Orofacial Myofunctional Disorders in Individuals with a Diagnosis of Down Syndrome
Individuals with Down syndrome are at risk for Orofacial Myofunctional Disorders (OMD) that affect feeding, oral resting posture, and speech clarity. This article by Robyn Merkel-Walsh, MA, CCC-SLP explores how Oral Placement Therapy, Myofunctional Therapy, and targeted TalkTools interventions can improve outcomes across the lifespan.
RMW
Robyn Merkel-Walsh, MA, CCC-SLP
TalkTools Instructor & Orofacial Myologist
8 min read
Key Takeaways
Individuals with Down syndrome are at high risk for Orofacial Myofunctional Disorders (OMD) affecting feeding, oral resting posture, and speech clarity — but these challenges are treatable, not inevitable.
Oral Placement Therapy (OPT) is distinct from non-speech oral motor exercises. OPT uses speech-like tactile cueing and is evidence-supported for individuals with OMDs including Down syndrome.
Four types of tactile therapy — pre-feeding, feeding therapy, OPT, and myofunctional therapy — should be used in combination for individuals with Down syndrome who present with complex oral-motor and feeding profiles.
Tongue protrusion, reversed swallowing, and bruxism in Down syndrome can be addressed with targeted TalkTools hierarchies including the Straw Hierarchy, Horn Hierarchy, and Bite Block programs.
Quick Answer
Orofacial Myofunctional Disorders (OMDs) in Down syndrome include tongue protrusion, low jaw posture, reversed swallowing, bruxism, and open-mouth breathing. These are not anatomical inevitabilities — they are treatable with targeted Oral Placement Therapy (OPT), Myofunctional Therapy, and structured feeding interventions. TalkTools provides a comprehensive framework of tactile therapy tools and hierarchical programs to address OMDs at every stage of development, from infancy through adulthood.
Presentation of the Problem
Individuals with Down syndrome are at risk for what is known as Orofacial Myofunctional Disorders, or OMD. OMDs can impact the oral phase of feeding, oral resting postures, and oral placement skills for speech clarity. OMD issues require tactile therapies, which include Myofunctional Therapy and Oral Placement Therapy (OPT). Myofunctional therapy and OPT are not the same as non-speech oral motor exercises.
The purpose of this article is to differentiate the difference between non-speech movements and speech-like movements in treatment for individuals with Down syndrome, and to explore various types of tactile therapies that may help facilitate progress.
What Kind of Therapy Are We Talking About — and Is It Evidence-Based?
The ongoing question in the field of speech pathology is whether Oral Motor Therapy is evidence-based. Evidence Based Practice (EBP) according to the American Speech and Hearing Association is "the integration of best research evidence with clinical expertise and patient values" (ASHA, 2005). There is a common misconception that EBP is limited to double-blind studies, when in fact EBP is very centered on valuing feedback from the individual receiving treatment and the clinical data collected in therapy.
Clinical Context
Oral-motor therapy has never been debated in cases of oral phase dysphagia or for tongue-thrust disorders. It therefore seems questionable why some experts continuously debate the ethics of these practices in the Down syndrome population, where OMD is highly predictable and treatable.
Another problem is that "Oral Motor Therapy" is a very general term that leads to confusion. Pre-feeding exercises, non-speech oral motor exercises, myofunctional therapy, strengthening exercises, swallowing exercises, oral imitation tasks, and the use of oral speech tools were all being associated under this umbrella term. In 2010, Diane Bahr and Sara Rosenfeld-Johnson wrote a landmark article in Communications Quarterly outlining the critical difference between Non-Speech Oral Motor Exercises (NSOME) and OPT. The major distinction: NSOME are movements unrelated to speech sounds, while OPT includes only speech-like movements (Bahr & Rosenfeld-Johnson, 2010).
OPT follows the principles of Van Riper's Phonetic Placement Therapy (PPT) and uses tactile cueing to help individuals who cannot respond to visual-verbal treatment cues. The International Association of Orofacial Myology (IAOM), founded over 35 years ago, has addressed the need for regulated educational opportunities and credentialing for therapists treating OMDs.
The Importance of Treating OMDs in Down Syndrome: Dispelling the Myths
When a baby is born with Down syndrome, there are common assumptions about craniofacial development, feeding, and swallowing. In 1997, Sara Rosenfeld-Johnson identified the "Oral-Motor Myths of Down Syndrome," which included:
Myths #1–4
Structural & Medical Assumptions
High narrow palatal vault · Tongue is too large for the mouth · Mild to moderate conductive hearing loss · Chronic upper respiratory infections
Myths #5–7
Postural & Functional Assumptions
Mouth breathing · Habitual open mouth posture · Tongue protrusion as a permanent structural feature
Sara Rosenfeld-Johnson referred to these as myths because clinical evidence suggests these issues can be prevented and/or improved with therapeutic intervention. For example, she presented case studies at the ASHA annual convention highlighting improvements in an adult patient with Down syndrome in just one month of OPT.
Despite progress in understanding, clinicians are still frequently faced with complex orofacial myofunctional challenges when treating individuals with Down syndrome, including poor speech intelligibility, tongue thrusting, bruxism, oral-phase feeding deficits, and inappropriate oral habits. It is essential to treat these issues in conjunction with language-based speech therapy.
The Four Types of Tactile Therapy for Down Syndrome
Because of the interconnected nature of OMDs, individuals with Down syndrome may require all four types of tactile therapy. Below is a framework for understanding how each approach contributes to comprehensive treatment:
Type 1
Pre-Feeding / Oral Sensory-Motor Therapy
Exercises introduced to improve jaw, lip, and tongue movements as prerequisites for safe, effective nutritive feedings. A pre-feeding plan is always one step ahead of a feeding plan — building the sensory-motor capacity needed for the next skill level.
Type 2
Feeding Therapy
Focuses on the oral and/or pharyngeal phases of feeding. Involves manipulation of food placement, selection of tastes, temperatures, and textures, and always prioritizes safety. Includes use of therapeutic feeding equipment such as adaptive spoons, cups, and straws.
Type 3
Oral Placement Therapy (OPT)
A specific therapy involving tactile cueing to facilitate the articulatory postures required for precise speech sound production. OPT follows Van Riper's Phonetic Placement Therapy: a therapist facilitates an oral posture with a therapy tool, drills it through repetition, and slowly fades the tactile cue once accuracy is achieved.
Type 4
Myofunctional Therapy
A comprehensive program used to correct the improper function of the tongue and facial muscles at rest, during chewing, and during swallowing. It is essentially a combination of the three therapies above, addressing oral-rest posture, oral habits, swallowing, and speech sound production simultaneously.
Assessment & Treatment Focus: OMD in Down Syndrome
The following table outlines the most common orofacial myofunctional problems observed in individuals with Down syndrome, the recommended TalkTools activity type, and the tactile intervention strategy to address each.
Problem / Observation
Therapy Type
TalkTools Tactile Intervention
Low jaw posture & tongue protrusion during oral rest
Pre-Feeding
Facilitate lip closure using a Jiggler tool placed between the lips to promote active lip seal and jaw elevation.
Reversed swallowing pattern / tongue thrust
Feeding & Myofunctional
Engage in therapeutic straw drinking using the Honey Bear to facilitate jaw stability, lip rounding, and tongue retraction (Rosenfeld-Johnson, 2009).
Teeth grinding (bruxism)
Pre-Feeding, Feeding & Myofunctional
Use appropriate biting activities, chewing, appropriate mouthing activities, and massage techniques (Bahr, 2001). Implement a gum chewing program to facilitate an appropriate replacement for teeth grinding (Rosenfeld-Johnson, 2009).
Interdental lisp
OPT & Myofunctional
Implement activities to superimpose lip closure with tongue retraction in order to improve strength and dissociation of the musculature, such as therapeutic horn and bubble blowing (Rosenfeld-Johnson, 2009; Merkel, 2002). Tools are faded when the oral placement skill is achieved and the individual can produce the target sound without the tactile cue.
Oral habits (thumb sucking, object mouthing)
OPT & Myofunctional
Use the Horn Hierarchy and oral habit replacement strategies; provide oral-motor activities that satisfy proprioceptive needs appropriately.
Weak lip closure / open mouth posture
Feeding & Myofunctional
Implement the Horn Hierarchy to strengthen the orbicularis oris and improve labial seal over the tongue.
Poor speech intelligibility from atypical oral placement
OPT
Apply tactile cueing from the Oro-Trainer series or speech-specific OPT tools to facilitate correct articulatory postures for target phonemes.
Clinical Rule: Treat OMDs in conjunction with language-based speech therapy — never in isolation. When oral-motor function improves, articulation therapy progress accelerates. Studies have shown that remediation of a tongue-thrust disorder through myofunctional therapy can make subsequent articulation therapy achievable in as few as four sessions (Gommerman & Hodge, 1995).
Key TalkTools Strategies for OMD in Down Syndrome
Straw Drinking: Tongue Retraction and Jaw Stability
Therapeutic straw drinking using the TalkTools Honey Bear is a cornerstone intervention for tongue thrust in Down syndrome. The squeeze-controlled flow allows the therapist to grade the amount of liquid, while the straw requires active lip rounding and draws the tongue posteriorly into the oral cavity to generate suction. This directly counteracts the habitual anterior tongue posture and builds muscle memory for correct resting posture. As skills develop, the child advances through the TalkTools Straw Hierarchy, which progressively increases the demand on tongue retraction and jaw stability.
Horn Hierarchy: Lip Closure and Abdominal Grading
The TalkTools Horn Hierarchy is a structured program of blow-horns graded by resistance, designed to strengthen lip closure, develop abdominal grading for respiration, and encourage a posterior tongue position. Blowing requires the lips to seal around the horn and the tongue to retract to channel airflow — both critical skills for individuals with tongue-thrust habits and open-mouth breathing associated with Down syndrome. The Horn Hierarchy is frequently used alongside the Straw Hierarchy as a complementary myofunctional intervention.
Bite Blocks and Bite Tubes: Jaw Stability and Chewing
Low jaw posture and jaw instability are central contributors to tongue protrusion in Down syndrome. When the jaw lacks stability, the tongue compensates by using the lower lip as a resting shelf, perpetuating the forward posture. TalkTools Jaw Grading Bite Blocks provide proprioceptive input to teach symmetrical, graded jaw elevation and reduce jaw sliding. Once basic jaw stability is established, TalkTools Bite Tubes develop the rotary chewing pattern, allowing the tongue to begin lateralizing food without reverting to a forward-protrusion pattern.
Clinical Insight
The problem is not that the tongue is too large — the problem is that it has nowhere stable to sit. Once jaw stability is established through structured Bite Block work, the tongue naturally retracts because it has a secure, stable platform from which to function. Address jaw first; tongue retraction often follows.
The comprehensive TalkTools feeding therapy reference covering oral-motor assessment and treatment frameworks. Includes pre-feeding hierarchies, feeding therapy progressions, and OPT strategies for complex populations including Down syndrome.
MYOTools™ 104: Comprehensive Intervention for the 4 MYODomains™ of OMDs
Virtual WorkshopRobyn Merkel-Walsh
A virtual workshop covering the four MYODomains of orofacial myofunctional disorders: oral rest posture, nasal breathing, swallowing, and chewing. Directly applicable to clinicians working with Down syndrome populations requiring comprehensive OMD intervention.
Oral Placement Therapy (OPT™) — Level 1 Specialist Training
WorkshopFoundational OPT Certification Path
Foundational training in the TalkTools OPT™ framework. Clinicians will learn to differentiate OPT from NSOME, implement the tool hierarchies for tongue retraction and jaw stability, and develop individualized plans for clients with Down syndrome and other complex diagnoses.
What are Orofacial Myofunctional Disorders (OMD) in Down syndrome?
Orofacial Myofunctional Disorders (OMDs) are atypical, adaptive movement patterns of the tongue, lips, and jaw that emerge when normal orofacial function is not established. In individuals with Down syndrome, OMDs frequently include tongue protrusion, low jaw posture, reversed swallowing patterns, habitual open-mouth breathing, bruxism, and inappropriate oral habits. These affect feeding safety, oral resting posture, and speech clarity, but can be significantly improved with targeted OPT, feeding therapy, and myofunctional therapy.
Is Oral Placement Therapy the same as non-speech oral motor exercises?
No. Oral Placement Therapy (OPT) is fundamentally different from Non-Speech Oral Motor Exercises (NSOME). OPT uses only speech-like movements and tactile cueing to facilitate the precise articulatory postures required for speech sound production. This distinction, clarified by Bahr and Rosenfeld-Johnson in 2010, is critical: OPT is evidence-supported for OMDs because it directly targets the oral motor patterns that underlie speech and swallowing function.
Why is tongue protrusion considered a myth in Down syndrome?
In 1997, Sara Rosenfeld-Johnson identified that several assumed features of Down syndrome — including tongue protrusion — are not anatomical inevitabilities but rather functional presentations that can be addressed therapeutically. The tongue is not inherently too large for the oral cavity; rather, reduced jaw stability and low muscle tone create conditions in which the tongue adopts a forward compensatory posture. Targeted OPT and jaw stability work using Bite Blocks can substantially change this pattern.
What TalkTools strategies help with tongue thrust in Down syndrome?
The Honey Bear Cup and the full Straw Hierarchy are the primary tools for tongue retraction. The Horn Hierarchy addresses lip closure and abdominal grading. Jaw Grading Bite Blocks establish the jaw stability needed to give the tongue a secure foundation to function from. These programs are typically used in combination under the framework of A Sensory-Motor Approach to Feeding.
What are the four types of tactile therapy for individuals with Down syndrome?
The four types are: (1) Pre-Feeding / Oral Sensory-Motor Therapy — developing oral-motor prerequisites for safe feeding; (2) Feeding Therapy — targeting the oral and pharyngeal phases of swallowing with therapeutic equipment; (3) Oral Placement Therapy (OPT) — tactile cueing to facilitate articulatory postures for speech; and (4) Myofunctional Therapy — a comprehensive approach addressing oral rest posture, swallowing, oral habits, and speech. Individuals with Down syndrome frequently require all four. Resources: A Sensory-Motor Approach to Feeding.
Where can therapists find training to treat OMDs in Down syndrome?
TalkTools offers a comprehensive training curriculum including workshops, webinars, and online courses. Foundational courses on OPT, the Straw and Horn hierarchies, and myofunctional therapy are available through TalkTools Education. For credentialing, the International Association of Orofacial Myology (IAOM) offers the Certified Orofacial Myologist (COM®) designation for eligible SLPs and dental hygienists.
Conclusions
Individuals with Down syndrome may present with orofacial myofunctional challenges. While some therapists argue that non-speech oral motor exercises are not appropriate for these individuals, experts in tactile therapies have worked diligently to differentiate NSOME from OPT. Evidenced Based Practice is not limited to double blind studies and includes client feedback and therapeutic outcomes. Experts in OMD have provided evidence over the years to support the use of tactile therapies, and the relationship between swallowing and speech. Practicing clinicians are providing more case studies in the research base and most importantly, individuals who have engaged in OPT have positive reports of progress. There is no doubt that more studies need to be performed, and experts in OPT are hopeful to have more support from universities to perform larger group studies.
About the Author
Robyn Merkel-Walsh, MA, CCC-SLP is a speech-language pathologist with over 20 years of experience devoted to oral motor, feeding and OPT. She works full time for the Ridgefield Board of Education, in addition to her private practice and affiliation as a lecturer for TalkTools®. Robyn is the Acting Chair of the Oral Motor Institute and has recently presented a poster session at the ASHA convention.
Originally published in the Down Syndrome Information Alliance. Reproduced at TalkTools Blog.
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Down SyndromeEBPEvidence BasedEvidence Based PracticeFeeding TherapyFrom the ExpertsMyofunctional Therapy/OMDOral Motor TherapyOral Placement TherapyOral Speech TherapyOral MotorOrofacial Myofunctional DisordersSara Rosenfeld-Johnson
