Tongue thrusts and lisps were the reason why Kate was first introduced to orofacial myofunctional therapy. As a young therapist, Kate treated many children for interdental lisps. She noted that some children appeared to be stuck in therapy for a long time. In these children, she observed additional issues related to breathing, poor teeth alignment and/or oral habits. The missing piece to therapy always seemed to be orofacial myofunctional therapy. Kate firmly believes that orofacial myofunctional therapy should be brought into speech therapy for children whose lisp don’t just stem from motor planning difficulties or phonological based disorders, but sits in the context of a greater orofacial myofunctional disorder.
Kate’s passion and advocacy in orofacial myofunctional therapy can be seen in previous episodes of the SPOT Therapy Hub Podcast including interviews with Australian based specialists – ENT Dr David McIntosh and Orthodontist Dr Derek Mahony.

Many people are familiar with the term ‘Lisp,’ which is a speech error that is most commonly associated with ‘s’ and ‘z’ sounds. Often people describe it as the protrusion of the tongue on ‘s’ and ‘z’ sounds so ‘silly sausage’ sounds like ‘thilly tho-thage’! Speech pathologists call this an interdental lisp, and it is a speech pattern that can affect other fricative sounds too including ‘sh’, ‘ch’, and ‘j’. Fricatives are the sounds where a lot of air escapes from our mouth. In some individuals, the ‘t’, ‘d’, ‘n’ and ‘l’ sounds are also impacted. For some, the tongue protrudes obviously, past the teeth or even past the lips. But a lisp can also be more subtle where the tongue is just pushing against the teeth.

In a nutshell – not all lisps are the same! It is important to find a Speech Pathologist who can differentiate the type of lisp in order to form an evidence-based treatment plan.

Speech Pathologists commonly describe four main types of lisps (interdental lisp, dentalised lisp, lateral lisp and palatal lisp).
The interdental lisp is the classic lisp where the tongue protrudes past the teeth. It is part of typical development until the age of 4. Past this age, speech therapy is recommended. In contrast, the lateral lisp is never seen in typical development. The lateral lisp is when we hear a slushy sound. Air is rushing through the outside of the teeth and inside of the buccal (cheek) cavities rather than through the central and thin groove that escapes through the upper and lower teeth. If we see a lateral lisp in a 2-3 year old, we need to ask why the child is presenting with such a profile.
These lateral lisps are notorious for being difficult to treat. Kate believes this is because a traditional phonological or motor-based approach is used when the lisp actually sits within the context of an orofacial myofunctional disorder. The lisp could also be a red flag for a structural issue such as a tongue tie or high vaulted palate. These structural features can be the barrier to success in therapy or achieving success in a reasonable timeframe. This is why it is so important that these factors and issues are identified right at the start of therapy rather than waiting until we experience burn out from therapy and then investigating other potential factors.
A speech therapist, especially one trained in orofacial myofunctional therapy should be able to do throughout assessment to determine which type of lisp is being observed, which sounds are affected and the impact of the lisp on intelligibility and communication. Some people can be quite intelligible with a lisp while for others it has a significant impact. The level of impact determines the urgency of intervention.

One of the things we look for with these children is if there is a tongue thrust. Tongue thrust itself is not a diagnosis but a symptom of orofacial myofunction disorder. Kate believes that a lisp and tongue thrust are best treated together.

A tongue thrust can refer to a forward or downward tongue resting posture. This means the tongue rests against or over the lower teeth, and possibly even over the lower lip. It is also used to describe a swallowing pattern in which the tongue either pushes against the lower teeth, or protrudes between the teeth when a swallow is initiated. Like lisps, which are sometimes obvious and sometimes not, tongue thrust can vary in its presentation. In some individuals it is easily recognised because the tongue pokes out between the teeth.  However, many adults and older children have learnt to keep their mouths closed when chewing and swallowing, so the signs may be a lot more subtle. This could include tensing of the muscles around the mouth (orbicularis oris) and tensing and dimpling in the chin. This is often due to the activation of the mentalis muscle which is also pulled on when there is a restriction or a tongue tie.
In a normal and functional swallow, these muscles around our mouth don’t turn on. But when there is a tongue thrust, they are activated to counter the forward force of the tongue to avoid spilling food and drink. Sometimes, children and adults have whole postural shifts to compensate for the lack of optimal function in their tongue. They might be nodding or jerking back or tilting their head.

A tongue thrust is considered normal in infants as part of their infantile swallow development. Although it is noteworthy to mention that there is debate on whether infantile tongue thrust is the same as the tongue thrust seen in adults.
A tongue thrust is the forward moving pattern used by infants when they are learning to manage puree and exploring with solids. We expect this to be matured by age 3. So a tongue thrust swallow observed in older children is considered a sign of orofacial myofunction disorder, which is basically when your tongue, lips, cheeks and jaw muscles are not working optimally together to support function.
As it is the functional use of our mouth that causes our face to grow, dysfunction in our swallowing and speech motor skills, can have significant effects on our facial structure which in turn impact on function. We swallow 1200-2000 times a day – that’s a lot of force. We’re not only swallowing when we’re eating and drinking but we swallow our saliva. The impact of a low resting tongue posture is even bigger over time if it is left unaddressed and it can be hard to say good-bye to your lisp if we don’t address this motor patterns and habits that are happening outside of the context of therapy and speaking.

The mantra of therapists who have special training in Orofacial Myofunctional Therapy (OMT), is; Function affects Form, and Form affects Function. Individuals with a tongue thrust and a lisp often also present with particular facial features, which may include a high, narrow palate and crowded teeth. Children as supposed to have space between their teeth so if they are all aligned and close together, they actually have crowded teeth. We also see open bites (because the tongue is occupying that space or due to oral habits such as thumb sucking and nail biting), cross bites (when the lower teeth sit outside the upper teeth), overbites (the upper teeth overlap too far and over the lower teeth), overjets (a big space between the upper and lower teeth) and retruded  or small jaws. 

Many clients who start speech therapy notice early improvements in the therapy room, however, seeing new speech patterns generalise to everyday, conversational speech seems to be an impossible goal. This can be disheartening for the child, family and therapist. When we hear reports of very slow progress, regression (i.e. being back at square one after taking a therapy break), difficulty achieving a really accurate sound, or finding that the sound can be produced only with ‘funny’ movements of the lips or jaw (compensatory movements), we know that we should be looking for other things like a tongue thrust. Together with the lisp, a tongue thrust points towards an underlying Orofacial Myofunctional Disorder (OMD). If you think about it, this makes sense. If your tongue is resting down and pushing forwards at rest (which is most of the time), and if it is thrusting forwards up to 2000 times a day when you swallow, it is going to be much harder to master a new ‘tongue in’ motor habit for speech, even though you may be able to do it when concentrating. We’re not just looking at achieving these sounds when using full concentration but to habituate it to the point it is automatic and you don’t have to think about it. For adults, we can say for it to be as natural as driving a car, and for children, to be as easy as brushing your hair.

In order to remediate speech errors and establish accurate tongue placement during speech, it is important to also address tongue posture at rest and during swallowing. Focusing only on speech, without considering co-morbidities, can lead to slow or limited progress with speech goals and limited generalisation to conversational speech across contexts. It is very important to not assume that a child will eventually get there by walking along the same path as sometimes the child does achieve success during sessions. But after months or even years later, when the goal is still not achieved, it is not evidence based to continue without looking at the other issues.  

If you’re feeling stuck in therapy for a lisp, seek out a Speech Pathologist with training in Orofacial Myofunctional Therapy (OMT). We are happy to help here at SPOT Therapy Hub and would love to point you in the right direction. We can give you a fresh perspective if you are already having speech therapy or to give advice if you are considering whether it is time to address your lisp. We can help assess to see if there is an orofacial myofunctional disorder factors and evaluate if it is appropriate to wait or take action as sometimes, tongue thrusts and lisps are still age appropriate. It is important to always seek professional advice even if a lisp might seem like a small issue as it can be a sign and symptom of something much bigger which we need to get on top of as soon as possible.

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