International Journal of Pediatrics and Adolescent Medicine 8 (2021) 1e4

H O S T E D BY Contents lists available at ScienceDirect

International Journal of Pediatrics and

Adolescent Medicine
journal homepage: http://www.elsevier.com/locate/ijpam

Treatment of speech sound disorders in children: Nonspeech oral

exercises
Abdulsalam Alhaidary
Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh, 11433, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Children with speech disorders need to receive effective services to improve their speech
Received 26 May 2019 intelligibility. A variety of treatments are available, and one of the most commonly used techniques is
Received in revised form oral-motor training, which includes nonspeech oral exercises.
13 July 2019
Methods: This paper conducted a review of the literature on using nonspeech oral exercises to treat
Accepted 17 July 2019
children with developmental speech sound disorders.
Available online 17 July 2019
Results: Despite the popularity of this treatment, the nonspeech oral techniques lack supporting evi-
dence in existing literature. Also, the justification of the proposed rationales for this treatment is being
Keywords:
Nonspeech oral exercises
questioned. Many other speech-based approaches that are supported by research are available for
Speech sound disorders speech-language pathologists. Some have suggested that any oral training and activity should be per-
Speech therapy formed in the context of speech. The appropriate role of nonspeech oral exercises is that they should be
Children ultimately practiced within the context of speech.
Conclusion: Generally, oral training that does not involve speech production should be considered
carefully with respect to a client's speech needs. Thus, further research is needed to examine the clinical
value of using nonspeech oral exercises to treat speech sound disorders in children.
© 2019 Publishing services provided by Elsevier B.V. on behalf of King Faisal Specialist Hospital &
Research Centre (General Organization), Saudi Arabia. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction of nonspeech oral exercises for treating developmental speech

The goal of speech intervention is to maximize a child's
communication skills by improving speech intelligibility [1]. To
achieve age-appropriate skills or a child's potential level, speech-
language pathologists (SLPs) apply different therapeutic ap-
proaches when treating children with speech sound disorders.
These children have difficulty with speech sound production due to
deficits at the linguistic or/and motoric levels of speech production
[2]. One of the most commonly used techniques is oral motor
training, which includes nonspeech oral exercises. About 67%e85%
of SLPs use such exercises to treat speech sound disorders [3e5].
However, the application of nonspeech oral exercises as an inter-
vention for speech difficulty continues to be controversial [6e8]. By
focusing on children with speech sound disorders who have a
normal developmental profile (e.g., with respect to intelligence,
emotions, behavior, and social skills), this paper reviewed the uses
E-mail address: aalhaidary@ksu.edu.sa.
Peer review under responsibility of King Faisal Specialist Hospital & Research
Centre (General Organization), Saudi Arabia.
sound disorders. These speech difficulties occur during the normal
period of speech-sound acquisition in the age range before 9 years
old. This pediatric population with speech sound disorders usually
comprises the highest number of cases seen by SLPs [1].
2. Defining nonspeech oral motor exercises
Typically, oral motor training has been incorporated into many
treatment protocols. Speech sound errors are the result of difficulty
with speech motor skills (i.e., difficulty with the mechanism for
producing speech) and/or linguistic knowledge (i.e., difficulty with
phonological rules) [9]. Clinicians may include oral motor training
in treatment plans in which the motor component of speech pro-
duction is involved, and such training may be conducted with or
without speech sound production. Nonspeech oral exercises may
be defined broadly as any nonspeech activity that is used to train
orofacial structures to improve sensory integration, motor coordi-
nation, and muscular strength [10,11]. This definition highlights the
term nonspeech, which suggests that training does not demand
speech sound production. Examples of these exercises are shown in
Table 1.

https://doi.org/10.1016/j.ijpam.2019.07.008
2352-6467/© 2019 Publishing services provided by Elsevier B.V. on behalf of King Faisal Specialist Hospital & Research Centre (General Organization), Saudi Arabia. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
2 A. Alhaidary / International Journal of Pediatrics and Adolescent Medicine 8 (2021) 1e4
Table 1
Examples of nonspeech oral activities.
Jaw stability and strength exercises (e.g., biting small rubber or plastic objects)
Lip exercises (e.g., closure, rounding, protruding)
Tongue exercises (e.g., elevation, spreading, retraction, wagging, pressing)
Sucking thickened fluids with straws
Chewing objects made of rubber
Blowing (e.g., horns, bubbles, balls)
Oral massage
Oral brushing
Icing of orofacial muscles
Cheek puffing
Whistle blowing
Several rationales support the application of nonspeech oral
exercises. For example, the first key rationale is to strengthen the
weak oral muscles (jaw, lip, and tongue) that are associated directly
with speech sound production. This rationale is a common claim
[3], and it is assumed to be easily diagnosed by many SLPs [12]. The
second key rationale relates to decomposing complex behavior
(speech) into smaller components (nonspeech oral gestures) to
facilitate learning. The structure of practice underlying nonspeech
oral exercises is known as part-whole training, which is assumed to
reduce the cognitive loads and unneeded practice that in turn fa-
cilitates learning [13]. The third key rationale for using nonspeech
oral exercises relates to the notion that speech emerges from other
oral motor behaviors such as chewing [10]. It is assumed that a
successful training program needs to follow a normal pattern of
development by enhancing the precursor skills (nonspeech oral
movements), which in turn improves the basic oromotor control
skills needed for speech tasks [14]. About 60% of SLPs use
nonspeech oral exercises because they assume that speech de-
velops from early nonspeech oral behaviors [3]. The last key
rationale for using nonspeech oral exercises is that they prepare
articulatory muscles for speech training [10]. About 65% of SLPs
have reported using these exercises as a warm-up activity [3].
Nevertheless, these rationales for using nonspeech oral exer-
cises have been challenged, for example, with respect to the
strengthening of weak oral muscles, concerns have been raised
related to subjective judgments of muscle strength. Tongue
strength commonly is assessed by applying an opposing force with
a tongue depressor. This subjective determination of muscle
strength is not a valid means for making clinical decisions about
whether to strengthen an assumed weak muscle, and subsequently
to measure potential gain. Also, a strong oral muscle may be un-
necessary due to the low amount of strength that is required for
normal speech tasks [10,15]. With respect to the part-to-whole
training rationale, the speech motor literature does not support
the superiority of either “whole” or “parts” training of the multiple
movements involved in the production of a target speech sound
[13]. Furthermore, with respect to the emergence of speech from
other oral motor behaviors, the divergence between speech and
early primitive behaviors (e.g., chewing) has been documented at a
very early age [16]. which suggests that nonspeech oral motor be-
haviors are not precursors for speech. For example, the mandibular
coordination of 15-month-old infants during speech (babbling and
spontaneous speech) is distinct from nonspeech behaviors (chew-
ing and sucking) [17]. Also, muscle warming-up may not be
required for normal speech because only a low force of oral muscles
is used [3]; for example, only 20% of the inter-labial force is used for
the production of labial sounds such as/b/ [18].
3. Research report on nonspeech oral exercises
The application of nonspeech oral exercises to treat children
with speech difficulties has been reviewed in several studies that
highlight the lack of efficacy data to support the use of these ex-
ercises e.g. [6,11,19e22] Forrest and Iuzzini [23] compared
nonspeech oral intervention to traditional intervention for children
with speech sound disorders (ages 3;3 to 6;3 years). The nonspeech
oral exercises included warm-up, facial stimulation, and tongue
strengthening, whereas the traditional therapy included training of
target sounds in words. Their findings showed that the difference in
the outcomes of the two approaches was significant. The traditional
intervention resulted in a 30% increase in the accuracy of target
sound production compared to only to a 3% increase for the
nonspeech oral exercises. In another study, Lass and Pannbacker
[19] evaluated the quality of the level of evidence provided in
studies (from 1981 to 2006) that focused on the use of nonspeech
oral intervention. Their research located 45 studies/reports, of
which 20 were published in peer-reviewed journals. Overall, the
reviewed studies reported no evidence to support the use of
nonspeech oral exercises to treat speech sound disorders in chil-
dren. For example, Guisti-Braislin and Cascella [24] found that four
first-grade children with speech sound disorders, who had a
normal oral mechanism, achieved a mild (not significant) gain
following nonspeech oral motor therapy. Polmanteer and Fields
[25] examined the effectiveness of NS-OMEs for treating SSD in
preschoolers. Although they reported positive outcomes, this study
had many flaws, such as an unequal severity distribution in which
children who received speech therapy were more severely
impaired than those who received nonspeech therapy. Other
studies that reported the effectiveness of using nonspeech oral
exercises focused solely on voice quality or nonspeech behaviors,
rather than speech sound production [26,27].
In addition, Lass and Pannbacker [19] reported that the evidence
for using a combined treatment approach (nonspeech oral exer-
cises and traditional therapies) is limited. The level of evidence in
the 25 reports that provide evidence for treating speech sound
disorders using a combined treatment approach was not strong,
since it was based on expert opinions (e.g., textbooks, manuals of
commercially available programs). Even though these reports
showed limited effectiveness, it is unclear whether the gain is
related to the nonspeech oral exercises or to the traditional speech
therapy. Also, it is common for SLPs to report positive outcomes
following the application of nonspeech oral exercises; however,
many of them tend to use nonspeech oral training with other
traditional speech approaches. About 93% of SLPs use a combina-
tion of approaches [3], which makes it difficult to determine
whether the speech gain is due to nonspeech training or the other
speech therapy [28]. Furthermore, the findings concerning using
nonspeech oral exercises to improve nonspeech behaviors may not
be considered to be clear evidence for treating speech sound dis-
orders with nonspeech oral exercises because the aim of using
nonspeech oral exercises is to improve nonspeech behaviors (e.g.,
feeding, oral pressure, and nonspeech oral movements), rather
than to treat speech sound disorders [19].
Furthermore, Williams, Stephens, and Connery [29] claimed
that conclusive supporting evidence for nonspeech oral exercises is
simply not available at this time and suggested that such training
should not be disregarded because it is popular among SLPs. While
this is true to some extent, the selection of the best available
treatment depends on three factors: clinical experience, a client's
characteristics, and research. Among these three factors, high-
quality research is the most important [28]. Clearly, research sup-
porting the use of nonspeech oral exercises is lacking, but many
other research-supported approaches are available to SLPs [15]. For
example, Gierut [1] conducted a review of the treatment efficacy for
functional phonological disorder. The search included 64 efficacy
studies published from 1980 to 1995, which reported positive
 A. Alhaidary / International Journal of Pediatrics and Adolescent Medicine 8 (2021) 1e4
outcomes for treating speech sound disorders. None of the 64
studies included nonspeech oral exercises. Moreover, Baker and
McLeod [30] evaluated the level of evidence provided in 120 pub-
lications on the treatment of children with speech sound disorders
using speech-based approaches. Similar to the studies that Gierut
[1] reviewed, these studies did not use nonspeech oral exercises,
and about 45% of the studies reported a strong evidence level for
speech-based approaches to treat speech sound disorders [30].
Thus, the scientific evidence supported using a speech-based
approach.
4. Role for nonspeech oral exercises
Parents, children, and SLPs have little time in the clinic, so ses-
sion time should be used wisely by selecting therapeutic tech-
niques that are effective and efficient. The assumption is that by
working on nonspeech oral exercises before teaching speech sound
production, the intervention time period can be reduced and pos-
itive outcomes increased [31]. However, this assumption is not true
with respect to the findings of the current literature, which sug-
gests that speech-based interventions, without using nonspeech
oral exercises, yield positive outcomes [21], whereas nonspeech
oral interventions lack sufficient evidence to support their effec-
tiveness [19,22]. Thus, a question is raised regarding the appro-
priateness of using valuable session time on techniques that do not
induce real changes in speech. When an intervention concerns
speech sound disorders in a pediatric population with a normal
developmental profile, SLPs should not list one of their short-term
goals as achieving nonspeech tasks because the supporting evi-
dence is still lacking. As indicated previously, with respect to this
population, many other therapeutic techniques have been proven
to be effective training for speech sound disorders. For example,
speech motor approaches may be used to treat sounds in increas-
ingly complex speech contexts (e.g., isolation, syllables, and phra-
ses) through repetitive drills that focus on articulator placement
and movement during speech production [9].
In brief, the appropriate role of nonspeech oral exercises in
treating developmental speech sound disorders is that they should
be practiced within the context of speech, since training tasks
should be similar to target behaviors [32]. However, nonspeech oral
exercises may be used with such a population as an activity to
clarify instructions regarding specific sound production, such as
blowing bubbles to demonstrate lip rounding [33] or to make the
beginning of a session attractive to a child [15]. Also, if used as a
speech treatment, nonspeech oral exercises should be regarded as
exploratory rather than evidenced-based techniques [22].
5. Conclusion
This paper conducted a review of the literature on using
nonspeech oral exercises to treat speech sound disorders in chil-
dren who have a normal developmental profile. It found that these
nonspeech oral techniques lack supporting research, and that their
theoretical justification is being questioned as irrelevant to speech
that is distinct from nonspeech behaviors. Oral motor training
should be performed in the context of speech. Speech-language
pathologists are encouraged to base their assessment on
evidenced-based research, their client's needs and wishes, and
their own clinical experience supported by theory [28]. Further
research is needed to identify the clinical value of using nonspeech
oral exercises to treat speech sound disorders in children.
Declarations of interest
None.
3
Acknowledgment
The author appreciates the support of the Deanship of Scientific
Research at King Saud University. The author also expresses his
gratitude to the anonymous reviewers of the earlier versions of the
manuscript. The author declares no competing interests.
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