm, valid and reliable evidence needs to be given more credence than intuition, anecdote and expert authority. Evidence must come from works that are independent and peer-reviewed.
  • Opinions and clinician’s own clinical experiences can be useful, but they can also be biased and even wrong!
  • Therapist Bias: Halo effect and Rosenthal effect (see Damico, 1988).

Logic

  • Clinical experience cautions: Finn, Bothe, and Bramlett (2005) provided criteria for distinguishing science from pseudoscience: (1) Treatments remain unchanged even with evidence against its effectiveness because disconfirming evidence is ignored; (2) Anecdotal evidence and personal experience are given extraordinary credence; (3) Inadequate evidence is accepted; (4) Peer review is avoided; (5) Methodology is disconnected from established scientific models; (6) Use of new terms that are not scientific nor conventional; (7) Grandiose outcomes are proclaimed; (8) Claims of success only within a holistic framework.
  • Many claims are made about NS-OME effectiveness in catalogs selling therapy materials, non-peer reviewed publications, CEU events, etc. But no evidence of effectiveness is provided.
  • Some claims of effectiveness are outrageous and are actually illogical when carefully examined.

Theory

Part-Whole Training and Transfer

  • Basic questions: Does training on a smaller portion of the articulatory gesture transfer over to the whole gesture? Is it more efficient with better learning by first training just part of the movement and not the whole movement?
  • Tasks that comprise highly organized or integrated movements (such as speaking) will not be enhanced by learning the constituent parts of the movement alone; training on just the parts of these well-organized behaviors can actually diminish learning. Highly organized tasks require learning the information processing demands, as well as learning time-sharing and other inter-component skills.
  • “Fractionating a behavior that is composed of interrelated parts is not likely to provide relevant information for the appropriate development of neural substrates” (Forrest, 2002).
  • Some clinician-researchers believe that it can be more effective to “Train the Whole” (Ingram & Ingram, 2001) and to use “Whole-Word Phonology and Templates” (Velleman & Vihman, 2002) rather than breaking up the gesture into small parts.

Strengthening the Articulatory Structures

  • Basic questions: Is strength necessary for speaking? If so, how much? Are the articulators actually strengthened by using NS-OME? How do SLPs objectively document weakness of articulators and also objectively document supposed increases in strength after NS-OME?
  • Articulatory strength needs are VERY low for speech and the speaking strength needs do not come anywhere close to maximum strength abilities of the articulators. For example, lip muscle force for speaking is only about 10-20% of the maximal capabilities for lip force, and the jaw uses only about 11-15% of the available amount of force that can be produced (see also Bunton & Weismer, 1994).
  • Agility and fine articulatory movements, rather than strong articulators, are required for the ballistic movements of speaking. NS-OME encourage gross and exaggerated ranges of motion, not small, coordinated movements that are required for talking.
  • NS-OME may not actually increase articulator strength. To strengthen muscle, the exercise must be done with multiple repetitions, against resistance, until failure…and then done again and again. Most NS-OME do not follow this basic strength training paradigm so there are probably no actual strength gains occurring due to these exercises.
  • Articulators can be strengthened (e.g., the tongue for oral phase of swallowing or the VP complex) but these strengthened articulators will not help with the production of speech.
  • Measurements of strength are usually highly subjective (e.g., feeling the force of the tongue pushing against a tongue depressor or against the cheek or just “observing” weakness), so clinicians cannot initially verify that strength is actually diminished and then they cannot report increased strength following NS-OME. Only objective measures (e.g., tongue force transducers) can corroborate statements of strength needs and improvement. Without such objective measurements, testimonials of articulator strength gains must be considered suspect.
  • See Chi-Fishman and Pfaizer (2003) for information on tongue anatomy, physiology, and strengthening principles

Relevancy of NS-OME to Speech

  • Relevancy is the only way to get changes in the neural system; the context in which a skill is learned is crucial. In order to obtain transfer from one skill to another, the learned skills must be relevant to the other skills. “…muscle fibers are selectively recruited to perform specific tasks, so static non-speech tasks do not account for the precise and coordinated activity needed during speech” (Hodge & Wellman, 1999).
  • For sensory motor stimulation to improve articulation, the stimulation must be done with relevant behaviors, with a defined end goal, using integration of skills. “The PURPOSE of a motor behavior has a profound influence on the manner in which the relevant neural topography is marshaled and controlled” (Weismer, 2006).
  • Most NS-OME dis-integrate the highly integrated task of speaking (e.g., practicing tongue elevation to the alveolar ridge with the desire that this isolated task will improve production of the lingual-alveolar sound /s/). For example, a motor task (e.g., shooting a free throw using a basketball) must be learned in the context of the actual performance goal. By analogy, no one would teach a ballplayer to pretend to hold a ball and then pretend to throw it toward a non-existent hoop with the eventual hope of improving free throwing ability. Breaking down basketball shooting or the speaking task into smaller, unrelated chunks that are irrelevant to the actual performance is not effective.
  • Another non-speaking example would be the illogical finger pounding on a tabletop to simulate playing on a piano. Learning and improving piano playing must be practiced on a piano, not on a tabletop. Likewise, learning and improving speaking ability must be practiced in the context of speaking. To improve speaking, children must practice speaking, rather than using tasks that only superficially appear to be like speaking.
  • Because isolated movements of the tongue, lips and other articulators are not the actual gestures used for the production of any sounds in English, their value for improving production of speech sounds is doubtful. That is, no speech sound requires the tongue tip to be elevated toward the nose; no sound is produced by puffing out the cheeks; no sound is produced in the same way as blowing is produced. Oral movements that are irrelevant to speech movements will not be effective as speech therapy techniques.

Task Specificity

  • Three related concepts: 1. same structures but different functions, 2. task specificity, 3. domain specific.
  • The same structures used for speaking and other “mouth tasks” (e.g., feeding, swallowing, sucking, breathing, etc.) function in different ways depending on the task and each task is mediated by different parts of the brain. The organization of movements within the nervous system is not the same for speech and nonspeech gestures. Although identical structures are used, these structures function differently for speech and for nonspeech activities.
  • Weismer (2006): The control of motor behavior is task (speaking) specific, not effector (muscle or organ) specific. There is strong evidence against the “shared control” for speech and nonspeech. “Motor control processes are tied to the unique goals, sources of information (e.g., feedback), and characteristics of varying motor acts, even when those share the same effectors and some neural tissue.”
  • Some examples of task specificity: Babbling and early nonspeech oral behaviors are not related (e.g., Moore & Ruark, 1996); Patients can have dysphagia with and without speech problems (i.e., “double dissociations”; Ziegler, 2003); It is well documented that the VP mechanism can be strengthened, however, reduction of speech nasality does not occur (e.g., Kuehn & Moon, 1994); Breathing for speech is different than breathing at rest or during other activities (e.g., Moore, Caulfield, & Green, 2001). See Weismer (2006) for summary of 11 studies that show that speech and nonspeech are different for a wide variety of structures, including facial muscles, jaw motion, jaw operating space, jaw coordination, lingual movement, lip motions, leavator veli palatini, and mandibular control.

Warm-Up/Awareness/Metamouth

  • Warm-up has a physiological purpose during muscle exercise: to increase blood circulation so muscle viscosity drops, thus allowing for smoother and more elastic muscle contractions (Safran, Seaber, & Garrett, 1989).
  • Warm-up of muscles may be appropriate (Pollock et al., 1998) when a person is about to initiate an exercise regimen that will maximally tax the system (e.g., distance running or weight training). However, muscle warm-up is not required for tasks that are below the maximum (e.g., walking or lifting a spoon-to-mouth). Because speaking does not require anywhere near the oral muscular maximum, warm-up is not necessary.
  • If clinicians are not using the term warm-up to identify a physiological task to “wake up the mouth,” then perhaps they believe that they are providing some form of “metamouth” knowledge about the articulators’ movement and placement.
  • Awareness and its role in therapy is always questioned. It is well known that young children have difficulty with various metaphonological awareness tasks (Kamhi & Catts, 2005). For articulation awareness, Klein, Lederer and Cortese (1991) reported that children age 5 and 6 years had very little consciousness of how speech sounds were made; 7 year olds were not very proficient with this either. According to Koegel, Keogel, and Ingham (1986), some children older than 7 years were successful during a metalinguistic speech intervention program, but only when they have the “…cognitive maturity required to understand the concept of a sound…”
  • It appears that young children cannot take advantage of the non-speech mouth-cues provided during NS-OME that can be transferred to speaking tasks. More research is needed to determine the minimum cognitive, linguistic, and motor abilities of children that are necessary for such “meta” skills.

Childhood Apraxia of Speech (CAS)

  • Children with CAS have adequate oral structure movements for nonspeech activities but not for volitional speech (Caruso & Strand, 1999), so this would preclude the use of NS-OME because non-speech is not the problem.
  • There is no muscle weakness for children with CAS, so there is no need to do strengthening exercises. If there is weakness, then the correct diagnosis is dysarthria, not apraxia.
  • “Non-speech therapy activities will not improve a child’s (with CAS) speech. Activities that address speech directly are critical for that purpose” (Velleman, 2003).
  • See the quote by Davis & Velleman (2000) below.

NS-OME for Non-Motor Speech Disorders

  • Some may believe that motor exercises can help children with motor production speech problems, such as functional misarticulators (phonetic/articulatory problems) or children with structural problems; however the evidence does not support this.
  • It makes no sense that motor exercises could help improve the speech of children who have non-motor problems such as language/phonemic/phonological problems like children in Early Intervention diagnosed as late talkers.

Cleft Lip/Palate

  • The VP mechanism can be strengthened through exercise (many studies have demonstrated this since the 1960s), but added strength will not improve speech productions.
  • See the quotes by Peterson-Falzone, Trost-Cardamone, Karnell, Hardin-Jones (2006) below.

Evidence

There are 10 studies evaluating the effectiveness of NS-OME: 9 show no benefits, 1 shows benefits (but it has many methodological flaws).

  1. Christensen & Hanson (1981). Ten children aged 5;8 to 6;9 years underwent 14 weeks of treatment, with half of the children receiving only articulation therapy and the other half receiving articulation and neuromuscular facilitation techniques. Both groups made equal speech improvements; the exercises did not help for better speech sound production BUT they were effective in remediating tongue-thrusting (probably due to task specificity).
  2. Gommerman & Hodge (1995). Single Subject Design (A-B-C) with a 16-year-old girl with tongue thrust and sibilant distortions. Therapy was baseline (A phase), myofunctional therapy (B phase), then articulation therapy (C phase). Tongue thrust was eliminated with myofunctional therapy but speech did not change until speech therapy was initiated.
  3. Colone & Forrest (2000). Monozygotic twin boys age 8;11 years old took part in a motor treatment for Twin 1 and phonological treatment for Twin 2. No improvements with motor training occurred but there were improvements using a phonological approach; when Twin 1 received phonological treatment, there were the same improvements as for Twin 2.
  4.  Occhino & McCane (2001). Single Subject Design (A-B-C-B-C) with a 5-year-old child. Oral motor exercises alone produced no improvement in the articulation of one of two phonemes and also no improvements in oral motor skills. Oral motor exercises prior to or along with articulation therapy did not have an additive or facilitative effect but productions did improve with articulation therapy.
  5. Abrahamsen & Flack (2002). Single Subject Design with a 4-year-old child for 10 hours of individual treatment using blowing, licking, and oral stimulation. There was no evidence of effectiveness in changing speech sound productions after this treatment.
  6. Bush, Steger, Mann-Kahris, & Insalaco (2004). Single Subject Design (ABAB Withdrawal) with a 9-year-old boy. OME added to articulation treatment, then removed, then re-added for the sounds /r/,/s/,/z/,/l/. “Oral motor treatment did not improve or reduce treatment’s success.”
  7. Roehrig, Suiter, & Pierce (2004). AB or BA Single Subject Design with six 3;6 to 6;0 year old boys and girls for 15 weeks of therapy: (A) Tradition, production-based therapy twice a week for ½ hour; (B) Passive OME and traditional therapy twice a week for ½ hour. “The addition of OME to the traditional articulation therapy approach did not add to participant’s overall progress; improvement following therapy with OME was not different from improvements following articulation therapy alone.”
  8. Guisti & Cascella (2005). Single Subject Design using two boys and two girls in first grade. Therapy followed Easy Does it for Articulation: An Oral Motor Approach for 15 one-half hour individual treatment sessions. No evidence of effectiveness in changing speech-sound productions.
  9. Hayes et al. (In submission). Six 4-year-olds, five boys and one girl who all had “functional misarticulations” were studied in a counterbalanced intervention design where children were randomly assigned to a specific order for an oral motor approach and traditional articulation approach. The traditional treatment resulted in significant speech sound changes but there was no support for oral motor therapy bringing about any changes. There was some evidence that NS-OME actually hindered learning.
  10. Fields & Polmanteer (2002). Eight 3- to 6-year-old children were randomly assigned to one of two groups: four children received 10 minutes of oral motor treatment and 10 minutes of speech therapy and four children received 20 minutes of only speech therapy. Fewer errors at the end of 6-weeks of treatment for the children who received the combination of treatments. But there were many methodological and statistical issues that may invalidate this finding, such as: the children in the speech-only group were more severe; there was an unequal gender distribution; and there was no report of what the treated sounds were so there can be no evaluation as to how difficult it was to treat certain sounds.

Combining Treatment Approaches

  • Most SLPs use a combination of treatment approaches so it is difficult to “tease apart” which approach is providing therapeutic benefit. Additionally, whenever intervention approaches are combined, it is unknown if and how they actually work in conjunction with each other to enhance performance.
  • There is much evidence that the NS-OME portion of combined treatments is irrelevant to speech improvements (see above).
  • NS-OME probably do not harm the child when used in combination with traditional approaches (however, Hayes et al. [2006] found that some children may be negatively affected by a combination approach).
  • It seems reasonable that if there is no speech improvement using combined approaches, then clinicians should eliminate the approach that is not effective (i.e., the NS-OME) so as to not waste valuable therapy time with an ineffectual technique.

In Conclusion

  • If clinicians want speech to improve, they must work on speech, and not on things that LOOK like they are working on speech.
  • Phonetic placement cues that have been used in traditional speech therapy are NOT the same as NS-OME.
  • NS-OME is a procedure not a goal. The goal of speech therapy is NOT to produce a tongue wag, to have strong articulators, to puff out the cheeks, etc. Rather, the goal is to produce intelligible speech.
  • We have been burned before. In the 1990s many SLPs inappropriately embraced Facilitated Communication (FC) as a treatment approach because they thought they observed that it worked. Once it was tested using scientific methodology, it was found to not work. Pseudoscientific methodologies can persuade clinicians to provide the wrong treatment.
  • Speech is special and unlike other motor movements.
  • Following the guidelines of Evidence-Based Practice, evidence needs to guild treatment decisions. Parents need to be informed that NS-OME have not been shown to be effective and their use must be considered experimental.
  • Just remember: Same structures, different functions. Same structures, different functions.

Relevant Quotes

  • Weismer, G. (2006). “…oromotor nonverbal tasks are unlikely to contribute to an understanding of normal and disordered speech production.”
  • Gerratt et al. (1991). “Preference for nonspeech maneuvers is surprising since so little research exists on the relations of these measures to speech…”
  • Davis & Velleman (2000): “There is presently no research available to support the efficacy of oral-motor therapy for improvement of speech productions skills. Thus, it is appropriate to work with children with DAS (Developmental Apraxia of Speech) on nonspeech oral-motor skills themselves, but improvement in speech should not be expected as a result.”
  • Peterson-Falzone, Trost-Cardamone, Karnell, & Hardin-Jones (2006):
    • “Do not invest time or advise a parent to invest time and money addressing a muscle strength problem that may not (and probably does not) exist. It is very frustrating to see clinicians working on “exercises” to strengthen the lips and tongue tip when bilabial and lingua-alveolar sounds are already evident in babble, or when bilabial and lingual/lingua-alveolar functions are completely intact for feeding and other nonspeech motor behaviors.”
    •  “Having a repaired cleft does not mean a child will lack the muscle strength needed to produce consonant sounds adequately. The presence of a cleft palate (repaired or unrepaired) has no bearing on tongue strength or function (why would it?). The majority of children who demonstrate VPI do so because their palate is too short to achieve VP closure. Muscle strength or lack thereof is not a primary causal factor associated with phonological delays in this population.”
    •  “…blowing should never be used to “strengthen” labial or soft palate musculature; it does not work. Children who appear to improve over time in therapy when using these tools are likely demonstrating improvement related to maturation and to learning correct motor speech patterns. Had therapy focused only on speech sound development, these children probably would have shown progress much sooner.”
  • Love, R.J. (2000):
    •  “…recently the profession has rejected the concept of a direct correlation between oral movements and speech and eating behavior.”
    •  “…speech movement control was mediated at a different level in the nervous system than was nonspeech movement control.”
    •  “…it is clear that the infantile reflexes involved in chewing and swallowing behavior are mediated at brain-stem levels, not at the cortical level of oral-motor control as is speech.”
    •  “…improvement of infantile chewing and swallowing behavior in no way contributes to the development of neural networks for speech production.”
    •  “…oral reflexes and chewing and swallowing behavior are relatively independent of speech production mechanisms.”
    •  “…recent studies of the development of mandibular action in normal children suggests that motor coordination for speech activities is clearly different than it is for nonspeech activities…”
    •  “…[there is] doubt that muscle weakness or pathological muscle imbalance of oral and mandibular muscles is critical for speech movements.”
  • Hodson, B.W. (1997):“…research data supporting efficacy of oral-motor exercises for unintelligible children as a whole are lacking.”
  • Tyler, A. (2005). “I strongly advise against the use of oral-motor exercises for children with phonological-articulatory disorders…”
  • National Joint Committee for the Communication Needs of Persons with Severe Disabilities (2006): “There are different types of oral-motor exercises. Typically, oral-motor treatment consists of three types of activities: active exercise, passive exercise, and external stimulation. Active exercise involves strength training and muscle stretching. Passive exercise involves clinician assistance and may involve massage, stroking, or tapping parts of the oral musculature. Clinicians also may use external stimulation, which includes hot and cold application, vibration, or electrical stimulation to the muscles involved in speech and swallowing. At this time, there is limited data-based evidence to support the use of oral-motor activities to help with speech production. Available evidence is based primarily on expert opinion; randomized clinical trials with a randomized control group, the highest level of evidence, have not been conducted. Data are available on the effectiveness of speech (articulatory and phonological) treatment. Thus, use of oral-motor treatment techniques may take time away from treatment approaches that are known to be effective, such as teaching the correct way to position the tongue to produce a correct speech sound. Some researchers suggest that speech and language treatment should be task specific. That means that treatment techniques should be related to the desired outcomes. If improved speech is the goal, it follows that treatment techniques should be speech-specific. Oral-motor treatment techniques are sometimes applied based on the assumption that oral motor problems contribute to speech problems. However, this may not be an accurate assumption, particularly when no muscle weakness is apparent in the oral mechanism.”
  • Smith (2006). “Infants do not start life with language and motor mappings in place; many years of learning must occur. The speaker must develop a set of maps that include language, motor, and auditory networks.”

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