Tongue-Tie: A complex issue requiring careful assessment

ByLondon Speech and Feeding September 27, 2024September 29, 2024

Tongue-tie, or ankyloglossia, is a condition where the lingual frenulum, the thin piece of tissue that connects the underside of the tongue to the floor of the mouth, is too short or tight. Tongue-tie is quite common in babies and is often not detected after birth. Tongue-tie can lead to a difficult start with breast feeding as it makes it very difficult for the baby to latch effectively.

In my clinical experience as a feeding therapist, I have seen many babies who were not able to latch well due to the frenulum being tight. In many cases an experienced feeding speech therapist/lactation consultant can really make a difference and help a new mum to latch the baby even though the tongue is tethered to the floor of the baby’s mouth. In some cases the frenulum can be divided and once this has been done, in some cases, feeding improves immediately or soon after the division. But this is not always the case. I have seen several babies who have had as many as four tongue-tie divisions and feeding was still difficult.

It is important to say that while tongue-tie can sometimes impact speech and feeding, it’s important to note that it’s not always the root cause of these difficulties. In recent years, there has been a surge of interest in tongue-tie division surgeries, with some cases being unnecessary. It’s crucial to understand the complexities of tongue-tie and the role of speech therapy in addressing related challenges.

The impact of tongue-tie on speech and feeding

When tongue-tie is severe, it can interfere with the tongue’s ability to move freely, affecting speech production and swallowing. Some common speech and feeding difficulties associated with tongue-tie include:

Feeding difficulties: Challenges with sucking, chewing, and swallowing.
Drooling: Excessive drooling due to difficulty controlling saliva.
Speech problems: Difficulty producing certain sounds, such as /l/, /r/, /t/, /s/ and /d/.

The importance of comprehensive assessment

Before considering any surgical intervention for tongue-tie, it’s essential to undergo a thorough evaluation by a qualified speech-language therapist (SLT). An SLT can assess the severity of the tongue-tie, its impact on speech and feeding, and determine if surgery is necessary.

Functional assessment: The SLT will assess the tongue’s range of motion, its impact on speech sounds, and the child’s overall oral motor skills.
Feeding evaluation: The SLT will observe the child’s feeding patterns and identify any difficulties related to tongue-tie.
Differential diagnosis: The SLT will rule out other potential causes of speech and feeding difficulties, such as apraxia of speech, dysarthria, or sensory processing disorders.

The role of speech therapy

Even in cases where tongue-tie is present, speech therapy can often be highly effective in addressing speech and feeding difficulties. Here’s how speech therapy can help:

Articulation therapy: Targeting specific speech sounds that may be affected by tongue-tie.
Childhood Apraxia of Speech (CAS): if the diagnosis by the SLT has shown that in fact the child has motor planning difficulties then there are very specific and effective treatment programmes that help with this and can make a real difference over time.
Feeding therapy: Strategies to improve swallowing, chewing, and oral-motor skills.
Sensory integration: Addressing underlying sensory processing issues that may contribute to feeding difficulties.

London Speech and Feeding Case Study: The importance of comprehensive assessment

One of my clients was initially diagnosed with tongue-tie and recommended for surgery at the age of eight years old. His speech had been perceived by parents and teachers as ‘mumbled and unclear’.

However, after a thorough evaluation, I was able to determine that the child’s primary issue was apraxia of speech, a neurological disorder that affects motor planning for speech. Parents decided to wait with surgery and trust my judgment and we proceeded with weekly intensive speech therapy to address motor planning difficulties around tricky sounds and words. I am delighted to say that the child’s speech has improved significantly, demonstrating the importance of comprehensive assessment and individualised treatment. He is no longer seen as a candidate for an operation, which would have been traumatic for him at his age and, as it turned out, entirely unnecessary.

Below is a short video clip of my working on the /l/ sound with this child.

Using the Gingo Puppet from GingoTalk

Conclusion

Tongue-tie is a complex issue that requires careful evaluation and individualised treatment. While surgery may certainly be necessary in some cases, it’s essential to consider the potential benefits and risks. Speech therapy can be a highly effective approach for addressing speech and feeding difficulties associated with tongue-tie, even in cases where surgery is still required. By working with a qualified speech-language therapist, parents can ensure that their child receives the best possible care and support.

Please feel free to contact me.

Sonja McGeachie

Early Intervention Speech and Language Therapist

Feeding and Dysphagia (Swallowing) Specialist The London Speech and Feeding Practice

The London Speech and Feeding Practice

Find a speech and language therapist for your child in London. Are you concerned about your child’s speech, feeding or communication skills and don’t know where to turn? Please contact me and we can discuss how I can help you or visit my services page.

Echolalia · Speech and Language Therapy

What Is Echolalia And Does It Have A Function? How Can Speech Therapy Help With Echolalia?

ByLondon Speech and Feeding January 11, 2022January 31, 2023

Echolalia is a term used when assessing or treating children with Autism. The term refers to the repetition or echoing of utterances, either our own or others’. It can also be echoing phrases heard on television, advertising jingles or catchy repeat phrases used in tv programmes or nursery rhymes and songs. Whilst we all use echolalia occasionally and it can be observed in typically developing children, we tend not to see/hear it beyond the age of 2.5 years old. Children with ASD, however, do use echolalia often into late childhood.

There are generally two types of Echolalia:

Immediate echolalia

Here the repeated phrases or words are produced immediately after someone has spoken the original words or within two conversational turns of the original utterance.

Delayed echolalia

The repeat echoing of the original utterance occurs sometime later, more than two conversational turns or with a much longer time delay. Due to the delay it can be hard to interpret the meaning of the echolalic utterance as it may refer to something that happened long ago and in a different context to the originally utterance.

(Stiegler, 2015, Fay 1967, Blanc 2014)

There are other unconventional speech behaviours which include:

Perseveration of Speech – persistent repetition of speech
Repetitive questioning – persisting even though answers were given
Vocalisations such as: humming, whistling, clicking, squealing etc.

Much research has gone into the meaning and treatment of Echolalia and the following list consists of possible functions that have been identified:

Information sharing
Responding to answers
Labelling
Drawing attention to self
Protesting
Requesting
Giving instructions
Self-regulation, calming

(Stiegler 2015, Prizant 1983)

Echolalia does have a function and is part of the Gestalt Learning Process (where longer units of speech are memorised and then used as a whole without the individual words being meaningful).

As a Speech and Language Therapist I promote sound and proven Intervention based on the Hanen Programme which helps provide a highly facilitative Interaction Style and I will tell you a bit more in my next blog how the “More Than Words” approach can help children with echolalia move through their Gestalt Learning into more analytic processing of language, grammar and meaning.

Lisp · Speech and Language Therapy

Succeed with lisps at London Speech and Feeding

ByLondon Speech and Feeding January 6, 2023February 10, 2023

A child is on the right-hand side, touching their lips and holding a mirror. They're facing an adult on the left hand side, also holding their hand to their lisps. — Mirror game

You may notice that your child or young person finds certain sounds difficult to produce. With a lisp, the sounds /s/ and /z/ are more problematic. You may notice that your child’s speech is affecting their confidence. They are quiet, and the teacher reports they don’t engage in classroom conversations. You feel it’s impacting on their social and emotional wellbeing. The good news is that with the support of a Speech and Language Therapist and the determination and motivation of your child, we can treat a lisp can.

You feel you have so many questions and you don’t know where to begin. Let’s start by answering some of the most frequently asked questions.

1. Is it normal for my child to have a lisp?

It’s important to remember that we can expect a lisp in a child up until four and a half years of age.

2. Can I do anything for my child’s lisp?

The best approach you can take is to provide a good model. You can show the correct sound and you can talk about where in the mouth your tongue or lips are. Your Speech and Language Therapist can recommend you on what you can say.

3. Should I wait to see if my child’s lisp resolves on its own?

As always, early intervention is advised as producing sounds as a lisp can be more ingrained the longer your child waits for therapy. It is true that some children’s lisps resolve on their own.

Therapy depends on many factors, one of which is deciding on whether your child is ready for therapy. It’s best to seek advice from a qualified Speech and Language Therapist about whether your child is ready for therapy. It takes motivation, determination, and practice.

4. What should I expect from a Speech and Language Therapist when they see my child?

Your Speech and Language Therapist will ask you as parents and carers about your child’s history. This is because they’ll want to confirm it is a lisp and no other areas of communication are affected. They may ask your child about the impact of their lisp on them (if your child is aware of their speech difficulty).

They will then assess your child using a speech assessment. Your Speech and Language Therapist will confirm their findings and will put a plan in place with you.

5. How will my child’s therapist fix my child’s lisp?

The start to fixing any sound is looking at discrimination between the sound your child is making vs the correct sound. Can your child hear the sound they should be making?
Your therapist may still get your child to discriminate two sounds. They will begin to work on the sound in isolation, so saying the child’s tricky sound by itself (e.g., /s/)
Then they will ask your child to say their tricky sound with a vowel, with a breath between the consonant and the vowel (e.g., s-oo, s-ow, s-ee, s-aa, s-ai)
Your child will then remove the gap between (e.g., soo, sow, see, saa, sai)
Your child will then be ready to move onto consonant-vowel-consonant words (e.g., sat, sit, seen, sown)
Your child’s therapist will tell that the next step is to produce sentences using your child’s tricky sound, /s/ in this example (e.g., Simon says silly sausages)
Your child is working towards generalising their ability but there are a few steps before this happens
Choose a context where your child can practise their talking, focusing on one sound (e.g., during 10 minutes of special time). This is an ideal environment as you can create opportunities for your child.
The next stage is saying the sounds correctly in general conversation
You’ll want your child to be less reliant on you for modelling the sound, so you’ll want to start to phase this out
It’s important for your child to self-correct and self-monitor. Encouraging this is the final stage to correcting your child’s lisp.

You and your child will need to be motivated, as it’s true: practice makes perfect!

For support on speech sound difficulties, feel free to contact me.

Speech and Language Therapy · Top tips

Explore the world of speech sound therapy for young children

ByLondon Speech and Feeding June 21, 2023May 31, 2023

Many parents who come to the clinic voice with the concerns about their child’s “speech”. On assessment we discover that actually besides the words not being clear what we most often don’t see is “language” (putting words together to request something for example). And we don’t see “social communication” (waving bye with a smile for example). So what is perceived as “speech” is much more than just not saying the speech sounds correctly. It might be that we need to increase the child’s vocabulary and language so that we can target specific speech sound patterns.

We’ll guide you through some of the most frequently asked questions.

What is the difference between speech and language?

Language is how we put words together (e.g., the cat ran up a tree). For non-verbal children this might be how gestures and symbols are put together. Both will put these into a meaningful context. Language needs to use either speech and/or gestures or signs or pointing to symbols in order to come into being. It needs words, either spoken or written, put into grammatical order so that thoughts can be expressed adequately: about the here and now, about what he had for breakfast this morning or what we are going to do this coming weekend. We put words together to express our feelings and thoughts. Speech is one aspect of this very complex process.

Speech is the specific sounds that make up a word (e.g., the sounds in fish are /f-i-sh/).

Some children are delayed in their speech but will catch up with their peers’ development with time. Others may be using disordered speech sound patterns. If you’re unsure, contact your Speech and Language Therapist as early intervention is vital. It might be that you’re given activities to carry out at home. Or a direct therapeutic intervention may be required, along with regular practice at home. The approach depends on your child and how they learn best.

When might your Speech and Language Therapist recommend direct Speech and Language Therapy?

There are several reasons why your child may need intervention to support their communication. Some of these include:

When they produce vowels incorrectly
When a child has significantly fewer consonants than they should have by their age
Error patterns that are not following a typical process
Fewer word approximations
When a child is ready for speech therapy. That is to say, when we can target speech production through interactive play but most often speech is targeted through repeated activities which focus on a few sounds or words at a time. For this to work ideally a child does need to be able to sit at a table and take part in the activities and games.

How can I work on speech and language targets at the same time?

You’ll want your child to be engaged in activities. It’ll need to be in short bursts to keep their attention. Let’s say you’re focusing on the /p/ sound. You may get a bag with objects and items with /p/ in them. Speak to your child’s Speech and Language Therapist about what position in the word they are targeting now.

Sing the ‘what’s in the bag’ song. Pull out each item in turn and emphasise the sound that you are working on such as “it’s a fox, ffffox”. You can then comment on what the fox is doing, or what they look like (e.g., look at this fffurry fffox. It’s very fffriendly. Oh, the fffox is running).

This activity gives you the opportunity not only to build vocabulary but also to expose your little one to a good model of speech sounds.

“I’m concerned my child won’t sit through the assessment”

This is a common concern. Don’t worry. If your child is not able to sit through an assessment then we usually offer play-based assessment. This means it is activity focused and can be wherever your child feels most comfortable; this is usually on the floor. It is often best to see children in their own homes or even nursery places where they can roam more freely and where they feel most comfortable. On reading the filled-out parent questionnaire we can decide whether a home visit/nursery visit or a clinic visit might work best for your child.

You will be guided all the way through from assessment to intervention and beyond. So, you’ll leave feeling empowered and confident to get started!

Contact Sonja for support with your child’s speech.

Games · Speech and Language Therapy

Explore seven activities to encourage speech development in school-aged children

ByLondon Speech and Feeding February 6, 2023February 10, 2023

Explore seven activities to encourage speech and language development in school-aged children — Encourage speech and language development in school-aged children

We hear too often parents ask, “what do I need to buy so I can support speech skills at home?” The advice I give is to use what you have at home; you don’t need specific toys or equipment. I’ll give you some ideas so you can adapt them for your child or young person’s interests.

Ensure you know which level your child is working at (e.g., sound level, consonant + vowel, consonant vowel, word, sentence, or generalisation level). If you’re unsure ask your child’s Speech and Language Therapist. The more practice your child has, the better, so practise little and often.

1. Bubbles

Explain to your child that you will play a game. You’ll take it in turns to say their tricky sound and practise at whichever level they are working at/towards.

2. Pop up pirate or similar

Explain the rules of the game to your child (as above). You could stick a picture to each of the swords for variety or stick photos on different characters beginning with their tricky sound. This would be particularly helpful if they are struggling for motivation.

3. ISpy

This is a great game where you can involve the whole family and you can even play it to and from school. Choose their tricky sound and everyone takes it in turns to say “ISpy with my little eye something beginning with [insert tricky sound]”.

4. Hide and seek with words

Explain to your child that you will hide pictures around the room. They will cover their eyes and will be told when they can look. Then they become a word detector and search for the pictures. After they’ve found each one, they are to say the sound (at whichever level they are working at).

5. Name 10!

Your child will name 10 words beginning with their tricky sound. Your Speech and Language Therapist will be able to give you the words at the level they are working at.

6. Sound focused game – silly sentences!

Your child will make silly sentences beginning with their tricky sound. E.g., if your child’s tricky sound is /s/ a silly sentence might be ‘Simon sat on sizzling sausages this Saturday’. Take turns to create them. Allowing your child to hear the correct sound is important for their production skills.

7. Throwing a beanbag on the correct sound

Have their tricky sound and the sound they make placed on the floor. They can use a beanbag or a ball to throw or place on the sound which you produce. Explain what you expecte them to do. Use specific praise (e.g., you listened well).

You can adapt all the above activities to meet your child’s needs. Please feel free to contact me should you need any further advice. I’m here to provide support, reduce your overwhelm and empower you to support your child’s speech and improve their communication. This will in turn reduce their frustration.

Speech and Language Therapy

My child is very hard to understand! How can Speech Therapy help?

ByLondon Speech and Feeding August 2, 2021January 31, 2023

There are many reasons for speech sound delay or disorders and the first step is a thorough assessment.

What does a Speech Assessment look like?

With younger children, around 2 – 2.5 years we often start by collecting a good speech sample during play or general chatting. Sometimes we do this with an audiotape so that we are able to listen to your child’s speech sounds repeatedly in order to determine any speech error patterns. A good way to get a speech sample is looking at a favourite book together and trying to get your child to name as many items, animals or characters as possible in the book. For older children, 4.5 years plus we do more formal speech sound assessments where we show your child a series of pictures which focus on varying sounds or sound patterns, for example:

Are the end sounds present or left off, does your child say BE_ instead of BED for example?
Are the back sounds produced at the front of the mouth, is a digger a DIDDER or a pig a PID?
Are sound blends reduced, for instances a snake becomes a NAKE ?
Or do many phonemes (single speech sounds) collapse all into one error sound? Like all F , R or L become a B?

Once we have discovered the error pattern we can then unravel the problem and work on solutions. We make a plan and prioritise which of the patterns we can target first, second and next. There are several approaches that can be used to tackle speech sound errors and most therapist have two or three favourite approaches as their go-to. I will fill you in on my favourite ones in future blogs.

What does a Speech Therapy session look like?

These days we have two options: on-line via zoom and face to face in the clinic setting.

Both are great options!

For all clients who live far away a zoom session will be the option to go for. But zoom sessions also work really well for the older child as, let’s face it, are there any kids out there who do not like a bit of screen time?

I find that children around 5 years old really love the on-line games and sessions are fun and very effective. We usually start off with a quick game to warm up and then we go into the speech sound patterns we need to improve and work on. There are 100s of tried and tested on-line games and game decks which can be hugely entertaining and really nice to work with.

In clinic, we also often start with a short game to settle in and then we target the various sound patterns we are working on within table top games, or arts and crafts activities. We aim to get up to 100 speech sound trials per session, using a variety of motivating games to keep our little ones going and focused.

Both, face to face and on-line sessions are between 40-45 minutes long – time usually flies by! – and then parents get to practise home exercises to make sure that the new speech sounds are being practised every day.

Over the coming weeks I shall do blogs on great games and home exercises that I give the parents and I will talk about games we do in the session that are fun and can be copied for home use. Watch this space!

Lisp · Speech and Language Therapy · Top tips

Living life with a lisp

ByLondon Speech and Feeding June 9, 2023May 31, 2023

You may be questioning ‘will my child grow out of having a lisp?’ There are so many myths out there that it’s sometimes difficult to find your way out of a complex maze of information.

The good news: lisps can be successfully treated by a Speech and Language Therapist and the earlier it’s resolved, the better. We know from the evidence base that some children’s lisps will resolve and, as always, it is completely age appropriate to have this speech pattern up until aged 4 ½.

As with any speech and language targets your child will need to be motivated to practise their newly acquired techniques, at home and in other settings. They will eventually be able to generalise this skill, but it takes lots of practice. So, think carefully about if your child is ready and motivated before commencing Speech and Language Therapy.

There are essentially two ways in which your child has acquired a lisp. It’s key here to mention that parents have no blame in this.

They’ve mis-learned it and now incorrect production has become a habit
Children have difficulties organising the sounds to make a clear production

You may be surprised to realise that there are different types of lisps. But all the techniques will be the same.

Interdental lisp

When your child pushes their tongue too far forward, they will make a /th/ sound instead of /s/ and /z/

Dental lisp

This is where your child’s tongue pushes against their teeth

Lateral lisp

Air comes over the top of the tongue and down the sides

Palatal lisp

Your palate is the roof of your child’s mouth. Sometimes they will touch their palate when making certain sounds (e.g., /s/ and /z/)

It’s useful for you to know what type of lisp your child has because you can then support them to make the correct production. You’ll be able to talk about where in the mouth their tongue is and where it needs to be to produce a clear sound. Your Speech and Language Therapist will be able to help you with this.

Top therapy tips for lisps

Awareness is key. Does your child know where their tongue and teeth are (i.e., are they behind their teeth)? Do they notice the air escaping? Use a mirror so that your child can see not only themselves but also you in the mirror.
Repetition! As with most therapeutic intervention, practice makes perfect. So little and often is key!
Make sessions fun, perhaps around your child’s interests or allow them to drink from a straw
Comment on how the sound is produced (e.g., /z/ is like a bee, /s/ is like a snake)
Use tactile cues. Your child’s vocal folds vibrate when they produce a sound like /z/ but not with /s/. You could use the words ‘loud’ and ‘quiet’ to describe this.
Start with a /t/ sound and gradually elongate the sound to an /s/

Having a lisp may not be problematic for some, but for other children, it can have a significant impact on their emotional wellbeing. Intervening at an early age can prevent this from happening. We always advocate for early intervention!

Contact Sonja for support on resolving your child’s lisp.