Aiden is constantly in motion, purposefully crashing into objects around him with little, if any, sense of caution. He avoids social interaction and doesn’t understand how to take turns in a conversation. Easily frustrated, Aiden tantrums and acts out, does not like to follow directions, and forgets basic instructions and routine tasks, like brushing his teeth after breakfast and putting empty juice boxes in the trash can.
Aiden’s parents turned to his pediatrician, who was concerned enough about issues of attention, hyperactivity and dysregulation to send the family to a neuropsychologist for testing.
Although Aiden had a prior history of receiving speech-language treatment for articulation, the neuropsychologist sent him to me because I am trained in orofacial myofunctional therapy. To check for an altered lingual frenulum (tongue-tie), I scheduled Aiden for an orofacial myofunctional assessment, which looks at oral and muscle functions related to proper oral rest postures, speaking, chewing, swallowing and nasal breathing support. I indeed discovered a tongue-tie, and given Aiden’s history and reported concerns, suspected his difficulties could be related to a little-known disorder.
Comprehensive intake
Part of my assessment involved collecting information from Aiden’s teachers, caregivers and health care providers, in addition to parent reports.Anything that affects a child’s ability to breathe through the nose during the day—such as allergies—raises a red flag, as that same issue may affect nighttime sleep breathing.
Aiden’s history included premature birth, jaundice, frequent ear infections, sinus infections and environmental allergies. Ear infections are not uncommon in children with lingual frenulum restrictions, as tongue-ties can result in swallow patterns that don’t adequately ventilate eustachian tubes to support optimal middle ear functioning. And anything that affects a child’s ability to breathe through the nose during the day—such as allergies—raises a red flag, as that same issue may affect nighttime sleep breathing.
The parents also indicated that Aiden is a picky eater, sitting at the table for an average of two minutes during meals and often leaving his plate untouched.
Aiden spoke at a very low volume, mumbling and running words together, with unfamiliar listeners understanding his connected speech less than 50 percent of the time. Aiden became frustrated when he wasn’t understood.
In addition to atypical and age-appropriate articulation errors, Aiden had an interdentalized lisp for phonemes /s/, /z/, /t/, /n/ and /l/. This tongue thrust also resulted in an abnormal swallow pattern (tongue-thrust swallow) for liquids and solids. Many instances of tongue thrust in speaking and swallowing are rooted in airway obstructions: For example, if the airway is obstructed during nighttime sleep breathing, the tongue will clear the oral cavity with a constant tongue-thrust pattern to maintain the airway, a behavior that is then generalized to the daytime.
Therefore, tongue thrusts may be more than just a speech issue in need of remediation—they often are indicators of an underlying airway issue.
Airway issues, in turn, can wreak havoc on learning and academics, behaviors and mood, attention and memory, abstract thinking, problem solving, and speech and language—secondary to reduced oxygen to the brain.
Aiden’s speech and swallowing issues—in addition to his altered lingual frenulum—raised the possibility that his daily struggles were related to a more pervasive and life-altering issue than initially suspected.
Mouth and face tell all
As speech-language pathologists know, one of the tongue’s biggest roles—and the most essential to human life—is maintaining the airway for breathing. A lingual frenulum restriction affects the genioglossus muscle (a known upper-airway dilator) because the frenulum fibers don’t stretch. This aspect of a speech-language assessment, however, can easily be overlooked in the midst of so much ground to cover in a limited amount of time.Aiden’s orofacial myofunctional exam revealed additional factors that pointed to a potentially compromised airway: a low forward tongue posture at rest (further visible by protrusion of the tongue through the teeth and lips), open lips at rest, a high narrow palate, wear patterns on the teeth (sign of possible nocturnal teeth grinding), enlarged tonsils and a convex facial profile (a pronounced head and recessed chin). Studies from the Journal of Craniofacial Surgery (see sources) show that a child with enlarged tonsils, malocclusion and convex facial profile has a two-to-three times greater risk for sleep-disordered breathing.
