Tongue Thrust Treatment for a School-age Child

Question

Answer

It is unusual that a child demonstrates a tongue thrust on the /t/, /d/, /l/, /n/ sounds without also thrusting on the sibilants, especially on /s/ and /z/. This may indicate that he is producing the /s/ and /z/ by positioning his tongue tip down, near or at the lower incisors. The alveolars /t/, /d/, /l/, /n/ would be more difficult to produce in that position. It may be that your student is attempting to lift his tongue tip for these productions. If so, he is not elevating the tongue tip sufficiently to produce these sounds at the incisive papilla area, but instead is producing them interdentally, resulting in a tongue thrust production.

You also report that he has a "reverse" swallow, (preferably termed a tongue thrust swallow) but you do not report the presence of other complications. Therefore, I assume that this child does NOT present with: (1) an open mouth rest posture; (2) a low and forward tongue rest posture; (3) inadequate lip rest posture; (4) restricted pharyngeal space; (5) inadequate neuromuscular development to produce the sounds correctly; or (6) malocclusion; and of which would signal the presence of additional orofacial myofunctional disorders (OMDs).

If this is a correct assumption on my part, then the tongue thrust swallow is likely a retained developmental habit pattern that this child did not outgrow. The persistent horizontal muscle pattern executed by the tongue for a tongue thrust swallow may encourage this child to produce the alveolar consonants /t/, /d/, /l/, /n/ horizontally and interdentally.

To correct this, one strategy is to encourage the production of these sounds with the tongue tip contacting the lingual surface of the maxillary central incisors. This would involve a slightly elevated position of contact compared with the current interdental production. This slight vertical change may be an easy accommodation for him to make. He may be able to produce these sounds within acoustically-acceptable limits without the visual distraction of a tongue thrust/interdental production. You could then move vertically to the maxillary incisal papilla area as the goal for tongue tip contacts during the production of these consonants.

Of interest is the research finding that dentalization on some speech sounds represents an acceptable production for this child's age group. Hale, Kellum, Richardson, Messer, Gross, Sisakun (1992) found that of the 133 second graders with a mean age of 8.4 years who were included in their study, 84.3% of the children produced the /t,d,n,l,s,z/ sounds with some type of dentalized tongue contact. They indicated that because of this percentage they could not consider the dentalized production atypical behavior for the purposes of their study.

The current treatment of orofacial myofunctional disorders, if any other characteristics of OMDs are identified, would include the establishment of a consistent tongue rest posture with the tip touching the incisal papilla and the anterior portion of the blade resting against the middle of the hard palate. A consistent tongue tip up rest posture provides a stable reference point from which the motor program for speech production may be executed. A rest posture with the tongue tip up would also encourage the correct production of the /t/,/d/, /l/, /n/, thus reducing the appearance of the tongue thrust when he produces these sounds. However, please keep in mind that if his current tongue rest posture is behind the lower incisors, encouraging a change to the tongue up rest posture will likely also change his reference point for the execution of sounds now produced correctly. If he is currently producing /s/ and /z/ adequately acoustically with the tongue in the lower position, you may see a frontal lisp emerge that you will need to address after the tongue up rest posture is established and maxillary alveolar productions of the /t/, /d/, /l/, /n/ become consistent.

I strongly advice that you do not attempt to correct the tongue thrust swallow unless you have specialty training as an orofacial myologist. A thorough orofacial myofunctional evaluation of a tongue thrust swallow would include an assessment of the presence or absence of thrusting as he swallows food, liquids, and/or saliva. The International Association of Orofacial Myology, a related professional organization with ASHA, offers specialty training with OMDs. If interested, you may find information about this group on their website, www.iaom.com.

If you find that this child does have any of the OMD conditions noted above, my recommendations, and your course of action, would be much different. If the child's rest posture suggests airway interference, the need for a thorough airway assessment by an ENT or allergy specialist should be discussed with the parents (if you are in a school setting, you may wish to enlist the assistance of the school nurse). A compromised airway is often the reason for the presence of a tongue thrust swallow, especially when it is accompanied by other orofacial myofunctional disorders. The etiology for a compromised airway is often enlarged tonsils and adenoids, allergic rhinitis, or other causes that may be identified in a thorough ENT evaluation.

If you suspect that delayed neuromuscular development for speech is the reason that the child is not correctly producing the sounds an swallowing correctly, I suggest that you complete an oral diadochokinetic assessment to help determine the precision, speed, and accuracy of the child's ability to perform the necessary motor program for these skills. This should include assessing both the alternating motion rate (AMR) and sequential motion rate (SMR) of the tongue.

I am a firm believer in the sequential motion rate assessment (SMR). Many times I have had children in therapy who perform within normal limits on the alternate motion rate, but the groping, and motor difficulties do not show up on AMR that show up on SMR. I do not put as much value on the actual rate of repetition but on the speed, accuracy, and rapidity of movements, and, as Duffy (2005) says, the 'regularity' of the production. Accordingly, although I recommend recording the rate of productions on oral diadochokinetic testing, I advise that you will get more information from direct observations of movements in all planes of space during the repetitions rather than focusing on a stop watch.

With this child, you may want to use the production of the alveolar sounds you have indicated which are of concern for the AMR: 'ta, ta, ta; da, da, da; la, la, la; and na, na, na'. In assessing the SMR, you may wish to use a combination of these alveolar sounds with a back production consonant like 'g' or 'k' such as: 'ta-ka-da; la-ga-da; na-ga-la'.

Some relevant data from diadochokinetic testing of children are appropriate here and should be kept in mind. Hale et al. (1992), using z scores to identify extreme-groups, found that 63% of the children who presented with an open-mouth rest posture fell into the 'slow' diadochokinetic group for single syllable repetition. Also, 67% of the children who presented with a detalized tongue rest posture, and 67% of the children who presented with a dentalized swallow on the trisyllabic production of 'pataka' fell into the 'slow' diadochokinetic group. The researchers did not consider this to be a causal relationship but they were able to establish a correlation of co-occurrence. Perhaps both behaviors are related to delayed neurological development for speech?

If this child has a delay in neuromuscular development for speech, this may also be reflected in his overall neuromuscular skill. Does the child exhibit low muscle tone in other activities, such as handwriting and gross motor skills? If so, a referral to his family physician for a more complete neuromuscular evaluation may be in order.

I hope that these comments and suggestions will help you to resolve the speech errors you note with this child.

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References

Duffy, J.R. (2005). Motor Speech Disorders: Substrates, Differential Diagnosis, and Management, 2nd Ed. St. Louis: Elsevier Mosby. P92.

Hale, S.T., Kellum, G.D., Richardson, J.F., Messer, S.C., Gross, A. M., Sisakun, S. (1992). Oral motor control, posturing, and myofunctional variables in 8-year-olds. Journal of Speech and Hearing Research, 35,1203-1208.

Patricia M. Taylor, Med, CCC-SLP, COM is a speech-language pathologist in private practice and a certified orofacial myologist (COM). She has served as Speech Therapist, Hearing Therapist, Special Education Program Supervisor, Act 89 Non-Public Schools Program Supervisor* Supervisor of EHA-B Program Support Services*, Special Education Grants Writer*, Special Education Computer Liaison*, Preschool Program Supervisor/Case Manager*, Teacher of Demonstration Class for Hearing Impaired (*Positions held concurrently). She is currently IAOM Research Director, and EDITOR-IN-CHIEF of the International Journal of Orofacial Myology, receiving a Special Award of Dedicated Service from the IAOM in 2004.