Hot Topic Blog - Mouth Developmentou & Function

WHAT I LEARNED ABOUT COMPENSATED SPEECH IN AN ADULT WITH ANKYLOGLOSSIA: A SHORT CASE STUDY

Ankyloglossia (i.e., tongue tie) is often discussed with regard to childhood speech and feeding disorders. However, I would like to share some insights I gained while working with an adult who had previously undiagnosed ankyloglossia.

History

Ed (named changed to protect anonymity) was a sixty-seven year old with cardiovascular disease (left infarct with cerebral atrophy). He had been transferred to the specialist hospital for a vascular procedure. He had suffered a neurological event while holidaying, and his speech and motor functions had been mildly affected. He was referred to me for an evaluation of his slurred speech.

On meeting Ed, I was taken aback by his persistent questions about the treatment methods I was going to use. He mentioned use of /s/ word lists and drill work. I was immediately intrigued with why Ed seemed so preoccupied with treatment methods in light of other more significant health concerns. I told him that a treatment plan would be formulated after I’d had a chance to assess him.

Assessment and Treatment

Ed passed the screening for his eating, drinking, and swallowing skills. At the start of the Oral Motor Examination, I observed Ed’s tongue to be grooved in the midline. However, he had ankyloglossia which only became apparent when I instructed him to elevate his tongue tip to the upper lip. The blade of his tongue was also wider than normal.

When talking, Ed compensated for his ankyloglossia by holding his tongue-tip behind his lower teeth. He maintained that the tongue-tie was no problem and that it didn’t affect him in any way. His former lisp was completely concealed. He was proud of his life-time of refined talking and, to him, over-correcting his speech was normal behaviour. Talking at a fast rate was not ordinarily a problem, but now there was slurring in his speech which had drawn unwelcomed attention.

Even his word retrieval problems, which gave rise to pauses in conversation, were dismissed as “historic” because Ed had lived with this problem for a long time. By the following day, the slurring of his speech appeared to have completely vanished and my contact time with Ed was quickly diminishing. There was no chance of targeting articulation skills or of suggesting tongue-tie release. Ed had successfully self-treated his slurred speech.

Every suggestion I made thereafter caused an objection. I was not building trust even though I made positive comments about his intelligibility and showed an understanding of the situation.

Ed challenged me to explain what I was going to treat and, because he wasn’t allowing much to be seen, nothing was going to be adequate enough. Had I done more testing, he would have found a way to counter the results. I must point out here that Ed also showed neurobehavioural symptoms which were increasingly becoming disruptive to his care.

Negotiating a functional therapeutic relationship in this case depended on me validating, without question, Ed’s compensated speech. The more I resisted this unspoken desire, the more strongly affronted Ed felt. I couldn’t win. There was just one option (i.e., abandon all attempts to effect changes in his speech).

What I Learned

I just hadn’t realized how much self-worth, image, dignity, and emotion were invested into this client’s solitary march toward undistorted speech (both currently and likely in the past). Thus ended my short-lived clinical relationship with Ed.

Afterwards, I thought of how much  Ed’s attitude resembled those of individuals I had seen many years ago who had both unrepaired cleft lips and severely lisped speech (and who also resisted speech treatment). As speech pathologists we know how to treat speech disorders. However, it is through experiences with clients like Ed that we learn about many other issues that can impact our treatment. Ed’s rejection of speech therapy seemed related to his own self-concept rather than my ability to treat him. Fortunately for Ed, he had functional speech. It is through experiences such as the one I had with Ed that we gain better insight into our clients and become better therapists. 

Thank you for reading my blog. If you have questions or comments regarding this article, please contact me via email verniepather@yahoo.ie.

About the Author

Vernie Pather graduated in 1988 from the University of Kwa-Zulu Natal, Durban, South Africa. She worked in public health hospitals for the first eight years of her career where she gained experience in numerous areas of clinical intervention, including cleft lip and palate speech. During this time, she was referred a minimum of one baby with ankyloglossia each year from the Paediatric Clinic, and the babies were immediately referred to ENT after assessment. She spent the next six years at the Childrens' Assessment and Therapy Centre. In 2002, she entered full-time private practice to pursue her interest in neuro-rehabilitation, where she remains at present.