Oral Motor Exercises to Help Speech in Toddlers and Preschoolers - Why Science Says They Don’t Work
Recently I’ve heard of mothers who are telling other mothers that they’d better be doing oral motor exercises at home with their kids and find SLPs who will do these with their kids to help their toddlers learn to speak more clearly. I wanted to let you all in on apparently what some SLPs aren’t telling you.
There’s a whole lot of research in the past few years that tell us that oral motor exercises DON’T work to help children learn to speak more clearly. Before all of you get fired up and start a campaign to write in to tell me how crazy I am, let’s take a look at what science says………..
In his ASHA presentation in November 2006, Dr. Gregory Lof, a PhD level speech-language pathologist from MGH Institute of Health Professions in Boston, titled his work, “Logic, Theory and Evidence Against the Use of Non-Speech Oral Motor Exercises to Change Speech Sound Productions.”
In real words - he’s saying that common sense tells you that these exercises don’t work to make children speak more clearly, and then he cites a whole bunch of scientific studies that back him up.
For those of you who are really confused, he’s defined “non-speech oral motor exercises” as “any technique that does not require the child to produce a speech sound but is used to influence the development of speaking abilities” and “a collection of non-speech 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.”
Again, but in English please! He’s talking about all of those mouth “exercises” or “games” that SLPs tell you to do including blowing, tongue push ups, pucker-smile, tongue wags, big smile, tongue to nose to chin, cheek puffing, blowing kisses, and tongue curling.
Basically, he’s saying any “game” or “exercise” that you have your child do that DOES NOT INVOLVE him making a speech sound is not going to help him learn to talk. This means that all the blowing, sucking, tongue exercises, and lip games you’ve been doing will not do one bit of good when it comes to helping him produce clearer speech. OUCH!
Now I can’t say that I’m an SLP who has over-relied on this kind of stuff. I’m a talker, and I push functional communication whether it be with signs or words in play practically every minute of the time I provide direct treatment to a child. I hardly spend any time doing oral motor stuff in sessions because, frankly, I feel like my time is better spent doing “REAL” therapy stuff, and in my opinion, that’s language-language-language.
I do not write goals that say, “Johnny will perform 10-15 repetitions of oral motor exercises to improve strength and coordination for intelligible speech.” I do not make claims that these kinds of activities will “improve muscle tone,” but I know lots of SLPs who do and who base their whole treatment plan around these kinds of goals and strategies for non-verbal children and for children who are struggling with speech intelligibility.
I’d like to say that I haven’t done lots of oral motor activities in sessions because it didn’t make sense to me clinically. But the truth is, it’s because I hadn’t found a way to make them fun enough to do on a consistent basis or for any length of time. Because of this, it never really felt right or worth pursuing for me, or especially for a kid.
Besides - have you ever really tried to get a 2 or 3 year old to do these kinds of things for more than a minute or two? You might have an initial novel period where they sit with you and try to do it, but unless you make it super fun and whacky, I’ve found it wasn’t successful for very long. It’s usually pretty hard for them to do, and again, it’s usually pretty boring.
BUT I have routinely recommended, out of some kind of SLP obligation, at least in my initial assessments, that mom and dad do these kinds of things with my little clients as part of ”homework.” I have even recommended these kinds of things for kids without low muscle tone or who don’t have sensory issues that are negatively affecting feeding. Why? Because it’s somehow ingrained in how we’ve been trained as SLPs. There are whole catalogues, entire textbooks, countless treatment manuals, and week-end long continuing education courses devoted to telling us how effective these are and how to do these.
As a matter of fact, Dr. Lof cited that 85% of SLPs in America who were surveyed said they use non-speech oral motor exercises to change speech sound production. Results were the same for Canadian SLPs. He cited other interesting statistics including the most frequently used exercises, the reported benefits, and the diagnoses of children when these kinds of exercises were used.
I will tell you that every “diagnosis” for kids I see were on that list including dysarthria (which is unintelligible speech due to low muscle tone), childhood apraxia of speech, structural anomalies (probably cleft lip/palate but not specified), Down Syndrome, enrollment in early intervention, late talker diagnosis, phonological impairment, hearing impairment, and functional misarticulations (meaning sound substitutions). This tells us that MOST SLPs are recommending this kind of task for MOST clients that they see - even toddlers enrolled in early intervention programs.
His conclusion, again based on a number of studies, was that it’s not appropriate for any of them. Double OUCH!
Again, I don’t feel too badly on a personal level since I haven’t used them all that much, but I feel super sad about all of the therapists who have and mostly for the moms they’ve convinced to try to do it.
In this presentation, he also dissected most arguments for using oral motor exercises including that children must first learn to produce isolated movements before they can use a speech sound, that you have to build up articulatory strength when a child has low tone, that these exercises “warm up” the mouth before talking, and that you have to have adequate coordination in non-speech exercises before you talk. He debunked every one of these very persuasive arguments for non-speech exercises with 10 different studies that prove otherwise. His conclusion was that no research supports the use of these for any reason when improving speech is the goal. Triple OUCH!
His bottom line was this -
“If clinicians want speech to improve, they must work on speech, and not on things that LOOK like they are working on speech.” (GOOD! To learn to talk, you must focus on talking and not blowing, wagging, puffing, etc…!)
“Phonetic placement cues that have been used in traditional speech therapy are NOT the same as non-speech oral motor exercises.” (GOOD! This means you can and should still give your child verbal, visual, and tactile cues about placement of his tongue or lips to help him make a speech sound correctly. The difference here is that you’re actually working on SPEECH and not just a movement.)
“Non-speech Oral Motor Exercises are a procedure and 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.” (GOOD! Goals must have speech and language outcomes. That’s a big duh to me, but again, these never made much sense to me anyway.)
“Speech is special and unlike other motor movements.” (GOOD! He means that using these kinds of exercises to improve feeding do not necessarily correlate to the same movements needed for speech. He cites studies that prove that same function/same structure argument doesn’t hold water. He also means that working on a particular oral exercise like lifting your tongue up and down 10 times in a row may not translate into a kid being able to lift up his tongue to produce a sound like /l/ when saying a word or in a phrase. No kiddin’! I gave up that kind of assumption early into my 2nd year of work when this rarely produced results!)
This last one really gives a kick in the seat of the pants to SLPs who depend on oral motor exercises as a staple in their treatment plans -
“Following the guidelines of evidence-based practice, evidence needs to guild treatment decisions.” (Here’s his parting blow - ) “PARENTS NEED TO BE INFORMED THAT NON-SPEECH ORAL MOTOR EXERCISES HAVE NOT BEEN SHOWN TO BE EFFECTIVE AND THEIR USE MUST BE CONSIDERED EXPERIMENTAL.” (Emphasis was mine, not his.)
My bottom line is this - I won’t be recommending or doing these in therapy anymore for kids whose focus is speech and language, and now not just because young children don’t like them and won’t do them, but because science tells me not to bother. Whew! Laura
Here’s the original article’s reference for those of you who want to read it yourself -
http://www.speech-language-therapy.com/Lof-2006-ASHA-06-Handout.pdf
Other articles from experts who’ve looked at the same issues & reached the same conclusion -
Caroline Bowen - http://www.speech-language-therapy.com/cb-oct2005OMT-ACQ.pdf
From the Apraxia Kids Site -
http://www.apraxia-kids.org/site/c.chKMI0PIIsE/b.980831/apps/s/content.asp?ct=464461
In the spirit of fairness, here are articles that disagree with Dr. Lof’s findings -
http://www.speech-language-therapy.com/oral-motor-TT-bathel.pdf
http://www.speech-language-therapy.com/williamsetalACQ2006.pdf
One more thing - Another SLP also cited Dr. Lof’s article and arrived at this conclusion which I also agree with -
“Oral Motor therapy does have its uses. While it is ineffective for improving speech production it is effective for treating many issues related to feeding. And that is an important distinction. If your child is drooling, or unable to move food around with his tongue and chew, Oral Motor Therapy can be very effective if provided by a competent therapist.” http://www.speechlanguagefeeding.com/Newsletter.html
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Comment by Amy on 19 August 2008:
Thank you for posting this. My son Joshua was diagnosed with low oral muscle tone, and while we do exercises with him, such as blowing, sucking on straws, and chewing Skittles, I was confused as to why these won’t really help with his speech. His therapist said she read it, but coulnd’t remember the site. Thank you for breaking it down into plain English, so people like me can understand it!
Comment by Laura on 19 August 2008:
Amy - I felt like I needed to address it because it’s come up so much lately in discussions with my own clients. Hope it’s helpful to you and your SLP and any other moms you might know who could benefit from the info! Laura
Comment by Sharon on 31 August 2008:
Part of the controversy is the quality of the exercises and matching the exercises to the child’s weaknesses relative to feeding. Then applying this to speech sound productions where the child does produce sound will make a difference. Some of our prior techniques & measurements in our field have been poor. New information about what does work and for whom is coming out. Don’t throw the baby out with the bathwater! Still dedicated after more than 30 years, Sharon
See http://www.oralmotorinstitute.org
Comment by Kerri on 31 August 2008:
Laura,
THANK YOU!!! I am an SLP and it’s so frustrating to try and constantly explain to parents how/why oral motor exercises are not proven to be effective treatment. Sadly there is so much commercialism of products out there promoting oral motor treatment that it’s very much out there for parents who “google.” And many clinicians just do what they see but don’t have the time to investigate the evidence on why/how it works. Thanks again for putting the evidence out there
Comment by Laura on 1 September 2008:
Sharon - Thank you so much for your input. I know that there are lots of SLPs who agree with you, but the research is stacking up against it, so someone better hurry up and start designing better studies to prove that non-speech oral motor exercises really do work to improve speech production!
Dr. Lof, the author of the study I referenced, was kind enough to directly send me his follow-up ASHA presentation in 2007, after reading my post here on the site. The 2007 paper contained even more studies that refuted the effectiveness of oral motor exercises to improve speech sound production. He also told me of new research that’s coming out in December in the ASHA journals, so it will be interesting reading for our field.
I think a little debate makes us all better because it challenges us to examine why we do what we do and the effectiveness of it. Frankly, if what I’m doing doesn’t work, I do want to figure it out so that I can move on to something that will work. In the end, that’s the best any of us can do for our clients and their families. Thanks again for your input! Laura
Comment by Laura on 1 September 2008:
Kerrie - Thanks for your comment! But as you can see from the other recent comment from Sharon, this is controversial in our field! How it all shakes out will be very, very interesting for us! We are going to talk about this in this Friday’s (September 5) show, so I’d LOVE for you to call and chat with me about this! Join us if you can! Laura
Comment by Jill on 1 September 2008:
I actually disagree with your statemeent regarding oral motor exrecises. I am a SLP in a hospital based setting. Though I agree with your statemnet that functional communication activities are best, teaching non verbal activities such as blowing and lip rounding help articulation as well as increase strength. This may be YOUR way of practice but you are having other parents read this and then discredit what tons of speech therapist use in their sessions. Just because you do not use it in your sessions does not mean it does not work.
Comment by Laura on 1 September 2008:
Jill - I totally acknowledged that I have used oral motor exercises with my population of children - toddlers in early intervention - and that I felt they were very limited in results and effectiveness with my particular population. We are probably comparing apples and oranges since you’re in a hospital-based practice and likely don’t see toddlers. Even then, you are certainly entitled to do whatever you want to do with the children you see, regardless of what is written here or anywhere else.
But I want to urge you to please re-read the article again because it’s not my opinion. This time you may want to check out the link to the original reference article. It’s based on a paper submitted by a PhD level SLP for ASHA in 2006 and again in 2007. Dr. Lof compiled many, many research studies about the effectiveness of non-speech oral motor exercises to target speech sound production. The results are staggeringly opposed to using non-speech oral motor exercises to target improved speech sound production. In the later study, he also looked at other methods, such as using traditional speech sound production cues (such as cueing a sound with a hand motion or tactile cue) or even a more complex treatment methodology like PROMPT, which uses both visual and tactile cues to teach sounds, and both of these methods, are NOT included in this category and therefore ARE scientifically effective with research to back it up), since these methods actually do target speech sounds in conjuction with an oral motor movement. According to the 2 dozen or more studies cited by Dr. Lof, RESEARCH (not me) tells us that using non-speech oral motor exercises to improve speech sound production cannot be proven in a clinical study.
Again, none of this was my idea or opinion. I am soooooo not a researcher, just a clinician who is looking for better ways to do things and more importantly, better ways to teach parents to do things. Your complaint is with the science, sister - not me.
You may turn out to be right, and at that point, I’ll change what I do again. Another SLP wrote in that new research is coming out to prove that these exercises do work, so we will see. If and when that data comes out, I’ll start blowing and sucking and wagging again, but until then, I’m not, and I won’t feel guilty about it. Do what you want to until then, or after for that matter. Sorry I got you all worked up. Laura
P.S. I have tried to post a link to the 2007 follow-up paper, but Dr. Lof sent it to me via a pdf file, and it’s not posted on the internet to my knowledge. If you’re interested, I’ll forward it on to you. He also gave me other references, and I’ll be glad to forward those as well.
Comment by Yvonne on 2 September 2008:
Please forward it to me Laura. I’m very interested in seeing his lastest report.
I always have to laugh a little when I tell parents that this is such a controversial issue in speech. It’s kind of funny how worked up us SLPs can get.
Comment by Laura on 2 September 2008:
Yvonne - I’ll send it by e-mail later on today. It is funny how worked up we get - me included! Debate is good for us. Laura
Comment by Ben on 8 September 2008:
Laura,
I’m a dad doing some research on the oral motor topic. After reading your article I have some questions:
1. You state that exercises that strengthen the “oral muscles” have no effect on speech production. That doesn’t make sense to me. Especially since you added that they ARE effective for feeding issues. If strengthening those muscles will help improve moving food around in the mouth as well as chewing why wouldn’t they help a child use those muscles to make sounds?
To me it’s like saying, building your leg muscles will improve your running, but it won’t help improve your ability to hop.
2. The oral muscles are used for speaking.
So, why wouldn’t improving those muscles help improve speaking? This I don’t understand. Improving the strength and stamina of all other muscles in the body help improve direct AND INDIRECT functions of those muscles - walking, throwing, bending, reaching, etc.
Why are the oral muscles exempt from this principle?
Comment by Laura on 8 September 2008:
Ben - Thanks so much for your questions! These are the same questions we SLPs are asking when looking at this research. As you can tell by some of the comments I’ve gotten from professionals, this is such a hot topic for us, so join the club!
I want to encourage you to read Dr. Lof’s original article yourself since he answered your questions in it, and the link is the first one that’s provided as a reference in my article. However, I’ll try to rearticulate his points.
The studies Dr. Lof cited can find no statistical difference in speech sound productions when children do non-speech oral motor exercises and when they don’t. The researchers concluded that -
1. It doesn’t really take that much “strength” to speak, so doing lots of exercises MAY make the structures stronger, but there’s NO statistical carry-over to clearer speech. Speech intelligility seems to be more dependent on agility and coordination than strength. Oral motor strength DOES seem to impact feeding, according to the research. (Again - please read it for yourself for specifics.)
One other thing I found fascinating about training muscles (say like for running, etc….) is that you exercise the muscle to the point of fatigue and then some, to make real gains in strength. This is usually not the case when using non-speech oral motor exercises using protocols or directions an SLP would typically give a child during speech therapy. So to use an exercise metaphor really is comparing apples to oranges.
2. The other point Dr. Lof makes so much more clearly than I can is that just because it’s the same structure doesn’t mean that it’s the same function. The example he gave that made the most sense to me and the parents that I’ve discussed this with was this - piano teachers don’t teach you to play the piano by hitting your fingers on a table. The movement of your fingers is the same, so why wouldn’t this work? The piano teacher is also working on melody, phrasing, dynamics, etc… not just the tapping movement required to push the keys.
I’ve used also this example with parents - would you simply do exercises in the gym to train for a marathon and hope you were ready because you made your legs stronger, or would you actually have to get out and put your feet to the pavement? You have to practice using the same mechanism AND the same function, so to talk, you need to practice using your mouth muscles during speech to get the effects you want.
Again - this is for NON-SPEECH oral motor exercises. Using the same movements you do in speech WITH VOICE seems to be the difference here. It’s the no voice/no speech sounds with an exercise that’s not recommended, according to current research.
I hope this information helps, and again, PLEASE, PLEASE, PLEASE read the original research for yourself, because Dr. Lof addressed these questions much more thoroughly than I did (and can for that matter!)
Dr. Lof e-mailed me after someone told him about this article on my site and was gracious enough to offer to respond to any specific questions from readers. I have forwarded your questions to him, so if I’ve not answered your questions, I hope he can.
Thanks again for your questions! You’re such a great dad for investigating methodology in order to help your child! I applaud your efforts! Laura
Comment by Gregory Lof on 11 September 2008:
Because I have not seen the specific child that this father is writing about, I will only briefly talk about two topics that he brought up: strength needs/strengthening the articulations and “task specificity.”
For talking, very little strength is needed to talk (about 10-15% of what the articulators can maximally do). This means that strength is usually not the problem with poor speech. But IF you were trying to strengthen the articulators, you would have to force the child to follow the basic strength enhancing paradigm that is used for all muscles: multiple repetitions (many many many movements), against resistance (some kind of “weights”), until fatigue. Think how much it takes to strengthen the biceps when someone works out at the gym. The same exercise regimen would have to be done with the mouth. I doubt that most nonspeech oral motor exercises follow this routine. Besides, there is evidence that children with speech sound disorders may actually have STRONGER tongues than do children without speech problems. I hope no one would try to weaken these strong articulators in the hope to improve speech!
There is a large body of evidence that proves that nonspeech movements and speech movements are different. Neuroimaging studies have demonstrated that different parts of the brain are used for talking movements than for nontalking movements. The brain seems to be wired for the task, not for the specific articulator. This is what is meant by “task specificity”: the brain represents movements for the task, not organized for specific muscles. This is why feeding (nonspeech) is different from movements for talking. The evidence on how “speech is special” and unlike other movements is well known in the speech-language pathology and oral physiology literature. Remember, speaking is a cognitive, linguistic, motor act…not just a motor act. This is what makes movements for speaking and nonspeaking so different.
These topics and others related to nonspeech exercises are more fully expanded upon in the July 2008 issue of the professional journal Language, Speech and Hearing Services in the Schools. I encourage speech-language pathologists (and parents) to read them. My take-home message is: if you want speech to change, work on speech.
Comment by Laura on 11 September 2008:
Dear Dr. Lof - Thanks so much for your reply to our difficult questions! I appreciate your willingness to share your expertise with us as we’re all working to understand this complex topic! Laura
Comment by Anon on 14 September 2008:
Question, if a therapist does the oral motive movements with a child and then adds a sound to the movements is that still considered to be non speech oral motor? Thanks
Comment by Laura on 14 September 2008:
Anon - Adding the sound makes it a speech oral motor task, and this is what the research says works to help speech become clearer. Doing the movement repetitively without sound is what is not recommended according to the current research. Thanks for the question - Laura
Comment by Anon on 14 September 2008:
Ok so doing the excercises before putting sounds to them is what the study says doesn’t work with apraxic kids…..which means the study doesn’t agree with the fact that you can ‘train’ the muscles to do the movements then right? I had someone tell me their spouse who’s a basketball coach actually have their team do the ‘practices’ like the study talks about to practice their game. Very interesting. Thanks for the clarification
Comment by Laura on 15 September 2008:
Anon - Yesterday I should have said adding the “WORD” instead of adding the “sound” is what sets these oral motor exercises apart since children need to practice using words to learn how to talk. Sorry if I caused any confusion here in my haste to respond to you!
I also should have addressed your second comment concerning apraxia in kids and oral motor exercises yesterday, but Dr. Lof has beat me to it! His comments to me are included in my new article about oral motor exercises with kids with apraxia. Look for it on the home page.
As far as using the basketball analogy, I’d try to think about speech in a different way if I were you. Take a look at Dr. Lof’s previous responses again for further, and more technical, clarification.
For most parents understanding that “Speech is different” or “Speech is special” should become our mantra so that we don’t get caught up in trying to make any other exercise analogy fit for explaining treatment for a speech delay. The neuroscience tells us that where speech is concerned, our brains don’t work like that. To use other motor activities to try to understand the complexity of speech production is really comparing apples to oranges.
Again - sorry I misspoke/mistyped and confused anyone! And special thanks to Dr. Lof who keeps lending us his expertise in this area! Laura
Comment by Robin on 17 November 2008:
Please look into a response to Dr. Lof, by Jennifer A. Bathel. It makes a lot of sense as to why SLP’s like myslef believe in Oral Motor.
Comment by Laura on 17 November 2008:
Robin - I have read Jennifer Bathel’s response, but thanks for pointing that out to our readers.
I am not opposed to oral motor exercises for kids who need to target this for feeding skills and for those who have such extremely low oral muscle tone and/or poor oral-sensory awareness (i.e. still drooling waaaaay past turning 2 because of a lack of awareness).
BUT I think the research is pretty compelling for thinking twice about doing oral motor exercises “rotely” with the guise of improving speech intelligibility for the majority of children where muscle tone has had no other negative functional impact (i.e. no feeding problems, no drooling, etc….).
Thanks for expressing your opinion on what continues to be a topic of discussion in our field.
Laura