Q: My client is 4;0 with a frontal lisp with a very small mandible (underbite) and chronic upper respiratory problems––congestion, nasal drip, mouth breathing, snoring, etc. He cannot breath through his nose. Do you think he is capable of learning to keep his tongue in for the sibilants given his underbite?

Yours is a very common question for which we have no clear answers.

In all likelihood both the under-bite and the upper respiratory problems are contributing to his speech problem.  If he also has had some hearing problems that come and go due to upper respiratory issues then there is more reason for his speech problem.

A person can have a huge under-bite and have excellent speech, so it alone cannot account for all his troubles.  But a small jaw with a normal sized tongue would cause tongue protrusion.  Upper respiratory problems also cause many clients to protrude the tongue so they can achieve more air space in the oropharynx.

There is no way to know if the client can be taught correct oral position during speech unless one tries.  However, I must say that I have found this type of work very difficult with a four-year-old.  A kid who can barely breathe correctly has a great deal of difficulty adjusting oral positions for speech.  Usually they are doing the best they can considering their medical situation.

I wish I had a good answer for you.  Some of these kids hang on for years in therapy with no progress, and that’s not right.  I think in many cases we need to let them go and put them on yearly follow-up so they can be pulled back into therapy when the medical situation is better.