Oral Myofunctional Therapy to Eliminate Tongue Thrust using the SMILE Program by Robyn Merkel-Walsh and Sara R. Johnson (TalkTools)
According to ASHA, Oral Myofunctional Disorders (OMD) is when the tongue moves forward in an exaggerated way during speech and/or swallowing. The tongue may lie too far forward during rest or may protrude between the upper and lower teeth during speech and swallowing, and at rest. Although a “tongue thrust” swallow is normal in infancy, it usually decreases and disappears as a child grows. By age 3 years, a child will typically develop a mature swallow and the tongue thrust is usually resolved. However a tongue thrust may persist due factors such as thumb sucking, cranio-facial abnormalities, allergies, repeated ear infections and Down’s Syndrome. In terms of speech, the most obvious impact of a tongue thrust is during the production of /s/, /z/, /sh/, /ch/, and /j/. The sounds appear distorted and will often attract listener attention due to the atypical quality. In addition, the /t/, /d/, /n/ and /l/ may also appear impacted.
Robyn Merkel-Walsh’s SMILE (SysteMatic Intervention for Lingual Elevation) program is a fun therapy program for tongue thrust or Oral Myofunctional Disorder. I particularly like this program because it is based on Sara R. Johnson’s Oral Placement Therapy. The program utilizes the oral-motor prerequisites (horn hierarchy, straw hierarchy, bite block hierarchy) that forms an essential part of my treatment program for my children with speech production disorders. It combines oral-motor, swallowing and articulation therapy techniques to treat myofunctional disorders.
The program is designed for children 7 years and older. She uses child-friendly terms such as the “Smile Spot” (alveolar ridge), the “Smile Swallow,” (mature swallow), and sad swallow (reverse swallow). The program taps into the meta-cognitive abilities by building the child’s awareness of the “SMILE parts” (cheeks, tongue tip, palate, teeth, lips, etc.).
The lessons are hierarchical, systematic and the progress is measurable. The first lesson includes cheek exercises, while the second targets the lips. The second lesson includes exercises to work on lip seal, lip rounding, lip strength, tone and dissociation. At this point the program also includes articulation drills for lip sounds (/p/, /b/, /m/ and /w/). The third lesson works on building appropriate oral posture at rest. The program uses “cute” illustrations of Mr. SMILE to demonstrate the difference between good oral posture and poor oral posture at rest. The exercises in this lesson use a variety of tools such as a nose flute to establish volitional nasal airflow. This is followed by exercises to maintain lip and jaw closure. The final aspect to this lesson is appropriate tongue placement (at the SMILE Spot) at rest. Lesson four A.K.A. the “Lazy Tongue Buster” incorporates a group of exercises that targets tongue protrusion (as a precursor to tongue retraction), tongue retraction, tongue lateralization and tongue elevation. This lesson also includes the articulation drills for tongue sounds /t/, /d/, /l/, /n/, /k/, /g/. Lesson five targets the oral habits often associated with myofunctional disorders such as thumb sucking, biting fingernails, biting bottom lip, chewing on pencils, leaving the mouth open, and licking lips. The assumption here is that these habits will interfere with developing a new tongue position and a mature swallow. Lesson six is essentially a review of the previous lessons. Lesson seven through ten teaches the “New Swallow” – with liquids and solids. Lesson eleven focuses on making the new swallow a daily habit. This lesson also targets the appropriate placement of tongue for articulation of /s/, /l/, /sh/, and /ch/. Lesson twelve is also a review lesson of all previous lessons. Lesson thirteen and fourteen consist of maintenance exercises for the new swallow and tongue placement to ensure that it is generalized and essentially a part of the child’s daily behavior.
The systematic, simple and well laid out program make it easy and fun for the children and the families to follow. The homework practice charts make it easy to log the children’s performance at home and ensure progress. Overall, I think the SMILE program is complete, holistic approach to remediate oral myofunctional disorders or tongue thrusts.
