Speech–language pathologists routinely work with children who have articulation disorders. Articulation is the set of motor processes involved in the shaping and production of speech and difficulty with motor production can lead to the inability to produce certain speech sounds (Bernthal and Bankson, 1998). Articulation disorders can range in severity from mild to severe and children with a mild articulation disorder usually have difficulty pronouncing a few consonant sounds past the age at which correct pronunciation is expected (Bauman-Waengler, 2004).
One approach to the treatment of articulation disorders is oral motor therapy (Johnson and Manning, 1999; Bahr, 2001). This approach relies on the premise that improved oral motor functioning helps the child develop enough control, strength, placement, movement and coordination to achieve and stabilize sound production (Hall et al., 1993; Strode and Chamberlain, 1997; Boshart, 1998; Bahr, 2001). Oral motor programs approach articulation as a full body process that includes gross motor activities, oral massage and oral motor exercises. Gross motor activities (for example, a correct aligned seating position) are said to promote postural tone and stability for speech production (Strode and Chamberlain, 1997; Bahr, 2001). Oral massage (for example, stroking of the facial muscles) is purported to improve a child's response to oral sensation, muscle tone and the ability to perform more precise oral movements (Bahr, 2001). Oral motor exercises are repetitive drills that rely on conditioning the muscles of the mouth and face (Marshalla, 1999). An example of an oral motor exercise is pucker resistance. This exercise requires the child to close-mouth smile and resist as the child's lips are pushed into a pucker.
There is a considerable amount of professional interest and discussion about whether discrete oral motor activities enhance articulation development (Moore and Ruark, 1996; S. Williamson, H. McDade and A. Montgomery, paper presented at the Annual Meeting of the American Speech–Language–Hearing Association; November 2001; New Orleans, Louisiana; Forrest, 2002). To date, there have been few controlled experimental studies of the efficacy of oral motor therapy for school children with articulation disorders, even though many speech–language pathologists utilize oral motor exercises in articulation therapy (G. Lof, 2001). In one report (C. Occhino and J. McCann, 2001) it was found that there was no improvement in articulation after implementation of oral motor therapy alone but there was improved articulation after a combination of oral motor and traditional articulation therapy. As an extension of that research, the following study examined the efficacy of one oral motor protocol, Easy Does it for Articulation: An Oral Motor Approach (Strode and Chamberlain, 1997), without traditional articulation therapy for children with mild articulation disorders. The research question was whether an oral motor therapy approach done without traditional articulation practice could impact children's mild articulation errors.
Four participants (Table 1) were recruited from a suburban public school district in Connecticut. All four participants were white, English speaking and enrolled in the first grade. All participants passed a hearing screening and their first-grade teachers reported the children had normal academic and cognitive abilities. Prior to this study, their school speech–language pathologist diagnosed all four children as having a mild functional articulation disorder of unknown origin. None of the participants had previously participated in speech–language therapy.
Prior to the study's onset, each child demonstrated adequate oral and speech motor production (that is, single sounds and sound combinations) as rated by an independent second speech–language pathologist using the Kaufman Speech Praxis Test for Children (Kaufman, 1995) and the Oral Speech Mechanism Screening Examination (OSMSE) (St Louis and Ruscello, 2000). The Kaufman is purported to measure oral motor and speech production along a continuum from simple to complex movements. The OSMSE was used to confirm that the structure and function of the participants' oral mechanism was intact. Oral mechanism screenings are common to the practice of diagnosing children's speech disorders (Tyler and Tolbert, 2002).
The children participated in an oral motor treatment protocol taken from Easy Does it for Articulation: An Oral Motor Approach (Strode and Chamberlain, 1997). The treatment protocol included gross motor activities, body positioning, jaw stability, face wake-ups and direct facilitation techniques (Table 2). All of the exercises were completed in three sets of 5 s each except for the gross motor activities, which were completed in one set of five repetitions. One exercise on the protocol, the tongue bite, was initially attempted but did not continue because it was difficult to judge whether the participants completed the exercise accurately.
Across 7 weeks, the four participants had 15 half-hour therapy sessions. The sessions were conducted on an average of two times per week, with a minimum of one therapy session per week and a maximum of three therapy sessions per week. Therapy was conducted in two groups of two children each. Participants 1 and 2 and participants 3 and 4 were grouped, respectively. The first author, a second-year graduate student in speech–language pathology, implemented the treatment protocol. Therapy occurred at the children's school in available school spaces, including the speech therapy room, the art room and the resource room. Therapy rooms consistently offered a quiet setting with no other people in the room. During each session, the participants consistently received verbal praise (for example, ‘you're doing a great job’) and verbal prompts to maintain their attention to the task. Videotaping was conducted randomly throughout the study, during sessions 3, 4, 5, 8 and 9. Inter-rater reliability was determined using an additional speech–language pathologist (the second author). Reliability was calculated using the following formula: agreement/agreement+disagreement×100. Overall, inter-rater reliability was 90.3% for implementation of the treatment protocol (range=85.7–94.8%).
The independent variable for this study was group membership as a child with a mild articulation disorder. The dependent variable was the participants' score on the sounds-in-words subtest from the Goldman Fristoe Test of Articulation (GFTA-2) (Goldman and Fristoe, 2000). The GFTA-2 was used to assess the participants' articulation of the sounds of American Standard English in word-initial, word-medial and word-final position, as well as consonant blends in the initial position. This test is often used to screen articulation (Khan, 2002; Miccio, 2002) and it is reported to have good reliability and validity (Goldman and Fristoe, 2000). An independent speech–language pathologist administered and scored the GFTA-2 and provided an impression about each participant's speech production. A video camera recorded all participants' responses during pre- and post-testing.
Pre- and post-test inter-rater reliability
Another second-year speech–language pathology master's student calculated test inter-rater reliability for randomly selected participants. Point-by-point agreement was calculated by comparing the score obtained by each rater for every item on the GFTA-2. Inter-rater reliability ranged from 0.84 to 0.97.
To examine if differences occurred in the children's speech before and after the oral motor protocol, pre- to post-test comparisons were calculated. The raw scores for the group at pre-test ranged from 4 to 13 errors (mean=9, SD=4.70) and the group had 2–10 errors (mean=6.5, SD=3.41) at post-test. On average, the participants made 2.5 fewer errors at post-test. Given the SDs of the pre- and post-test, these data suggest that the number of errors did not significantly change. In addition, the pre- to post-test difference was consistent with the normal variance of standard scores identified in the standardization of the articulation test itself (Goldman and Fristoe, 2000). Therefore, these data reveal no real difference in the children's speech despite the slight gain noted at the posttest.
The purpose of this study was to corroborate a previous research report (C. Occhino and J. McCann, 2001) about whether oral motor exercises done alone might impact the speech of children with mild articulation disorders. The children in this study had no changes in their speech after a clinical trial based on Easy Does it For Articulation: An Oral Motor Approach (Strode and Chamberlain, 1997). This lack of progress was noted from the opinion of an independent speech–language pathologist and per administration of the GFTA-2.
It is reasonable to suggest that the study's duration (7.5 treatment hours) and the small number of participants (that is, four) were factors associated with the lack of progress. Because speech–language pathologists are expected to make rational clinical decisions based upon clinical judgment and evidence-based practice, it is important to explore why the oral motor exercises in this study did not prove effective.
One reason why the children did not make gains in their speech production was because they were initially found to have intact oral motor skills. While the oral motor exercises were purported to increase oral motor strength (Strode and Chamberlain, 1997), the children did not have difficulty with the strength of their speech. Speech–language pathologists who recommend ostensible strength exercises should first document that the articulation errors are secondary to a lack of strength itself. This may be difficult; Forrest, for example, has already argued that it is unclear how much strength is actually needed for the production of individual speech sounds (Forrest, 2002).
Another reason why gains were not seen in the children's speech was that their speech errors related to placement of the articulators. The children's articulation errors might have been better managed if the treatment approach was more specific to each particular speech error pattern. The Easy Does it For Articulation: An Oral Motor Approach program encourages children to practice a general set of mouth positions that are not specifically tailored to specific sounds or the errors children make when pronouncing the sounds incorrectly. Practicing speech–language pathologists should question how children would generalize discrete oral motor exercises into the actual production of the target sounds.
A third reason why the children did not make gains relates to whether children are better off learning sound production in whole units or discrete parts. A traditional articulation approach has long advocated practicing individual physical movements associated with speech production (Bauman-Waengler, 2004). More recently, it has been suggested it is more effective to learn the complex whole of articulation instead of the discrete parts (Geirut, 2001; Forrest, 2002). Finally, the children may not have shown improvement because their already established sound patterns were past the age in which sound acquisition patterns could be influenced. Forrest (2002) argued that early sound production, not later sound correction, relies on oral motor development and shaping.
Speech–language pathologists should be cautious in recommending oral motor exercises for children with mild articulation impairments. The rationale for using general oral motor exercises for children's articulation errors should continue to be questioned by speech–language pathologists seeking effective strategies to remediate mild articulation errors.
Appreciation is extended to Deborah Sokol, Kathleen Steadman, Jane Hindenlang, Denise LaPrade Rini, Marianne Kennedy, Kevin McNamara and the Graduate Student Affairs Committee at Southern Connecticut State University.
Bahr DC 2001. Oral Motor Assessment and Treatment. Needham Heights, Massachusetts: Allyn and Bacon.
Bauman-Waengler J 2004. Articulatory and Phonological Impairments: A Clinical Focus. 2nd ed. Boston: Allyn and Bacon.
Bernthal JE, Bankson NW 1998. Articulation
and Phonological Disorders. 4th ed. Needham Heights, Massachusetts: Allyn and Bacon.
Boshart CA 1998. Oral Motor Analysis and Remediation Techniques. 2nd ed. Terrecula, California: Speech Dynamics.
Forrest K 2002. Are oral-motor exercises useful in the treatment of phonological/articulatory disorders? Seminars in Speech and Language 23:15–25.
Geirut JA 2001. Complexity in phonological treatment: Clinical factors. Language, Speech, and Hearing Services in Schools 32:229–241.
Goldman R, Fristoe M 2000. Goldman Fristoe Test of Articulation
. 2nd ed. Circle Pines, Minnesota: American Guidance Services.
Hall PK, Jordan LS, Robin DA 1993. Developmental Apraxia of speech: Therapy Clinical Practice. Austin Texas: Pro-Ed.
Johnson SR, Manning DF 1999. Using simple tools in oral-motor therapy. Advance for Speech–Language Pathologists and Audiologists 9:20–21.
Kaufman NR 1995. Kaufman Speech Praxis Test For Children. Detroit, Michigan: Wayne State.
Khan LM 2002. The sixth view: assessing preschoolers' articulation
and phonology from the trenches. American Journal of Speech–Language Pathology 11:250–254.
Lof G (November 2001). Paper presented at the Annual Meeting of the American Speech-Language-Hearing Association, New Orleans, Louisiana: Forrest, 2002.
Marshalla PR 1999. Oral Motor Techniques in Articulation
and Phonological Therapy: Millennium Edition. Temecula, California: Speech Dynamics.
Miccio AW 2002. Clinical problem solving: assessment of phonological disorders. American Journal of Speech–Language Pathology 11:221–229.
Moore CA, Ruark JL 1996. Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research 39:1034–1059.
Occhino C and McCann J (November 2001). Paper presented at the Annual Meeting of the American Speech-Language-Hearing Association, New Orleans, Louisiana.
St Louis KO, Ruscello DM 2000. Oral Speech Mechanism Screening Examination. 3rd ed. Austin, Texas: Pro-Ed.
Strode R, Chamberlain C 1997. Easy Does it for Articulation
: An Oral Motor Approach. East Moline, Illinois: Linguisystems.
Tyler AA, Tolbert LC 2002. Speech–language assessment in the clinical setting. American Journal of Speech–Language Pathology 11:215–220.