9 year old, /r/ problem, ankyloglossia, feeding issues

Hi Sandra, I am taking your /r/ e-course right now and have a question for you about a 9-year-old client who was diagnosed as an infant with a tongue tie but parents were advised not to have it clipped at the time. As a result, he had tremendous feeding problems which mom recalls were a “nightmare.”  His 2-year-old brother was also born with a tongue-tie but had it clipped at birth and subsequently had no feeding issues. This client has good range of motion with his tongue, (protrusion, retraction, elevation, etc.), however, I’ve noticed that when he retracts and elevates his tongue to produce a vocalic /r/, he raises his jaw and cannot keep his mouth open. I looked under his tongue and saw that the lingual frenum was anchored close to the floor of the mouth thus making it impossible for him to keep his mouth open while retracting and elevating the tongue.  He also has a high, narrow palate with a long narrow face. I advised his mother to speak to an ENT about the tongue tie to see if anything could be done.  She hasn’t gone yet so I wanted to ask you if you have any research on clipping the frenum and improving production of vocalic /r/.  Any other information you could provide would be very helpful.  I am the third SLP he has seen since he was 5 and the first one to point out the high palate and the fact that the tongue tie may be preventing progress on the vocalic /r/. I truly empathize with the frustration he has experienced in not being able to change this sound error.  When I told him that the difficulty he was experiencing may not have to do with his inability to work hard and do what is asked of him but rather something structural beyond his control, he was so relieved he let out a huge sigh. Thanks for your time.

Hi, It is a shame that his pediatrician didn’t pick up on it.  Unfortunately, many professionals are still quite uninformed and unaware of the consequences of restricted frenula.  I’m not sure if any studies exist, but I am finding that more and more therapists are reporting a genetic component. You mentioned that this client has good range of motion with his tongue (protrusion, retraction, elevation, etc.). Somehow, I can’t imagine that he has a good range of motion, protrusion and elevation based on what you reported about the difficulty elevating his tongue and his inability to keep his mouth open during ER attempts. You reported that the lingual frenum was anchored in a manner that makes it impossible to retract and elevate with his mouth open.    Maybe the mid portion of the body of the tongue is compensating for his other difficulties and it appears that these functions are within normal range, but I truly doubt it.  We look at several things here.  First of all, look at where the frenum inserts into the floor of the mouth.  Is it on or right below the lower alveolar ridge?  Or is it fairly far back on the floor?  Also, look where the frenum inserts into the tongue itself.  Is it about midway or is it closer to the tip?  Or is it far down at the base of the tongue?  Now check and see if it seems to be embedded into the tongue tissue above the place where it appears to attach to the underside of the tongue.  Look at the length of it.  And check if it is thick or thin, flexible or inflexible.  All of these are considerations and how they “come together” is important.  In our IATP (International Affiliation of Tongue tie Professionals), we are also finding it common for the ankyloglottic person to have an ankylo’d labial frenum.  Look under his upper lip and see if the frenum on the underside.  It should not be tight or causing the upper lip to be pulled at all.  You mention his high, narrow palate with long narrow face.  I have found so many /r/ kiddos with high narrow palates that I don’t need a study to tell me the two often go hand in hand.   I don’t know of specific studies regarding a connection between the frenum and /r/, but based on my many years of working with this type of problem, I am satisfied with my observations and results. Common sense tells us that one cannot obtain and maintain the ER sound with the existence of a restricted tongue AND a high narrow palate.  It is a sad state of affairs that past therapists didn’t bother to look in his mouth. Continued lack of success in therapy could make him feel like he was failing over and over again because he couldn’t get the /r/ sound habituated.   I also truly empathize with the frustration he has experienced in not being able to change this sound error.    I just consulted with another SLP in South Florida with a 9 year old boy; same story!  And last week I saw a 17 year old young man here in Orlando who took therapy for /r/ during his entire elementary, middle school and high school education!!!  I have a 10 year old young man scheduled this week who has been in therapy for /r/ for years.  It turns out his father is tongue tied and I fully expect to find a restricted lingual frenum once I examine the boy.  I encourage you to trust your “gut” about these things.   Here is what I would do IF he is ankyloglottic (use my criteria above and get back with me):    

•  I would not “subject” the young man to therapy if he is tongue tied.
• I would not treat him if he also has the high palate
• Check to see if he can suction flat to his palate and see how much of the sides of the tongue overlap the arch/teeth.  If, in a short while you can get him to fit his tongue within his high narrow palate, you might have a shot at the ER but only IF the tongue tie is taken care of.  Otherwise, he will need the palate expanded, if an orthodontist also finds that it is high and narrow.

I think this young man and his family are very fortunate to have found you, …truly.  You will be able to give him the right direction and I will help you…let me know your findings and …good for you for looking deeper than the others did, for seeking  information from the online course, for emailing me….we need more SLPs like you! My best, Sandra Holtzman