Today I am reviewing an awesome social-pragmatic language app by Hamaguchi Apps called: Between the Lines Advanced, which focuses on targeting the following skills:
Those of you who follow my blog know that I absolutely adore the “Between the Lines” app series by Hamaguchi apps, which focuses on targeting aspects of social language including tone of voice and non-verbal body language, perspective taking as well as idiom interpretation. I have already reviewed Levels 2 as well as Advanced, HERE and HERE, previously on my blog, so today I will be reviewing level 1, which is the simplest version in the the series geared towards “social beginners” . Continue reading Between the Lines Level 1: App Review and Giveaway
I enjoyed reviewing Between the Lines Advanced so much that today I am bringing you an intermediate version of this awesome social-pragmatic language app called: Between the Lines Level 2, which also focuses on targeting: Interpretation of vocal tone, Recognition of facial expressions, Interpretation of body language as well as Recognition of idiomatic expressions and slang, just on a less advanced level and in a less challenging format. The app uses photos and mini videos of people in a variety of real-life dynamic social situations to teach social skills. Continue reading App Review and Giveaway: Between the Lines Level 2
As an SLP who works with children with social pragmatic language disorders, I can’t but think of what happens after these clients leave school? How will they continue to improve their social cognitive abilities in order to effectively meet social challenges in their workplace? Michelle Garcia Winner and Pamela Crooke effectively address this issue in their recent book “Social Thinking® At Work: Why Should I Care”. In it, they offer practical advice to adults with social thinking® challenges regarding how to navigate the intricacies of social interaction in the workplace. Continue reading After the Graduation: Review and Giveaway of Social Thinking® At Work
In my therapy sessions I spend a significant amount of time improving literacy skills (reading, spelling, and writing) of language impaired students. In my work with these students I emphasize goals with a focus on phonics, phonological awareness, encoding (spelling) etc. However, what I have frequently observed in my sessions are significant gaps in the students’ foundational knowledge pertaining to the basics of sound production and letter recognition. Basic examples of these foundational deficiencies involve students not being able to fluently name the letters of the alphabet, understand the difference between vowels and consonants, or fluently engage in sound/letter correspondence tasks (e.g., name a letter and then quickly and accurately identify which sound it makes). Consequently, a significant portion of my sessions involves explicit instruction of the above concepts.
This got me thinking regarding my students’ vocabulary knowledge in general. We, SLPs, spend a significant amount of time on explicit and systematic vocabulary instruction with our students because as compared to typically developing peers, they have immature and limited vocabulary knowledge. But do we teach our students the abstract vocabulary necessary for reading success? Do we explicitly teach them definitions of a letter, a word, a sentence? etc.
A number of my colleagues are skeptical. “Our students already have poor comprehension”, they tell me, “Why should we tax their memory with abstract words of little meaning to them?” And I agree with them of course, but up to a point.
I agree that our students have working memory and processing speed deficits as a result of which they have a much harder time learning and recalling new words.
However, I believe that not teaching them meanings of select words pertaining to language is a huge disservice to them. Here is why. To be a successful communicator, speaker, reader, and writer, individuals need to possess adequate metalinguistic skills.
In simple terms “metalinguistics” refers to the individual’s ability to actively think about, talk about, and manipulate language. Reading, writing, and spelling require active level awareness and thought about language. Students with poor metalinguistic skills have difficulty learning to read, write, and spell. They lack awareness that spoken words are made up of individual units of sound, which can be manipulated. They lack awareness that letters form words, words form phrases and sentences, and sentences form paragraphs. They may not understand that letters make sounds or that a word may consist of more letters than sounds (e.g., /ship/). The bottom line is that students with decreased metalinguistic skills cannot effectively use language to talk about concepts like sounds, letters, or words unless they are explicitly taught those abilities.
So I do! Furthermore, I can tell you that explicit instruction of metalinguistic vocabulary does significantly improve my students understanding of the tasks involved in obtaining literacy competence. Even my students with mild to moderate intellectual disabilities significantly benefit from understanding the meanings of: letters, words, sentences, etc.
I even created a basic abstract vocabulary handout to facilitate my students comprehension of these words (FREE HERE). While by no means exhaustive, it is a decent starting point for teaching my students the vocabulary needed to improve their metalinguistic skills.
For older elementary aged students with average IQ, I only provide the words I want them to define, and then ask them to look up their meanings online via the usage of PC or an iPad. This turns of vocabulary activity into a critical thinking and an executive functions task.
Students need to figure out the appropriate search string needed to in order to locate the answer as well as which definition comes the closest to clearly and effectively defining the presented word. One of the things I really like about Google online dictionary, is that it provides multiple definitions of the same words along with word origins. As a result, it teaches students to carefully review and reflect upon their selected definition in order to determine its appropriateness.
A word of caution as though regarding using Kiddle, Google-powered search engine for children. While it’s great for locating child friendly images, it is not appropriate for locating abstract definition of words. To illustrate, when you type in the string search into Google, “what is the definition of a letter?” You will get several responses which will appropriately match some meanings of your query. However the same string search in Kiddle, will merely yield helpful tips on writing a letter as well as images of envelopes with stamps affixed to them.
In contrast to the above, I use a more structured vocabulary defining activities for younger elementary age students as well as students with intellectual impairments. I provide simple definitions of abstract words, attach images and examples to each definition as well as create cloze activities and several choices of answers in order to ensure my students’ comprehension of these words.
I find that this and other metalinguistic activities significantly improve my students comprehension of abstract words such as ‘communication’, ‘language’, as well as ‘literacy’. They cease being mere buzzwords, frequently heard yet consistently not understood. To my students these words begin to come to life, brim with meaning, and inspire numerous ‘aha’ moments.
Now that you’ve had a glimpse of my therapy sessions I’d love to have a glimpse of yours. What metalinguistic goals related to literacy are you targeting with your students? Comment below to let me know.
Recently I began writing a series of posts on the topic of comprehensive assessment of dyslexia.
In part I of my post (HERE), I discussed common dyslexia myths as well as general language testing as a starting point in the dyslexia testing battery.
In part II I detailed the next two steps in dyslexia assessment: phonological awareness and word fluency testing (HERE).
Today I would like to discuss part III of comprehensive dyslexia assessment, which discusses reading fluency and reading comprehension testing.
Let’s begin with reading fluency testing, which assesses the students’ ability to read word lists or short paragraphs with appropriate speed and accuracy. Here we are looking for how many words the student can accurately read per minute orally and/or silently (see several examples of fluency rates below).
Research indicates that oral reading fluency (ORF) on passages is more strongly related to reading comprehension than ORF on word lists. This is an important factor which needs to be considered when it comes to oral fluency test selection.
Oral reading fluency tests are significant for a number of reasons. Firstly, they allow us to identify students with impaired reading accuracy. Secondly, they allow us to identify students who can decode words with relative accuracy but who cannot comprehend what they read due to significantly decreased reading speed. When you ask such children: “What did you read about?” They will frequently respond: “I don’t remember because I was so focused on reading the words correctly.”
One example of a popular oral reading fluency test (employing reading passages) is the Gray Oral Reading Tests-5 (GORT-5). It yields the scores on the student’s:
Another types of reading fluency tests are tests of silent reading fluency. Assessments of silent reading fluency can at selectively useful for identifying older students with reading difficulties and monitoring their progress. One obvious advantage to silent reading tests is that they can be administered in group setting to multiple students at once and generally takes just few minutes to administer, which is significantly less then oral reading measures take to be administered to individual students.
Below are a several examples of silent reading tests/subtests.
The Test of Silent Word Reading Fluency (TOSWRF-2) presents students with rows of words, ordered by reading difficulty without spaces (e.g., dimhowfigblue). Students are given 3 minutes to draw a line between the boundaries of as many words as possible (e.g., dim/how/fig/blue).
The Test of Silent Contextual Reading Fluency (TOSCRF-2) presents students with text passages with all words printed in uppercase letters with no separations between words and no punctuation or spaces between sentences and asks them to use dashes to separate words in a 3 minute period.
Similar to the TOSCRF-2, the Contextual Fluency subtest of the Test of Reading Comprehension – Fourth Edition (TORC-4) measures the student’s ability to recognize individual words in a series of passages (taken from the TORC-4′s Text Comprehension subtest) in a period of 3 minutes. Each passage, printed in uppercase letters without punctuation or spaces between words, becomes progressively more difficult in content, vocabulary, and grammar. As students read the segments, they draw a line between as many words as they can in the time allotted. (E.g., THE|LITTLE|DOG|JUMPED|HIGH)
However, it is important to note oral reading fluency is a better predictor of reading comprehension than is silent reading fluency for younger students (early elementary age). In contrast, silent reading measures are more strongly related to reading comprehension in middle school (e.g., grades 6-8) but only for skilled vs. average readers, which is why oral reading fluency measures are probably much better predictors of deficits in this area in children with suspected reading disabilities.
Now let’s move on to the reading comprehension testing, which is an integral component for any dyslexia testing battery. Unfortunately, it is also the most trickiest. Here’s why.
Many children with reading difficulties will be able to read and comprehend short paragraphs containing factual information of decreased complexity. However, this will change dramatically when it comes to the comprehension of longer, more complex, and increasingly abstract age-level text. While a number of tests do assess reading comprehension, none of them truly adequately assess the students ability to comprehend abstract information.
For example, on the Reading Comprehension subtest of the CELF-5, students are allowed to keep the text and refer to it when answering questions. Such option will inflate the students scores and not provide an accurate idea of their comprehension abilities.
To continue, the GORT-5 contains reading comprehension passages, which the students need to answer after the stimuli booklet has been removed from them. However, the passages are far more simplistic then the academic texts the students need to comprehend on daily basis, so the students may do well on this test yet still continue to present with significant comprehension deficits.
Similar could be said for the text comprehension components of major educational testing batteries such as the Woodcock Johnson IV: Passage Comprehension subtest, which gives the student sentences with a missing word, and the student is asked to orally provide the word. However, filling-in a missing word does not text comprehension make.
Likewise, the Wechsler Individual Achievement Test®-Fourth Edition (WIAT-IV), Reading Comprehension subtest is very similar to the CELF-5. Student is asked to read a passage and answer questions by referring back to the text. However, just because a student can look up the answers in text does not mean that they actually understand the text.
So what could be done to accurately assess the student’s ability to comprehend abstract grade level text? My recommendation is to go informal. Select grade-level passages from the student’s curriculum pertaining to science, social studies, geography, etc. vs. language arts (which tends to be more simplistic) and ask the student to read them and answer factual questions regarding supporting details as well as non factual questions relevant to main ideas and implied messages.
That’s it for today’s post! Click (HERE) for part IV of this series which will discuss components of Writing and Spelling testing.
Here’s a familiar scenario to many SLPs. You’ve administered several standardized language tests to your student (e.g., CELF-5 & TILLS). You expected to see roughly similar scores across tests. Much to your surprise, you find that while your student attained somewhat average scores on one assessment, s/he had completely bombed the second assessment, and you have no idea why that happened.
So you go on social media and start crowdsourcing for information from a variety of SLPs located in a variety of states and countries in order to figure out what has happened and what you should do about this. Of course, the problem in such situations is that while some responses will be spot on, many will be utterly inappropriate. Luckily, the answer lies much closer than you think, in the actual technical manual of the administered tests.
So what is responsible for such as drastic discrepancy? A few things actually. For starters, unless both tests were co-normed (used the same sample of test takers) be prepared to see disparate scores due to the ability levels of children in the normative groups of each test. Another important factor involved in the score discrepancy is how accurately does the test differentiate disordered children from typical functioning ones.
Let’s compare two actual language tests to learn more. For the purpose of this exercise let us select The Clinical Evaluation of Language Fundamentals-5 (CELF-5) and the Test of Integrated Language and Literacy (TILLS). The former is a very familiar entity to numerous SLPs, while the latter is just coming into its own, having been released in the market only several years ago.
Both tests share a number of similarities. Both were created to assess the language abilities of children and adolescents with suspected language disorders. Both assess aspects of language and literacy (albeit not to the same degree nor with the same level of thoroughness). Both can be used for language disorder classification purposes, or can they?
Actually, my last statement is rather debatable. A careful perusal of the CELF – 5 reveals that its normative sample of 3000 children included a whopping 23% of children with language-related disabilities. In fact, the folks from the Leaders Project did such an excellent and thorough job reviewing its psychometric properties rather than repeating that information, the readers can simply click here to review the limitations of the CELF – 5 straight on the Leaders Project website. Furthermore, even the CELF – 5 developers themselves have stated that: “Based on CELF-5 sensitivity and specificity values, the optimal cut score to achieve the best balance is -1.33 (standard score of 80). Using a standard score of 80 as a cut score yields sensitivity and specificity values of .97. “
In other words, obtaining a standard score of 80 on the CELF – 5 indicates that a child presents with a language disorder. Of course, as many SLPs already know, the eligibility criteria in the schools requires language scores far below that in order for the student to qualify to receive language therapy services.
In fact, the test’s authors are fully aware of that and acknowledge that in the same document. “Keep in mind that students who have language deficits may not obtain scores that qualify him or her for placement based on the program’s criteria for eligibility. You’ll need to plan how to address the student’s needs within the framework established by your program.”
But here is another issue – the CELF-5 sensitivity group included only a very small number of: “67 children ranging from 5;0 to 15;11”, whose only requirement was to score 1.5SDs < mean “on any standardized language test”. As the Leaders Project reviewers point out: “This means that the 67 children in the sensitivity group could all have had severe disabilities. They might have multiple disabilities in addition to severe language disorders including severe intellectual disabilities or Autism Spectrum Disorder making it easy for a language disorder test to identify this group as having language disorders with extremely high accuracy. ” (pgs. 7-8)
Of course, this begs the question, why would anyone continue to administer any test to students, if its administration A. Does not guarantee disorder identification B. Will not make the student eligible for language therapy despite demonstrated need?
The problem is that even though SLPs are mandated to use a variety of quantitative clinical observations and procedures in order to reliably qualify students for services, standardized tests still carry more value then they should. Consequently, it is important for SLPs to select the right test to make their job easier.
The TILLS is a far less known assessment than the CELF-5 yet in the few years it has been out on the market it really made its presence felt by being a solid assessment tool due to its valid and reliable psychometric properties. Again, the venerable Dr. Carol Westby had already done such an excellent job reviewing its psychometric properties that I will refer the readers to her review here, rather than repeating this information as it will not add anything new on this topic. The upshot of her review as follows: “The TILLS does not include children and adolescents with language/literacy impairments (LLIs) in the norming sample. Since the 1990s, nearly all language assessments have included children with LLIs in the norming sample. Doing so lowers overall scores, making it more difficult to use the assessment to identify students with LLIs. (pg. 11)”
Now, here many proponents of inclusion of children with language disorders in the normative sample will make a variation of the following claim: “You CANNOT diagnose a language impairment if children with language impairment were not included in the normative sample of that assessment!” Here’s a major problem with such assertion. When a child is referred for a language assessment, we really have no way of knowing if this child has a language impairment until we actually finish testing them. We are in fact attempting to confirm or refute this fact, hopefully via the use of reliable and valid testing. However, if the normative sample includes many children with language and learning difficulties, this significantly affects the accuracy of our identification, since we are interested in comparing this child’s results to typically developing children and not the disordered ones, in order to learn if the child has a disorder in the first place. As per Peña, Spaulding and Plante (2006), “the inclusion of children with disabilities may be at odds with the goal of classification, typically the primary function of the speech pathologist’s assessment. In fact, by including such children in the normative sample, we may be “shooting ourselves in the foot” in terms of testing for the purpose of identifying disorders.”(p. 248)
Then there’s a variation of this assertion, which I have seen in several Facebook groups: “Children with language disorders score at the low end of normal distribution“. Once again such assertion is incorrect since Spaulding, Plante & Farinella (2006) have actually shown that on average, these kids will score at least 1.28 SDs below the mean, which is not the low average range of normal distribution by any means. As per authors: “Specific data supporting the application of “low score” criteria for the identification of language impairment is not supported by the majority of current commercially available tests. However, alternate sources of data (sensitivity and specificity rates) that support accurate identification are available for a subset of the available tests.” (p. 61)
Now, let us get back to your child in question, who performed so differently on both of the administered tests. Given his clinically observed difficulties, you fully expected your testing to confirm it. But you are now more confused than before. Don’t be! Search the technical manual for information on the particular test’s sensitivity and specificity to look up the numbers. Vance and Plante (1994) put forth the following criteria for accurate identification of a disorder (discriminant accuracy): “90% should be considered good discriminant accuracy; 80% to 89% should be considered fair. Below 80%, misidentifications occur at unacceptably high rates” and leading to “serious social consequences” of misidentified children. (p. 21)
Review the sensitivity and specificity of your test/s, take a look at the normative samples, see if anything unusual jumps out at you, which leads you to believe that the administered test may have some issues with assessing what it purports to assess. Then, after supplementing your standardized testing results with good quality clinical data (e.g., narrative samples, dynamic assessment tasks, etc.), consider creating a solidly referenced purchasing pitch to your administration to invest in more valid and reliable standardized tests.
Hope you find this information helpful in your quest to better serve the clients on your caseload. If you are interested in learning more regarding evidence-based assessment practices as well as psychometric properties of various standardized speech-language tests visit the SLPs for Evidence-Based Practice group on Facebook learn more.
References:
Today I am reviewing two products by Lindsey Swanson-Karol of the Word Nerd Speech Teach Blog related to the core curriculum: the Common Core Based Language Assessment as well as her Robot Phonological Awareness Pack.
Those of you who follow my blog know that when I select materials, I always try to make sure that the materials are multipurpose, multi-functional, and curriculum embedded.
First up is the Common Core Based Language Assessment. This 14 page informal language assessment is based on the common core for K-5 grade in the areas of the curriculum relevant to speech-language pathology. Continue reading Focus on the common core
Today it is my pleasure and privilege to interview 3 Australian lactation consultations: Lois Wattis, Renee Kam, and Pamela Douglas, the authors of a March 2017 article in the Breastfeeding Review: “Three experienced lactation consultants reflect upon the oral tie phenomenon” (which can be found HERE).
Tatyana Elleseff: Colleagues, as you very well know, the subject of ankyloglossia or tongue tie affecting breastfeeding and speech production has risen into significant prominence in the past several years. Numerous journal articles, blog posts, as well as social media forums have been discussing this phenomenon with rather conflicting recommendations. Many health professionals and parents are convinced that “releasing the tie” or performing either a frenotomy or frenectomy will lead to significant improvements in speech and feeding.
Presently, systematic reviews1-3 demonstrate there is insufficient evidence for the above. However, when many professionals including myself, cite reputable research explaining the lack of support of surgical intervention for tongue tie, there has been a pushback on the part of a number of other health professionals including lactation consultants, nurses, dentists, as well as speech-language pathologists stating that in their clinical experience surgical intervention does resolve issues with tongue tie as related to speech and feeding.
So today, given your 33 combined years of practice as lactation consultants I would love to ask your some questions regarding the tongue tie phenomena.
I would like to begin our discussion with a description of normal breastfeeding and what can interfere with it from an anatomical and physiological standpoint for mothers and babies.
Now, many of this blog’s readers already know that a tongue tie occurs when the connective tissue under the tongue known as a lingual frenulum restricts tongue movement to some degree and adversely affects its function. But many may not realize that children can present with a normal anatomical variant of “ties” which can be completely asymptomatic. Can you please address that?
Lois Wattis: “Normal” breastfeeding takes time and skill to achieve. The breastfeeding dyad is multifactorial, influenced by maternal breast and nipple anatomy combined with the infant’s facial and oral structures, all of which are highly variable. Mothers who have successfully breastfed the first baby may encounter problems with subsequent babies due to size (e.g., smaller, larger, etc.), be compromised by birth interventions or drugs during labor, or incur birth injuries – all of which can affect the initiation of breastfeeding and progression to a happy and comfortable feeding relationship. Unfortunately, the overview of each dyad’s story can be lost when tunnel vision of either health provider or parents regarding the baby’s oral anatomy is believed to be the chief influencer of breastfeeding success or failure.
Tatyana Elleseff: Colleagues, what do we know regarding the true prevalence of various ‘tongue ties’? Are there any studies of good quality?
Pamela Douglas: In a literature review in 2005, Hall and Renfrew acknowledged that the true prevalence of ankyloglossia remained unknown, though they estimated 3-4% of newborns.4
After 2005, once the diagnosis of posterior tongue-tie (PTT) had been introduced,5, 6 attempts to quantify incidence of tongue-tie have remained of very poor quality, but estimates currently rest at between 4-10%.7
The problem is that there is a lack of definitional clarity concerning the diagnosis of PTT. Consequently, anterior or classic tongue tie CTT is now often conflated with PTT simply as ‘tongue-tie’ (TT).
Tatyana Elleseff: Thank you for clarifying it. In addition to the anterior and posterior tongue tie labels, many parents and professionals also frequently hear the terms lip tie and buccal ties. Is there’s reputable research behind these terms indicating that these ties can truly impact speech and feeding?
Pamela Douglas: Current definitions of ankyloglossia tend to confuse oral and tongue function (which is affected by multiple variables, and in particular by a fit and hold in breastfeeding) with structure (which is highly anatomically variable for both the tongue length and appearance and lingual and maxillary frenula).
For my own purposes, I define CTT as Type 1 and 2 on the Coryllos-Genna-Watson scale.8 In clinical practice, I also find it useful to rate the anterior membrane by the percentage of the undersurface of the tongue into which the membrane connects, applying the first two categories of the Griffiths Classification System.9
There is a wide spectrum of lingual frenula morphologies and elasticities, and deciding where to draw a line between a normal variant and CTT will depend on the clinical judgment concerning the infant’s capacity for pain-free efficient milk transfer. However, that means we need to have an approach to fit and hold that we are confident does optimize pain-free efficient milk transfer and at the moment, research shows that not only do the old ‘hands on’ approach to fit and hold not work, but that baby-led attachment is also not enough for many women. This is why at the Possums Clinic we’ve been working on developing an approach to fit and hold (gestalt breastfeeding) that builds on baby-led attachment but also integrates the findings of the latest ultrasound studies.
I personally don’t find the diagnoses of posterior tongue tie PTT and upper lip tie ULT helpful, and don’t use them. Lois, Renee and myself find that a wide spectrum of normal anatomic lingual and maxillary frenula variants are currently being misdiagnosed as a PTT and ULT, which has worried us and led Lois to initiate the article with Renee.
Tatyana Elleseff: Segueing from the above question: is there an established criterion based upon which a decision is made by relevant professionals to “release” the tie and if so can you explain how it’s determined?
Lois Wattis: When an anterior frenulum is attached at the tongue tip or nearby and is short enough to cause restriction of lift towards the palate, usually associated with extreme discomfort for the breastfeeding mother, I have no reservations about snipping it to release the tongue to enable optimal function for breastfeeding. If a simple frenotomy is going to assist the baby to breastfeed well it is worth doing, and as soon as possible. What I do encounter in my clinical practice are distressed and disempowered mothers whose baby has been labeled as having a posterior tongue tie and/or upper lip tie which is the cause of current and even future problems. Upon examination, the baby has completely normal oral anatomy and breastfeeding upskilling and confidence building of both mother and baby enables the dyad to go forward with strategies which address all elements of their unique story.
Although the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF) is a pioneering contribution, bringing us our first systematized approach to examination of the infant’s tongue and oral connective tissues, it is unreliable as a tool for decision-making concerning frenotomy.10-12 In practice many of the item criteria are highly subjective. Although one study found moderate inter-rater reliability on the ATLFF’s structural items, the authors did not find inter-rater reliability on most of the functional items.13 In my clinical experience, there is no reliable correlation between what the tongue is observed to do during oral examinations and what occurs during breastfeeding, other than in the case of classic tongue-tie (excluding congenital craniofacial abnormalities from this discussion.
In my practice as a Lactation Consultant in an acute hospital setting I use a combination of the available assessment tools mainly for documentation purposes, however, the most important tools I use are my eyes and my ears. Observing the mother and baby physical combination and interactions, and suggesting adjustments where indicated to the positioning and attachment technique used (which Pam calls fit and hold) can very often resolve difficulties immediately – even if the baby also has an obvious frenulum under his/her tongue. Listening to the mother’s feedback, and observing the baby’s responses are primary indicators of whether further intervention is needed, or not. Watching how the baby achieves and retains the latch is key, then the examination of baby’s mouth to assess tongue mobility and appearance provide final information about whether baby’s ability to breastfeed comfortably is or is not being hindered by a restrictive lingual frenulum.
Tatyana Elleseff: So frenotomy is an incision (cut) of lingual frenum while frenectomy (complete removal) is an excision of lingual frenum. Both can be performed via various methods of “release”. What effects on breastfeeding have you seen with respect to healing?
Lois Wattis: The significant difference between both procedures involves the degree of invasiveness and level of pain experienced during and after the procedures, and the differing time it takes for the resumption and/or improvement in breastfeeding comfort and efficacy.
It is commonplace for a baby who has had a simple incision to breastfeed immediately after the procedure and exhibit no further signs of discomfort or oral aversion. Conversely, the baby who has had laser division(s) may breastfeed soon after the procedure while topical anesthetics are still working. However, many infants demonstrate discomfort, extreme pain responses and reluctance to feed for days or weeks following a laser treatment. Parents are warned to expect delays resuming feeding and the baby is usually also subjected to wound “stretches” for weeks following the laser treatments. Unfortunately, in my clinical practice I see many parents and babies who are very traumatized by this whole process, and in many cases, breastfeeding can be derailed either temporarily or permanently.
Tatyana Elleseff: Thank you! This is highly relevant information for both health professionals and parents alike. I truly appreciate your clinical expertise on this topic. While we are on the topic of restrictive lingual frenulums can we discuss several recent articles published on surgical interventions for the above? For example (Ghaheri, Cole, Fausel, Chuop & Mace, 2016), recently published the result of their study which concluded that: “Surgical release of tongue-tie/lip-tie results in significant improvement in breastfeeding outcomes”. Can you elucidate upon the study design and its findings?
Pamela Douglas: Pre-post surveys, such as Ghaheri et al’s 2016 study, are notoriously methodologically weak and prone to interpretive bias.14
Renee Kam: Research about the efficacy of releasing ULTs to improve breastfeeding outcomes is seriously lacking. There is no reliable assessment tool for upper lip-tie and a lack of evidence to support the efficacy of a frenotomy of labial frenula in breastfed babies. The few studies which have included ULT release have either included very small numbers of babies having upper lip-tie releases or have included babies having a release upper lip ties and tongue ties at the same time, making it impossible to know if any improvements were due to the tongue-tie release, upper lip-tie release or both. Here, to answer your previous question, to date, no research has looked into the treatment of buccal ties for breastfeeding outcomes.
There are various classification scales for labial frenulums such as the Kotlow scale. The title of this scale is misleading as it contains the word ‘tie’. Hence it can give some people the incorrect assumption that a class III or IV labial frenulum is somehow a problem. What this scale actually shows is the normal range of insertion sites for a labial frenulum. And, in normal cases, the vast majority of babies’ labial frenulums insert low down on the upper gum (class III) or even wrap around it (class IV). It’s important to note that, for effective breastfeeding, the upper lip does not have to flange out in order to create a seal. It just has to rest in a neutral position — not flanged out, not tucked in.
Lois Wattis: I entirely agree with Renee’s view about the neutrality of the upper lip, including the labial frenulum, in relation to latch for breastfeeding. Even babies with asymmetrical facial features, cleft lips and other permanent and temporary anomalies only need to achieve a seal with the upper lip to breastfeed successfully.
Tatyana Elleseff: Thank you for that. In addition to studies on tongue tie revisions and breastfeeding outcomes, there has been an increase in studies, specifically Kotlow (2016) and Siegel (2016), which claimed that surgical intervention improves outcomes for acid reflux and aerophagia in babies”. Can you discuss these studies design and findings?
Renee Kam: The AIR hypothesis has led to reflux being used as another reason to diagnose the oral anatomic abnormalities in infants in the presence of breastfeeding problems. More research with objective indicators and less vested interest is needed in this area. A thorough understanding of normal infant behavior and feeding problems which aren’t tie related are also imperative before any conclusions about AIR can be reached.
Tatyana Elleseff: One final question, colleagues are you aware of any studies which describe long-term outcomes of surgical interventions for tongue ties?
Pamela Douglas: The systematic reviews note that there is a lack of evidence demonstrating long-term outcomes of surgical interventions.
Tatyana Elleseff: Thank you for such informative discussion, colleagues.
There you have it, readers. Both research and clinical practice align to indicate that:
Now, I’d like to take a moment and address the myth of tongue ties affecting speech production, which continues to persist among speech-language pathologists despite overwhelming evidence to the contrary.
For that purpose, I will use excerpts from an excellent ASHA Leader December 2005 article written by an esteemed Dr. Kummer who is certainly well qualified to discuss this issue. According to Dr. Kummer, “there is no empirical evidence in the literature that ankyloglossia typically causes speech defects. On the contrary, several authors, even from decades ago, have disputed the belief that there is a strong causal relationship (Wallace, 1963; Block, 1968; Catlin & De Haan, 1971; Wright, 1995; Agarwal & Raina, 2003).”
Since many children with restricted frenulum do not have any speech production difficulties, Dr Kummer explains why that is the case by discussing the effect of tongue tip positioning for speech production.
“Lingual-alveolar sounds (t, d, n) are produced with the top of the tongue tip and therefore, they can be produced with very little tongue elevation or mobility.
The /s/ and /z/ sounds require the tongue tip to be elevated only slightly but can be produced with little distortion if the tip is down.
The most the tongue tip needs to elevate is to the alveolar ridge for the production of an /l/. However, this sound can actually be produced with the tongue tip down and the dorsum of the tongue up against the alveolar ridge. Even an /r/ sound can be produced with the tongue tip down as long as the back of the tongue is elevated on both sides.
The most the tongue needs to protrude is to the back of the maxillary incisors for the production of /th/. All of these sounds can usually be produced, even with significant tongue tip restriction. This can be tested by producing these sounds with the tongue tip pressed down or against the mandibular gingiva. This results in little, if any, distortion.” (Kummer, 2005, ASHA Leader)
In 2009, Dr. Sharynne McLeod, did research on electropalatography of speech sounds with adults. Her findings (below) which are coronal images of tongue positioning including bracing, lateral contact and groove formation for consonants support the above information provided by Dr. Kummer.
Once again research and clinical practice align to indicate that there’s insufficient evidence to indicate the effect of restricted frenulum on the production of speech sounds.
Finally, I would like to conclude this post with a list of links from recent systematic reviews summarizing the latest research on this topic.
Ankyloglossia/Tongue Tie Systematic Review Summaries to Date (2017):
References
Author Bios (in alphabetical order):
Dr. Pamela Douglas is the founder of a charitable organization, the Possums Clinic, a general practitioner since 1987, an IBCLC (1994-2004; 2012-Present) and researcher. She is an Associate Professor (Adjunct) with the Centre for Health Practice Innovation, Griffith University, and a Senior Lecturer with the Discipline of General Practice, The University of Queensland. Pam enjoys working clinically with families across the spectrum of challenges in early life, many complex (including breastfeeding difficulty) unsettled infant behaviors, reflux, allergies, tongue-tie/oral connective tissue problems, and gut problems. She is author of The discontented little baby book: all you need to know about feeds, sleep and crying (UQP) www.possumsonline.com; www.pameladouglas.com.au
Renee Kam qualified with a Bachelor of Physiotherapy from the University of Melbourne in 2000. She then worked as a physiotherapist for 6 years, predominantly in the areas of women’s health, pediatric and musculoskeletal physiotherapy. She became an Australian Breastfeeding Association Breastfeeding (ABA) counselor in 2010 and obtained the credential of International Board Certified Lactation Consultant (IBCLC) in 2012. In 2013, Renee’s book, The Newborn Baby Manual, was published which covers the topics that Renee is passionate about; breastfeeding, baby sleep and baby behavior. These days, Renee spends most of her time being a mother to her two young daughters, writing breastfeeding content for BellyBelly.com.au, fulfilling her role as national breastfeeding information manager with ABA and working as an IBCLC in private practice and at a private hospital in Melbourne, Australia.
Lois Wattis is a Registered Nurse/Midwife, International Board Certified Lactation Consultant and Fellow of the Australian College of Midwives. Working in both hospital and community settings, Lois has enhanced her midwifery skills and expertise by providing women-centred care to thousands of mothers and babies, including more than 50 women who chose to give birth at home. Lois’ qualifications include Bachelor of Nursing Degree (Edith Cowan University, Perth WA), Post Graduate Diploma in Clinical Nursing, Midwifery (Curtin University, Perth WA), accreditation as Independent Practising Midwife by the Australian College of Midwives in 2002 and International Board Certified Lactation Consultant in 2004. Lois was inducted as a Fellow of the Australian College of Midwives (FACM) in 2005 in recognition of her services to women and midwifery in Australia. Lois has authored numerous articles which have been published internationally in parenting and midwifery journals, and shares her broad experience via her creations “New Baby 101” book, smartphone App, on-line videos and Facebook page. www.newbaby101.com.au Lois has worked for the past 10 years in Qld, Australia in a dedicated Lactation Consultant role as well as in private practice www.birthjourney.com
