Q: I am confused over the term NS-OME (Non Speech Oral Motor Exercises). Some people are saying that we cannot use things like toothettes, bite sticks, whistles, or straws in therapy. I use many things like this in therapy. Shouldn’t we do whatever we can to help our clients learn to make speech sounds?

Your question is a good one.  Yes, we are supposed to use whatever we can to help our clients learn to produce speech sounds.  Van Riper said it like this ––

“Every available device should be used to make the student understand clearly what positions of tongue, jaw, and lips are to be assumed” (Van Riper, 1954. p. 238).

But this ideas has come under criticism today because of the new notion of the NS-OME ––

“Party horns…blow ticklers…bubbles…straws… Items like these are being used across America to treat a wide range of communication disorders… [This] has elicited spirited debate (to put it mildly) among SLPs and communication scientists” (Powel, 2008, p. 374).

Let me help you with this by sharing a section from my next book.  The following is abstracted from The Marshalla Guide to 21^st Century Articulation Therapy, in a chapter entitled “The Tools of Articulation Training.”  I have copied parts of the introduction to that chapter here.  The chapter itself, when the book is published, will contain an extensive list of these tools and how to use them.

The Marshalla Guide to 21^st Century Articulation Therapy

The Tools of Articulation Training

Where did the idea to use an object to train speech movement come from?  Who first advocated these practices?  Is this a modern idea without historical backing?

History

The fact is that the use of objects to teach speech movement is not a new idea.  Van Riper called these the “old traditional methods” (1947, p. 185) and wrote that they have been around for hundreds of years.  He wrote about them in his discussion of phonetic placement methods ––

“For centuries, speech correctionists have used diagrams, applicators, and instruments to ensure appropriate tongue, jaw, and lip placement.  [These] phonetic placement methods are indispensable tools in the speech correctionist’s kit… Every available device should be used to make the student understand clearly what positions of tongue, jaw, and lips are to be assumed”  (Van Riper, 1954, pp. 236-8).

Van Riper said that both verbal descriptions and instruments were to be used in the process of phonetic placement.  In recent decades, however, some writers of modern articulation texts have downplayed the importance of using instruments, and they have focused our attention on using verbal descriptions.  In fact, some textbooks lead one to believe that the phonetic placement method is only about describing speech movements.  But Van Riper’s original writing clearly takes us beyond the simple verbal instruction.  Van Riper said that phonetic placement is the process of using “every available device” to guide speech production.

Van Riper devoted several pages of the early editions of his text to the use of tools in phonetic placement, but apparently he felt clumsy in their use –– “In our experience, they are more dramatic than useful” (1947, p. 187).  Van Riper was the one who drew our attention most solidly to ear training.  He wrote that ear training was the most important aspect of any articulation program.  He said that we always should start the teaching of any phoneme by modeling it –– a process he called the stimulation method.  However, in that same paragraph, the great therapist said that objects must be employed when ear training alone fails.  He wrote, “…when the stimulation method fails, they [objects] must be used” (1947, p. 186).  Van Riper insisted that using objects was a valuable method of teaching phonemes.  He said that these items don’t need to be used when the client succeeds with auditory methods alone, but that objects must be employed when simple model-and-imitate methods are not enough.

Early Tools

When early editions of Van Riper’s book were published, phonetic placement devices were constructed of the only materials available at the time including wood, cotton, feathers, metal, glass (mirrors), paper, cardboard, cloth, rubber, leather, and other natural substances.  Van Riper’s referenced Scripture (1912) for these methods, for Scripture was the first to write about them in the United States.  Scripture described how to use tongue depressors, tooth props, handkerchiefs, rubber hoses, rubber wedges, rubber bulbs, “breath indicators,” metal rods, feathers, tissue paper, toothpicks, pencils, “probes,” “applicators,” “a bent laryngeal electrode,” and a “velar hook made of a rubber pen holder.”  He even used a Bunsen burner to teach clients about airflow (Scripture, 1912, p. 122–172).

In 1925, Borden and Busse published a book of phonetic placement techniques that also was highly recommended by Van Riper.  These New York University Speech Clinic professors discussed a number of probes they called “mechanical intervention and stimulations” (Borden and Busse, 1925, p. 159).  These instruments were constructed of wires, metal plates, wood, and rubber, and were designed to teach the client how to place the lips and tongue for phoneme productions.  Their tools were named as follows ––

• Fricator: A flat metal plate on a handle used to hold the blade of the tongue down.
• Fraenum Fork: A forked metal brace used to push the tongue into position.
• S-Concentrator: A thin, hard rubber tube (like a bent straw) used to achieve midline frication.
• Ladator: An odd-shaped tool used to hold the lips out of the way.
• Ruvator: A flat metal plate on a handle used to hold the back of the tongue down.
• Bent metal tongue depressor: A bent metal object that looked like today’s laryngeal mirror that was used to inhibit tongue’s “tendency to bunch up.”
• Ordinary wooden applicator: A thin wooden stick used to create a narrow central groove of the tongue.

The tradition of using objects in articulation therapy originally came to the U.S. from Europe.  An article published in France in 1965 described a series of tools, called guide-langue, that were being used for speech correction at the time (Borel-Maisonny, 1965).  These were a set of 24 metal tools that were constructed like laryngeal mirrors, first made of metal and later plastic.  Each was comprised of a long thin handle with a shape on the end.  The shapes were of balls and paddles of various sizes, shapes and widths.  The tools were designed to teach jaw, lip, and tongue placement for all phonemes.  The Borel-Maisonny article contains schematic illustrations depicting how to use them to teach phonetic placement.  Borden reminded us of these tools in 1984 ––

“Speech pathologists in France, called orthophonists, carry around with them a tool kit with all sorts and shapes of oral probes for pushing the tongue around and for increasing awareness of tactile sensation in the mouth”  (Borden, 1984, p. 57).

In my thirty years of travel across the US and Canada to teach continuing education courses, I have met scores of international speech-language professionals––therapists from Poland, Germany, France, England, Russia, Brazil, Romania, the Czech Republic, and many other countries.  These professionals invariably approach me during breaks to explain that they were taught phonetic placement methods by using tools back in their home country.  They are confused as to why SLP’s in the United States are not trained in these basic methods today.

Today in the USA

The use of tools in articulation therapy today often gets lumped under the broad heading oral-motor techniques because they are used to guide oral (jaw, lip, tongue, velum) movements or positions for phoneme production.  The term oral-motor simple means “mouth movement.”  Modern textbooks that limit their discussion to only those methods that have been studied under the rigorous standards of today’s research methods have banned these ideas from their pages, or they mention them with obvious skepticism.  But old textbooks on articulation therapy are filled with them, and the methods survive in books with the term oral-motor in their title.  Prominent among these are Oral-Motor Techniques in Articulation and Phonological Therapy (Marshalla, 1992), and Oral-Motor Techniques for Speech Clarity (Rosenfeld-Johnson, 2001).

Many of the old-time phonetic placement methods also have survived in a several books designed to preserve them.  Prominent among these are Eliciting Sounds: Techniques and Strategies for Clinicians (Secord et al, 2007), Sound Strategies for Sound Production (Gilbert and Swiney, 2007), and The Late Eight (Bleile, 2006).

Today’s Tools

The introduction of plastic and vinyl to the production of household objects has caused a virtual explosion in the number of items that might be utilized today for stimulating the movements and positions necessary for phonetic placement.  The SLP practicing in the 21^st century can chose from hundreds of items in order to follow Van Riper’s early directive to use every available device with clients who do not imitate phonemes well.  In essence, we now have tools to teach almost all aspects of respiration, phonation, resonation, and articulation control, from producing voice for a basic vowel, to elevating the back lateral margins of the tongue for an /r/.

Everyday objects are being used in this endeavor.  These include dental floss holders, tongue cleaners, kazoos, baby chew toys, tooth brushes, horns, bubble wands, lip retractors, lip gloss, dental wax, plastic straws, coffee stirrers, whistles, gummy bears, licorice whips, toy harmonicas, eyedroppers, laryngeal mirrors, and many other items.

Professional tools designed to stimulate specific oral movements in speech and feeding have and are being developed as well.  These include, for example, Chewy-Tube®, LifteR®, Toothette®, SpeechBuddies®, Ark Probe®, LipGym®, Jaw Grading Bite Blocks®, and the Z-Vibe®. The old See-Scape® and TalkBack® tools also fit in this category.  And of course, the tongue depressor probably is the most widely used professional tool of them all.

I believe that old-time practitioners who wrote the traditional books would have been thrilled to have the cornucopia of today’s objects available for phonetic placement.  They, like us, were creative and devoted people who would do just about anything to help their clients learn to produce better speech sounds.  It is perhaps unfortunate that some of these procedures have come to be called oral-motor techniques because the new term has caused much confusion and heartache within the profession.  These procedures were never intended to replace traditional articulation therapy methods, as some have assumed, nor were they intended to compete with methods of phonological therapy.  Modern SLP’s, who use a wide variety of toys and tools in their practice, simply have taken the old phonetic placement methods to new heights.  They are using new tools to accomplish old goals devised many years ago for phonetic placement.

Are These Non-Speech Oral-Motor Exercises?

Every writer of the phonetic placement methods, of oral motor techniques, has discussed the use of these toys and tools within the context of a complete articulation therapy program. Compare these quotes from Van Riper, Marshalla, and Rosenfeld-Johnson ––

• 1958:  “The therapist…is attempting to give the case the appropriate location and formation.  As soon as this has been achieved, the therapist stimulates the case with the correct sound”  (Van Riper, 1958, p. 147).
• 1992:  “One does not eliminate other aspects of a client’s articulation or phonological program in favor of doing oral-motor therapy alone. One utilizes oral-motor techniques as one engages in a program of articulation and phonological treatment”  (Marshalla, 1992, p. 16).
• 2001:  “It is a tactile teaching technique which supplements traditional therapy… Please remember that the exercises in this manual do not replace anything you are using now”  (Rosenfeld-Johnson, 2001, p. 1).

The application of tools and toys in articulation therapy today is NOT a process of using “non-speech oral-motor exercises” as has been accused of late (e.g., Powell, 2008; Ruscello, 2008; Lof, 2008; Lof and Watson, 2008; Lass and Pannbacker, 2008).  There is nothing “non-speech” about them.  These methods are expanded descriptions of articulation techniques that have been around for hundreds of years.  These arethe traditional methods.

Unfortunately, when phonology entered the field in 1968 (Chomsky and Halle, 1968; Jacobson, 1968), our focus was turned to distinctive features, and then to phonological processes, and many of the old methods of phonetic placement were ignored as a result.  There even was much discussion that we did not even need the old methods any more.  But the problems of phonetic placement did not go away.  We still had kids with lateral lisps, frontal lisps, and distorted /r/.  We still had kids who could not lift the back of the tongue to produce /k/ and /g/, who could not lift the sides of the tongue for the sibilants’ groove, who could not press their lips together for /p/ and /b/, who could not lift the velum to produce an oral sound, and so forth.  Therapists continued to search for ways to get cooperative movement from the jaw, lips, tongue, and velum in order to achieve their speech targets.

Ideas to facilitate better oral movement for speech and feeding were being described as oral motor techniques in the late 1970’s.  Therapists, like myself, who were combining ideas about articulation, phonology, feeding, dysphagia, orofacial myology, motor speech disorders, neurodevelopmental treatment, and sensorimotor integration, began to teach others how to utilize these methods.  The old phonetic placement methods had been elevated to a new vista that combined articulation with many decades worth of new information about postural reflexes, muscle tone, gradation of movement, stability and mobility, flexion and extension, and other concepts borrowed from motor therapists.  A new perspective of speech movement had emerged and it was called oral-motor.  It was a combination of old ideas about phonetic placement with new ideas about movement itself.

As in all things, the more an idea is spread, the thinner the concept becomes.  By the 1990’s, some speech-language professionals had begun to substitute blowing horns and wagging the tongue for traditional articulation procedures.  This was an error.  One cannot replace good old-fashioned ideas about teaching phonemes or phonological patterns with wagging the tongue or blowing whistles.  Why this error began to occur, I cannot say for certain.  My best guess has been that, for whatever reason, these therapists did not learn traditional articulation therapy well in the first place, and they knew almost nothing about the old phonetic placement methods.  Therefore, when exposed to the new ideas about oral motor techniques, they thought that this was all that articulation therapy was.  But that is an incorrect view.  Oral-motor techniques get the mouth to move better, but they do not substitute for broader ideas about phoneme stimulation.  They are techniques that are used within a program of articulation therapy.  They are used for phonetic placement as well as to help prepare the oral mechanism for the movements necessary for phoneme production.

Despite the lack of university support, countless thousands of SLPs practicing in the North America use certain tools in the training of speech today.  Evidence that these objects are being used widely comes from product catalogues that teem with these items.  These toys and tools are being used despite the fact that very few of them have undergone the rigors of laboratory research considered so important today.  Tremendous controversy on the subject exists as a result.  Researchers cry out for restrictions in the use of such methods while practicing clinicians use what is available to them as always.  Practicing clinicians cannot wait for the research to come in.  They must act in practical and logical ways every day, just as they always have.  Using toys and other objects in therapy is part of the creative process of articulation therapy that was recommended by Van Riper and the other traditional masters ––

“There are no doubt almost as many ways of carrying out these basic principles as there are clinicians” (Van Riper and Irwin, 1958, p. 118).

References

• Bleile, K. (2006) The Late Eight. San Diego: Plural.
• Borden, G. (1984) Consideration of motor sensory targets and a problem in perception. In Treating Articulation Disorders: For Clinicians by Clinicians. Winitz, H. (Ed.) pp. 51-66. Baltimore: University Park Press.
• Borden, R. C., & Busse, A. C. (1925) Speech Correction. New York: Crofts.
  
• Borel-Maisonny, S. (1965) Correction des erreurs motrices de la parole. Reeducaticu Orthophonique, No. 10.
• Bosley, E. C. (1981) Techniques for Articulatory Disorders. Springfield: Charles C. Thomas.
• Chomsky, N., & Halle, M. (1968) The Sound Pattern of English. NY: Harper & Row.
• Gilbert, D. W., & Swiney, K. A. (2007) Sound Strategies for Sound Production. Austin: Pro-Ed.
• Jacobson, R. (1968) Child Language Aphasia and Phonological Universals. The Hague: Mouton.
• Lass, N. J., & Pannbacker, M. (2008) The application of evidence-based practice to nonspeech oral motor treatments Language, Speech and Hearing Services in the Schools, 39, p. 408-421.
• Lof, G. L. (2008) Controversies surrounding nonspeech oral motor exercises for childhood speech disorders. Seminars in Speech and Language 29, 4, p. 253-255.
• Lof, G. L., & Watson, M. M. (2008) A nationwide survey of nonspeech oral motor exercise use: Implications for evidence-based practice.  Language, Speech, and Hearing Services in the Schools, 29, 4, p. 392–407.
• Marshalla, P. (Unpublished manuscript) The Marshalla Guide to 21^st Century Articulation Therapy. Mill Creek, WA: MSL.
• Marshalla, P. (1992) Oral-Motor Techniques in Articulation and Phonological Therapy. Mill Creek: Marshalla Speech and Language.
• Powell, T. W. (2008) “The use of nonspeech oral motor treatments for developmental speech sound production disorders: Interventions and interactions.” Language, Speech and Hearing Services in the Schools, 39, p. 374-379.
• Rosenfeld-Johnson, S. (2001) Oral-Motor Exercises for Speech Clarity. Tucson: Talk Tools.
• Ruscello, D. M. (2008) An Examination of Nonspeech Oral Motor Exercises for Children with Velopharyngeal Inadequacy. Seminars in Speech and Language 29, 4, p. 294-303.
• Scripture, E. W. (1912) Stuttering and Lisping. NY: Macmillan.
• Secord, W. A., & Boyce, S., & Donohue, J., & Fox, R., & Shine, R. (2007) Eliciting Sounds: Techniques and Strategies for Clinicians. NY: Thomson Delmar Learning.
• Van Riper, C. (1958, 1954, 1947) Speech Correction: Principles and Methods. Englewood Cliffs: Prentice-Hall.
• Van Riper, C. & Irwin, J. (1958) Voice and Articulation. Englewood Cliffs: Prentice-Hall.