How Speech Language Pathologists Learn to Treat Patients With Lisping Disorders

“I learned nothing about remediating lisps in grad school! How could this be?” writes SLP Molly Beiting.

That’s a surprise, because lisping is one of the more common speech impediments, with estimates suggesting that as many as 23% of the patients SLPs see struggle with lisping disorders of varying levels of severity. Lisps are also one of the most-often portrayed speech disorders in popular media: from Drew Barrymore, whose barely perceptible lisp is mild if not a little cute, to Sylvester the Cat and Daffy Duck’s less-than-sensitive and completely cartoonish portrayals of severe and dramatic lisping.

True lisping is the inability to accurately articulate /s/ and /z/ sounds due to inaccurate tongue placement. You might also find yourself working with patients who lisp on /sh/, /ch/, and /j/, although these lisps are less common.

When Beiting started working in an elementary school she found herself face to face with these classic difficulties in some of the children she worked with. After quite a bit of self-study, Beiting became increasingly proficient at treating those with a lisp and even created her own starter curriculum that she developed for other SLP professionals to fill what she saw as a gap in standard curriculum offered in SLP graduate programs.

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Why People Lisp

Lisping is considered a functional speech impediment, which means that the individual’s difficulty making specific sounds doesn’t necessarily have any known origins. A few possible reasons an individual might have a lisp include:

  • The individual learned to say these sounds incorrectly as a child and needs to relearn them.
  • There is a jaw alignment issue. All5 host Sam is a good example of this type of lisp.
  • The individual was born with ankyloglossia, or tongue tie, where the tongue is partially tethered to the floor of mouth, restricting movement.

In many cases, there doesn’t seem to be any clear reason that the child struggles to accurately place their tongue when speaking. The good news is that even if this is the case, you can still help.

Types of Lisp

Professionals divide lisps into four categories:

  1. Frontal Lisps – In frontal lisps you might find individuals that push their tongue too far forward, so that your patient will “go to the thoo (zoo)” and “eat some thoop (soup)”. Frontal lisps are the most common type of lisp. For a classic example of a frontal lisp check out this clip.
  2. Lateral Lisps – With lateral lisps air slips over the sides of the tongue so that /s/ and /z/ sounds come out wet and slushy. Individuals with a lateral lisp often sound as if they have too much saliva in their mouth (think Sylvester the Cat).
  3. Palatal Lisps – In a palatal lisp the speaker touches their tongue to the roof of their mouth when saying /s/, /z/, and sometimes /r/. Specialist Caroline Bowen AM, PhD, SLP says that if you try to pronounce an /h/ followed closely by a /y/ and prolong it you will get an approximation of the sound this type of lisp makes. Confused? Listen to SLP Mark Little’s portrayal of a palatal list here.
  4. Dental Lisp – This can be easily confused with a frontal lisp. With a dental lisp, instead of sticking their tongue between the front teeth the individual pushes their tongue against the teeth. So, what you hear will sound like a frontal lisp but when you work with the individual to figure out where their tongue is you’ll find that it doesn’t come through their teeth.

Tongue Thrust or Lisp? Does it Matter?

Just because an individual speaks with an apparent lisp doesn’t mean that lisping is the primary problem to address.

Tongue thrust, also known as “reverse swallow”, is an orofacial muscular imbalance where the tongue comes forward in an exaggerated manner between the teeth. This can happen while speaking, swallowing, or even when the tongue is at rest.

Because tongue thrust can cause significant dental issues in the future, it’s important to determine whether or not your patient’s lisp is actually the result of tongue thrust.

When addressing the difference between a normal lisp and tongue thrust, Gal Levy writes that there are a few things you want to keep an eye out for:

  • Protrusion of tongue between or against upper and/or lower front teeth when articulating /s/, /z/, /t/, /d/, /n/, /l/, and/or /sh/.
  • Open-mouth resting posture that includes parted lips and/or tongue resting against teeth.
  • Cracked, chapped, or sore lips from frequent licking.
  • Mouth breathing even in the absence of allergies.

If you notice your patient has a combination of the above, you are most likely looking at a tongue thrust issue. Therapy for a tongue thrust focuses less on articulation and more on swallowing and resting tongue patterns, so simply treating for a lisp won’t solve the issue.

Most children with tongue thrust issues outgrow them by age six, but if you consult with a child older than six you will want to get them started on therapy earlier than later.

Treatment for Lisping

Each type of lisp needs to be treated according to it’s specific tongue placement issues, however you’ll find that treatments used for adults are usually similar to those used for children.

Your treatment plan will likely follow a path similar to this:

  1. Assessment: Test the individual with problem sounds that occur at the beginning, middle, and end of words. Look for evidence of the four types of lisp, as well as tongue thrust. Watch for any words where your patient actually pronounces their problem sounds correctly. You can find words lists to help in your assessments here and here.
  2. Awareness: Sometimes an individual is only minimally aware of their own problem. Help them with this by using some modeling techniques: say the words with and without a lisp, asking them to identify your correct and incorrect pronunciation. Consider taking video of the individual speaking, and ask them to listen for correct and incorrect pronunciation.
  3. Tongue Position: Next you’ll help the individual find the right tongue position. If they were able to say the problem sounds accurately in any of the words during assessment, you’ll go back to those words and help them become aware of where their tongue position is. Once you find it, you’ll practice saying the sound correctly.
  4. Words and Phrases: Next you’ll build on this tongue placement by saying the sounds repeatedly in single words, and then moving up to phrases. You can find a great list of activities and word games for this here.
  5. Conversation: After working on numbers 1-4 repeatedly for each problem sound, you’ll begin working on using the sound in conversation.

At What Age Should We Start Treating a Lisp?

A parent come to you expressing worry that their three year old is lisping. Is it too early to start therapy?

The answer is that it really depends.

You’ll want to first understand what type of lisp the child is exhibiting, and then encourage the parent to either wait or start therapy based on your assessment. Generally you’ll want to follow these standards for starting therapy:

Frontal Lisp: 7-8 years old

Lateral Lisp: 4 ½ years old

Palatal Lisp: 3-4 years old

Dental Lisp: 4 ½ years old

Lateral and Palatal lisps are not developmental and children will not grow out of them. Because of this, it’s important to stress to parents that they shouldn’t just “wait and see.” Lateral lisps in particular can be difficult to correct, and the earlier you start the more likely you will be to see success.

When to start treating earlier:

Hindy Lubisnky, MS, CC-SLP and director of the Graduate Program in Speech-Language Pathology at Touro College writes that sometimes you will want to start treating a child earlier than the recommended ages. She offers this list of concerns that may indicate the need for earlier intervention:

  • Has the child’s hearing been tested?
  • Is intelligibility significantly affected?
  • Is only one sound (i.e., /s/) affected, or are multiple sounds affected?
  • Is the child a sloppy eater?
  • Does the child use their lips when eating?
  • Is the child using their tongue inappropriately when eating?
  • Is the child a mouth breather, also holding their mouth open at rest?
  • Can the child lick food off their upper lip?
  • Can the child closer their teeth and keep them closed, tongue inside, to the count of five?
  • Does the child have recurring upper respiratory illnesses?

Some of these issues are signs of low oral musculature tone and need to be addressed early on.  Addressing low tone issues along often resolves lisping.

Chronic respiratory issues and mouth breathing can be signs of medical issues that will compound any speech issues, so you’ll want to refer the child for further examination if you suspect respiratory issues before starting therapy.

Additional Certification In Treating Lisps

Although there aren’t any industry standards for certification in treating lisps you can find a handful of webinars, books, and conferences to help you better treat patients who lisp.

Here are a few suggestions to get you started:

On Site Continuing Education Courses: Periodically, experienced SLP’s offer on-site courses in their area of expertise. You may need to travel to take these courses, but sometimes you can work with your therapy center or school district to bring the courses to you. Here are a some solid options:

Online Resources: Helpful downloads and courses from other SLP’s can also be found online. A few that you might want to check out include:

  • Course: Effective Evaluation and Intervention Procedures for Frontal and Lateral Lisp Disorders, taught by SLP Christine Ristuccia. This course is FREE!
  • Course: Techniques for the Lateral Lisp, taught by expert Pam Marshalla.
  • Course: Frontal Lisp, Lateral Lisp, taught by expert Pam Marshalla.
  • Therapy Materials: Lisp-related therapy materials from Karen Krogg, The Pedi Speechie.
  • Therapy Materials: Lisp-related session plans from Molly Beiting at Speech Language City.
  • APP: Abitalk offers an app called Lisp Therapy that you can use with children when working on their lisp.

Books: Sometimes in a world of fast-paced technology you still just need a really solid book to fully explore the depths of an issue. Both of these books by highly experienced SLP’s should give you a solid foundation to work from.

One of the exciting aspects of working as an SLP is that as you improve your ability to help patients you can also contribute to the wider conversation on speech-language difficulties.

As you further your skills and eventually become an expert yourself, consider following SLP Molly Beiting’s example and providing materials online through a blog or Teachers Pay Teachers. Your contribution has the potential to impact children and adults you may never work with personally.