Q: I have a 5-year-old client who has a tongue thrust on all the sibilants. She also has ankyloglossia, and is low in tone around her mouth and lips. She has a tonic bite reflex and holds her cheeks very tightly when I brush her teeth. She has sensory issues and is very uncomfortable (although cooperative) during teeth brushing. She tends to have an open mouth position and her lips are oftentimes wet. None of this affects her speech intelligibility. She speaks very clearly and people wouldn’t even know she has a tongue thrust if they closed their eyes. With that said is there any reason in your opinion to clip the tongue? Also, which sound would you start with? She is stimulable for all of them. What kind of oral-motor stuff would be helpful?
I shall comment on each of your points in turn:
The term “tongue thrust” historically has had many meanings. It has meant “frontal lisp,” “reverse swallow,” “infantile swallow,” and “strong thrusting behavior after the swallow.” I assume you mean the first, meaning that the client has a frontal lisp with interdental tongue placement during production of the sibilants. If so, I would engage in therapy procedures to stabilize the jaw, and anchor her tongue at the back-lateral margins, so that the tongue does not slip forward during speech. I also would utilize many other procedures of traditional articulation therapy as outlined in my book called Frontal Lisp, Lateral Lisp.
The presence of the tongue-tie would indicate to me that the client actually does not stick the tongue-tip out during her lisping pattern, but that the tongue-tip actually stays anchored to the floor of the mouth, and it is the body of the tongue that the client bulges or thrusts forward during sibilant productions. I would assume the same is true of her productions of all the other lingua-alveolars: T, D, N, and L. (It would be odd if she did not do the same pattern on these sounds as well because it is an overall movement pattern, not a specific phoneme problem.) I always recommend that these clients be referred for surgery to snip or laser the restricting lingua frenum. The reasons for this are explained in this Q/A posted in February, 2009. Following surgery, I would engage the client in activities to facilitate tongue-tip elevation, such as those posted to this Q/A in November, 2008.
The client is showing signs of oral-tactile hypersensitivity, or tactile defensive behavior. I would work to normalize her responses to tactile sensitivity as described in my book Oral-Motor Techniques in Articulation and Phonological Therapy. Forcing the client to tolerate a difficult oral-tactile experience like tooth brushing is not a good way to normalize oral hypersensitivity. It should cause an increase in negative responses instead. Read my chapter on this issue for a better way to approach this.
By the way, a client with low oral tone usually has oral tactile hyposensitivity, not hypersensitivity. A client with hyposensitivity who reacts negatively and emotionally to oral stimulation like yours (tactile defensive behavior) is having a strong aversive reaction to stimulation because she cannot perceive what is going on in her own mouth. Stop brushing the client’s teeth. This is invasive and terribly irritating, and not the way to normalize sensitivity. Let her brush her own teeth while watching carefully in a mirror. The control and additional visual stimulation will help her handle this activity. Use other activities such as those suggested in my book to help normalize sensitivity. You are not trying to get her to tolerate oral-tactile stimulation. You are trying to normalize her responses.
Low Oral Tone
Low oral tone is part of this client’s overall picture of deficient oral skill. Low tone in the oral mechanism usually results in a low jaw position, a low-and-forward tongue position, and relatively inactive lips. I would engage in activities to increase reactivity of the facial and oral muscles, mostly using resistance.
Doesn’t Effect Intelligibility
A “mild” articulation problem usually does not affect intelligibility. It affects maturation of speech, precision and accuracy of articulation, and the listener’s perception of the lisper. While the client with a lisp can get his verbal messages across, he has not attained the perfection of articulation that will carry him into any and all speaking situations successfully. Speech may sound correct, but it looks bad. This may limit the client’s educational, employment, and perhaps even social opportunities.
Today this view is perhaps a politically incorrect way to discuss articulation errors, but those of you who know me know that I do not accept the philosophy of political correctness. I believe in freedom of speech as guaranteed in our constitution. The blatant fact is that the best speech possible is desirable for most people so that they can be all that they are meant to be. People have expressed this concept since the elocutionists who did so quite boldly and without any constraints upon their opinions. For example:
“Poor creature that lisps! What frightful ungainliness he stamps upon his speech by substituting this blemished sound for S and kindred sibilants! … An intelligent person has no excuse for lacking sufficient energy and perseverance to overcome a defect that makes the speech of the wisest man appear childish and even idiotic.”
You did not say anything about this client’s level of cognition, or her other social-emotional skills. I am wondering if this client is on the autism spectrum, mainly because I am wondering why you are brushing her teeth. All that I wrote above must be placed within the constellation of skills this child has.
If she is on the autism spectrum, then these activities may be inappropriate for her, as they may cause addition social/emotional problems. Please consider what I wrote above to be appropriate for the client with a motor-speech or articulation deficit only, not a client on the autism spectrum.