Barbara Davis, Ph.D.,1 and Shelley Velleman, Ph.D.

ABSTRACT

Children who are performing at a prelinguistic level of vocal

communication present unique issues related to successful intervention
relative to the general population of children with speech disorders.
These children do not consistently use meaning-based vocalizations to
communicate with those around them. General goals for this group of
children include stimulating more mature vocalization types and connecting these vocalizations to meanings that can be used to communicate consistently with persons in their environment. We propose a
means, motive, and opportunity conceptual framework for assessing and
intervening with these children. This framework is centered on stimulation of meaningful vocalizations for functional communication. It is
based on a broad body of literature describing the nature of early
language development. In contrast, nonspeech oral motor exercise
(NSOME) protocols require decontextualized practice of repetitive
nonspeech movements that are not related to functional communication with respect to means, motive, or opportunity for communicating.
Successful intervention with NSOME activities requires adoption of
the concept that the child, operating at a prelinguistic communication
level, will generalize from repetitive nonspeech movements that are not
intended to communicate with anyone to speech-based movements that
will be intelligible enough to allow responsiveness to the childs wants
and needs from people in the environment. No evidence from the
research literature on the course of speech and language acquisition
suggests that this conceptualization is valid.
KEYWORDS: Prelinguistic development, vocalization, language
development, NSOMEs, intervention, generalization

1
Department of Communication Sciences and Disorders,
University of Texas at Austin, Austin, Texas; 2Department
of Communication Disorders, University of MassachusettsAmherst, Amherst, Massachusetts.
Address for correspondence and reprint requests:
Barbara Davis, Ph.D., University of Texas at Austin,
Austin, TX (e-mail: babs@mail.utexas.edu).
Controversies Surrounding Nonspeech Oral Motor

312

Exercises for Childhood Speech Disorders; Guest Editor,

Gregory L. Lof, Ph.D.
Semin Speech Lang 2008;29:312319. Copyright #
2008 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel: +1(212) 5844662.
DOI 10.1055/s-0028-1103395. ISSN 0734-0478.

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Establishing a Basic Speech Repertoire

without Using NSOME: Means, Motive,
and Opportunity

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he goal of this Seminars in Speech and

Language issue is to consider the tenets of oral
motor intervention,1,2 here termed nonspeech
oral motor exercises (NSOMEs), for various
subgroups of children within the large and
varied population of childhood speech disorders. Children who function at the prelinguistic level of vocal development form a significant
subgroup within this population. These
children, and their level of function relative
to linguistic communication, bring unique
challenges to the process of assessment and
intervention for the achievement of optimal
functional outcomes. As such, it is important
to consider their unique clinical needs in evaluating the claims of NSOMEs.
The prelinguistic period generally encompasses vocalization development across the first
12 months of life in typically developing children. Between 12 and 18 months, children
begin the seminal process of attaching sounds
to meanings in early words. At the same time,
they display dramatic growth in using recognizable sounds and syllable types for producing
these word forms. The children we consider
in this article include both children who are
developmentally young and children who are
chronologically older but continue to function
at the prelinguistic stage of vocal development.
Developmentally young children include infants and toddlers identified in the first 3 years
of life who begin clinical intervention very
early. These children are not often capable of
complying consistently with organized therapy
task demands. Stimulating use of the vocal
system for communication must, of necessity,
be embedded in functional communicative routines with familiar communication partners.
Targets include increasing the developmental
level of vocal forms and connecting these forms
with meanings.
Chronologically older children include children with severe to profound levels of speech
delay/disorder who may have auxiliary cognitive, motor, social, or sensory issues underlying

the persistence of prelinguistic levels of vocal

communication. Additionally, there may be no
expectation of normalization to age-appropriate use of the vocal system for linguistic communication. Thus maximization of available
prelinguistic vocal capacities for functional
communication may be an overall clinical goal
for these children.
Although these two subgroups of children
are quite different in many ways, a general
clinical goal for both is to support acquisition
of the components of linguistic communication, the sounds and sequences of sounds that
comprise the building blocks of recognizable
words. Equally important is to scaffold their
ability to use these components for connections
between vocal output and recognizable meanings. The overall goal is to support children in
learning to deploy these connections to meet
their needs.
A basic tenet of NSOMEs2 is that children
will generalize nonspeech movement patterns
(such as licking or feeding) to control of movement patterns for speech sounds and sequences.
Rosenfeld-Johnson2 cautions that production
practice should not begin until all the respiratory, phonatory and articulatory movements
underlying each sound are first learned
(p. 7). Marshalla3 has hypothesized that those
children who do not develop age-appropriate
speech production patterns have unspecified
difficulties during the sensorimotor period
when neural pathways should have been developed. She suggests that a child without normal tactile (active or passive) experiences may
not develop adequate foundations for movements required for development of speech.
From the NSOME perspective, children with
speech sound disorders have unspecified neural
deficits in structure or function that result in
a need to increase strength of peripheral oral
muscles.4 Part-whole training is suggested for
intervention1 to organize and stimulate development of neural connectivity and strengthen
peripheral components of the production

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LEARNER OUTCOMES: As a result of this activity, the reader will be able to (1) summarize the typical course of
vocal development in normally developing and atypical children; (2) explain how speech and language development involves the integration of means, motives and opportunities for communication, and how these can be
clinically assessed and targeted for intervention; and (3) describe specific intervention strategies appropriate to
children at various stages of vocal communicative development.

SEMINARS IN SPEECH AND LANGUAGE/VOLUME 29, NUMBER 4

system before targeting a childs motivation to

communicate, the responsiveness of persons
in the larger communication environment, or
particular sound system goals. At present,
no peer-reviewed evidence is available that
supports any of these basic assertions.5
The general goal of this Seminars in
Speech and Language issue is to review theories
and evidence already available from several
disciplines relative to the neural and motor
development that is the stated target of
NSOME intervention. For children who are
functioning at a prelinguistic level, these
assertions are particularly critical. Clinicians
may assume that lack of the use of the vocal
system for communication connotes neural
compromise and inadequate strength levels,
necessitating NSOME as a critical first
step. Although neural compromise may be a
present and contributing factor in severe levels
of speech delay or disorder, we are referring
here to the assertion in the NSOME literature that a broad set of children with speech
disorders have unspecified neural compromise
that will be remediated specifically through
NSOMEs.
A primary goal of this particular article is
to consider an alternative perspective to the use
of NSOME for establishing a basic speech
repertoire in children operating at the prelinguistic level. In our view, this goal is far more
appropriately addressed in the context of
understanding communication and language
development as based on a complex suite of
child capacities supported by communication
partners to guide the process of language development. The preponderance of research evidence over several years in widely diverse
research disciplines supports the view that
speech and language capacities are acquired as
a process that includes learning to deploy
speech forms (means of communication) to
convey intentions (motives for communication)
to supportive communication partners (opportunities for communication). Ideally, young
children have multiple interactive opportunities
per day that help them understand the need
and importance of using their vocal system to
get what they want and need.
Clearly, speech and language acquisition is
driven by physical maturation and movement,

2008

often the focus of NSOMEs, but equally

importantly it is facilitated by the social and
cognitive capacities of the child. Crucially,
speech and language acquisition does not proceed via the decontextualized practice of
component physical abilities. Children must
deploy those physical abilities for vocalizations
connected with meaning in multiple social
interactions with supportive communication
partners. To accomplish the social component
of communication, children must have the
cognitive capacities for understanding why
they want to communicate and for understanding who to communicate with. In chronologically or developmentally young children who
cannot consistently comply with decontextualized drill activities, embedding assessment
and intervention protocols in natural communication contexts is crucial to building the
means (How?), motive (Why?), and opportunity
(Who?) for optimizing their communication
and language capacities. Fig. 1 illustrates the
triad of components for clinical assessment and
intervention with children operating at the
prelinguistic vocal developmental level.
The clinical hierarchies described in contemporary NSOME intervention guides do not
connect with this broad communication scaffolding for developing a basic speech repertoire.
The varied NSOME activities (e.g., straws,
bubbles, etc.) offer decontextualized practice
on physically repetitive nonspeech movements
not logically connected with the rapid and
varied movements needed for goal-directed
speech-related behaviors. NSOME movements are embedded in stimulating activities.
Strategies that would help the child to bridge
from these nonspeech actions to the planning
and production of sounds needed to build
words are usually not included. The implication
of NSOMEs are that children who are functioning at a prelinguistic communication level
will somehow generalize and diversify the decontextualized nonspeech physical movements,
yielding the complex and diverse speechrelated movements that must be implemented
for functional communication. They must
make the further inference that the physical
requirements of producing speech-related
sounds are connected with the cognitive and
social requirements of coding meaning to get

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314

Figure 1 The communicative triad of means,

motive, and opportunity for structuring assessment and intervention protocols with prelinguistic
children.

what they want and need. No component

in NSOME protocols addresses these critical
pieces of the communication puzzle.
Similarly, no NSOME protocols include goals
for caregiver responsiveness to functional
communications from the child. Motivation
to communicate and opportunities from the
environment to understand the need to
communicate are missing entirely. A recent
NSOME case study6 describes combining
NSOME with other intervention components for a nonverbal child. However, credit
for the childs improvement is assigned to
the NSOME component of intervention.
This lack of exactness in evaluating the precise
contribution of NSOMEs in the context of
diverse and unspecified other intervention
activities must be addressed via the rigor
of evidence-based practice before attributing
improvement to NSOMEs.

CLINICAL ASSESSMENT
For children operating at a prelinguistic level,
the clinician must assess the childs motives,
means, and opportunities for communication to
plan a comprehensive intervention program.
Within the functional communication paradigm for intervention we are proposing here,
there is no rationale for addressing one of
the three components if the other two are not
accounted for. In the context of the present
article, there is no rationale for addressing
means if motive and opportunity are not present

for the child who is using prelinguistic

means of communicating. Additionally, means,
motive, and opportunity must be assessed in
the childs natural environment because these
developmentally young children may not
be able consistently to comply with task
demands. Assessment instruments such as the
Communication and Symbolic Behavior Scales
(CSBS; Brookes Publisher, Baltimore, MD)7
can be used to evaluate children across these
dimensions of functional communication. Our
goal in this short article is not to be exhaustive
in providing a template for assessment but to
illustrate the kinds of questions that must be
answered to plan intervention from a functional
communication-embedded perspective.
The childs motives, or pragmatic intentions, are related to the Why? question about
use of language forms and/or prelinguistic
communication means. This assessment question is addressed through assessment of what,
if any, basic communicative intents the child
is using. Basic communicative intents of requesting, giving, showing, rejecting/avoiding,
greeting, and commenting are central to understanding why the child initiates contact with
his or her environment.
Means, the How? question, must be assessed
in tandem with motives. Here the clinician
must assess how the child accomplishes his or
her motive to communicate. Table 1 lists a
summary of communication means.
A third aspect of the assessment triad for
stimulating communication means in children
functioning at a prelinguistic level is opportunity.
Responsive communication partners are representative of the Who? question for functional
communication assessment and intervention.
Responsivity comprises a basic requirement for
intervention with prelinguistic children. Their
functionally oriented motives and means employed in communication initiations or in response to initiations by others need to be shaped
toward more mature means by responsive
partners. Ideally, responsive partners include a
network of family members, professionals, and
caregivers that encompasses important persons
in childrens environments. The clinical assessment question to be answered in planning
intervention is Who are the key players in
the childs environment who can be consistently

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2008

Table 1 Communication Means for Clinical Assessment

Gestural/Sign

Vocalizations

Nonverbal

Presymbolic

No vocalizations

Eye gaze

Pointing

Pitch or loudness changes

Physical manipulation

Reaching

Vowels only

Other idiosyncratic

Other idiosyncratic
Symbolic

Consonants only
Nonrhythmic syllables

Single gestures

Repetitive syllables

Combined gestures

Diverse syllables

Linguistic signs

child focused as well as consistently responsive

to the childs motives and immature means
to communicate? Second, assessment should
include the ways in which communication
partners are responding to the childs motives
and means for communication. These are some
questions to be asked: How often is the child
successful with the tools at his or her disposal?
What occurs when there are communication
breakdowns? How are communication partners
signaling successful understanding of the childs
message?

CLINICAL INTERVENTION
Once we have determined the childs current
functioning with respect to means, motive, and
opportunity, we then have to design therapeutic interventions that will address areas of
deficit within this framework. Intervention is
designed to target areas of deficit and rely on
support from areas of relative strength. Clearly,
neither NSOME treatment nor speech-based
motor therapy will inspire communication
in a child without either communicative intent
or supportive listeners who can respond to
idiosyncratic attempts at vocal communication.
Therefore, this section considers therapy
approaches for all three of the priority areas.
Because our primary purpose is to contrast
our perspective with that of those who use
NSOMEs, we focus mainly on means. But first,
a few words about motive and opportunity.

Motive and Opportunity

Several intervention approaches have been developed to address motives and opportunities

that are key to supporting communication

development in prelinguistic children. All of
these approaches focus on connecting the
childrens communicative means, which may
not be in the vocal modality, to functional
communication. These include the Hanen
training programs for parents, caregivers, and
professionals,8 Picture Exchange Communication Systems (PECS),9 Prelinguistic Milieu
Therapy (PMT),10 the Social Partnership
Model (SPM),11 and Functional Communication Training (FCT).12 Researchers have documented the progress in means that children
make when their motives and opportunities are
addressed in these programs. Interventions
designed to increase communication during
the prelinguistic stage result in better linguistic
outcomes.8,1316 Thus addressing motive and
opportunity is inseparable from addressing
means.

Means
Because our purpose is to present an alternative
to NSOMEs for developing a basic speech
repertoire in prelinguistic children, the remainder of the article focuses specifically on means.
However, as we have noted in assessment, a
core principle underlying this information is
that motive and opportunity are critical components for diversifying communicative means in
developmentally young children.
For many children who have both motives
and opportunities to communicate, vocal development may still be slow. Varied modes
of nonvocal communication will likely need to
be established first to decrease frustration
and facilitate aspects of cognitive and social

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316

development dependent on interactions with

others. It is well established that providing
an alternative means of communication, such
as basic signs, picture exchange (PECS), or
simple electronic devices, does not decrease
the likelihood that a child will establish oral
communication. Strong evidence suggests that
enhancing a childs overall communicative effectiveness may instead increase oral communication capacities17. Thus augmentative and
alternative communication (AAC) training or
using other augmentative devices does not
constitute giving up on oral communication.
Speech remains a goal even for children
whose primary means of interacting is likely
to continue to depend on nonvocal means.
The backlash against nonspeech motor
treatment has been interpreted as a claim that
motor deficits should not be directly addressed
in intervention.1 This assertion is far from
accurate. As discussed elsewhere in this series,
many successful intervention approaches are
based on principles of motor learning. The key
distinction is whether the intervention targets
speech-related movements. For chronologically
young or developmentally young children, as
with other children with speech sound delay or
disorder, it is necessary to practice on activities
that are as complex and as hierarchically organized as speech to improve speech.18,19
Children with little or no vocal output
have few or no practiced speech movement
patterns to draw on for the production of real
words. To make oral communication effective
for such children, intervention approaches that
build on existing motor representations and
automatize new motor schemas will be most
efficient and successful. Building on existing
motor synergies involves what has been termed
shaping, which involves beginning with a
vocalization that the child already produces
and supporting gradual evolution into a more
specific refined, useful utterance.
How can these new motor synergies be
automatized? Here the principles of motor
learning2022 come into play. Despite their focus
on muscle strength, NSOME approaches typically focus on peripheral aspects of the speech
production system only. Principles of motor
learning go deeper, into the planning and programming of speech production, as well as its

execution. Planning and programming incorporates a cognitive processing component into the
consideration of how to pursue intervention.
The motor learning literature indicates
that enough practice has to be provided so
the motor schema will be available for planning, programming, and executing further
utterances. Developmentally and chronologically young children can be encouraged to
respond more consistently in natural play contexts where motive and opportunity are present
to stimulate use of available means. Therefore,
to maximize the number of uses of targeted
forms per session, activities that incorporate
repetition in a meaningful and playful way
should be used. For example, one can point to
ones toes while repeating toe, toe, toe, toe ten
times or point to the M&Ms in The M&Ms
Brand Counting Book while saying m, m, m.
If a child has communicative intents
(motives) and only produces nonspeech vocalizations, the clinician can begin by attributing
meaning to reflexive or other nonspeech vocalizations. Clearly associating physiologically
based sounds with meaning, such as a grunt
when moving a heavy object,23 a sharp intake
of breath while pretending to touch a toy knife,
or snoring while pretending to sleep, can support the child in connecting communication
with vocal output that is within his or her
capacities. Stimulating the child to use available
nonspeech vocalization capacities to communicate is conceptually different from the practice
of NSOMEs. These stimulations are used in
a meaningful context and incorporate means,
motive, and opportunity for the purpose of
encouraging meaningful oral communication.
Encouragement to attribute meaning to nonspeech behaviors does not pursue the NSOME
goals of strengthening muscles that are already
strong enough for speech purposes, organizing
an oral action that is not useful for talking, or
stimulating a neural connection for nonspeech
that is different from the neural connectivity
associated with speech production. Instead, it
furthers the goal of connecting oral sounds to
meanings.
For children with nonmeaningful prerhythmic or semirhythmic (i.e., marginal
babble) vocalizations, its helpful to pair
vocalizations with rhythmic movement (e.g.,

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bounce on ball) and model canonical babble

(highly rhythmic, with nonspeech rhythm).
Songs and rhymes can be sung/recited using
consonant vowel (CV) syllables in place of
words. Meaning can be introduced by pairing
real-word vocalizations as close to canonical
syllables as possible (CV, vowel consonant
[VC], etc.; e.g., go go go, up up up) with
action and speech rhythm.
For children with meaningful but vowelonly vocalizations, clinicians could start by
modeling meaningful consonant-alone vocalizations (e.g., shhh, mmmm), sound effects
(animal noises, vroom, pouring sounds, etc.),
and words with emotional content and early
emerging consonants, such as glottals and
glides (uh-oh, yeah!, wow, whee,
haha). Tactile cues can help cue for lip
closures. Labial cues are especially easy and
transparent. Once the child is able to approximate some of these, then clinicians can move
on to modeling other words illustrating meaningful CV and VC syllables with early occurring consonants (e.g., [b], [p], [m],[n], [w]).
Homonymy and variability may be characteristic of children who are emerging into the
first use of meaningful word forms. For a child
using homonymy (i.e., the same production for
many different words), there may be a pattern
(template) that the child imposes on words,
such as reduplication or an alternation of alveolar and labial consonants.23 Once a pattern has
been identified, the goal is to make the childs
communicative means more effective by diversifying: shaping his or her vocalizations into
more diverse patterns (e.g., labial-alveolar instead of alveolar-labial) or introducing different
patterns (e.g., CVC for a child who is producing
only CV and CVCV words). For excessive
variability (i.e., many different productions for
the same word), in contrast, the goal is to make
the childs communicative means more effective
by stabilizing vocalization output. Here opportunity is paramount. A major goal is to systematize adult interpretations of child-initiated
attempts by modeling and selective responding.
The message is that consistency matters. This is a
principle that encourages a clinician to consider
means, motive, and opportunity for increasing
the success of communication and moving
toward linguistically based output in children

2008

who are operating at the prelinguistic level of

vocal development.

CONCLUSION
We have presented a functional communication
alternative to using NSOMEs for children who
are operating at a prelinguistic level of vocal
communication. Many speech-language pathologists feel at a loss when it comes to stimulating language in children with severe speechlanguage disorders, especially those who have
no preexisting communicative intent or no
speech-like vocalizations. For these clinicians,
consideration of implementation of NSOMEs
versus communicatively embedded communication is of critical importance as they seek to
deliver efficient and effective services to this
group of children within the larger population
of speech-disordered clients. For researchers,
studying the claims and effectiveness of
NSOMEs provides vital support to understanding the basic nature of speech disorders as well
as supporting best clinical practices. One auxiliary goal of this series of articles may be to
point out areas where researchers need to accept
the charge of evaluating NSOMEs as well
as proposed clinical intervention alternatives
following evidence-based practice guidelines.24

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