10th World Cleft Lip & Palate Congress of the International Cleft Lip and Palate Foundation (ICPF)

24-28 Oct 2016, Hyatt Regency Hotel, Chennai, India. www.cleft2016icpf.com

Symposium 3. Speech in Cleft Care: Challenges Facing the Speech Pathologist

Management Strategies in Restoration of Speech and Language in Children

Usha A Dalvi, MSc (Speech & Hearing) PhD
Assoc. Prof. of Audiology & Speech Language Pathology, SRM Medical College, SRM University

Manuscript
Humans have a distinct mode for communication, namely Speech. Everyone has his own right to
communicate. The presence of a cleft lip and palate or isolated cleft palate may have negative
impact a child’s effective communication. It causes significant setback in their social, emotional,
and educational domains. Restoration of communication ability is a critical aspect of
comprehensive cleft care.
Language disorders

Communication disorders associated with cleft palate, is directly associated with speech
production defects, especially articulation and resonance. However, it is essential that one
understands that communication is made up of several components including hearing, receptive
language, expressive language, speech, resonance, voice, and The social use of language is most
commonly referred to as ‘pragmatic skills’” All these components can be affected by the
presence of a cleft. There is a common assumption that very little that occurs in the
communication development of affected children prior to the onset of words or prior to palate
repairs.

Articulation Disorders
Children with cleft palate as well as all other children progress through a sequence of stages
which need not be associated with their chronological age. Speech and language are closely
linked especially during early development. Children with cleft palate have limitation of oral
structures, which result in complex speech and language behavior. This restricts the early sound
acquisition and directly leads to reduced early lexicon development resulting in the onset and
progression of early expressive language. They also exhibit limited social interaction skills like
turn taking and use of gestures. Compensatory errors occurs as early as three years (Chapman et
al., 2003; Salas-Provance et al 2003). Golding-Kushner (2001) estimated that at least 25% of
preschool aged children with clefts undergo speech therapy for compensatory errors
The compensatory error sounds are made by shifting the place of articulations posteriorly in the
vocal tract. The ranges of compensatory articulation errors include glottal stops, velar and
pharyngeal fricatives, posterior nasal fricatives and nasal substitutions (Morris and Ozanne,
2003). The most common is glottal stop and is substituted for some or all the stop consonants /p/,
/b/, /t/, /d/, /k/, /g/ and occasionally for fricatives /f/, /s/, /sh/. These glottal stops do not occur
in many languages. When it occurs as a compensatory error in a cleft child, it affects
intelligibility of speech.

Resonance

Another commonly associated disorder in individuals with cleft palate is the incomplete
separation of the oral and nasal cavities. When this separation is not normal, or is disturbed,
several alterations in speech can occur, namely, hyper nasality, mixed resonance, cul-de-sac
resonance, weak pressure consonants, and compensatory articulation patterns. Hyper nasality is a
resonance disorder. It refers to inordinately high nasal resonance on vowels and vocalic
consonants. It is the result of abnormal coupling of the oral and nasal cavities and is a physical
phenomenon that is typically assessed by perceptual means. There is wide variability across
languages (and even across dialects of a given language) in terms of what is normal or acceptable
nasal resonance. On the other hand, nasal emission is an articulation disorder; it is the passage of
air through the nose for high pressure consonants that should not be associated with any nasal
airflow. Nasal emission may be audible or inaudible. It is often associated with reduced intra oral
air pressure. Hyper nasality and nasal emission may occur in the same speaker and often do
coexist, but they are not the same phenomena. Hypo nasality is reduction in normal nasal
resonance usually resulting from blockage or partial blockage of the nasal airway by any number
of causes, including upper respiratory tract infection, hypertrophied turbinate’s, and a wide,
obstructing pharyngeal flap. Hyper-hypo nasality (mixed resonance) is simultaneous occurrence
of hyper nasality and hypo nasality in the same speaker usually as the result of incomplete
velopharyngeal closure in the presence of high nasal cavity resistance that is not sufficient to
block nasal resonance completely. Cul-de-sac resonance is a variation of hypo nasality usually
associated with tight anterior nasal constriction often resulting in a muffled quality.

The severity of the problem will vary from one child to another, depending on the type/severity
of the cleft, age at the time of palatal surgery, efficacy of the palatal repair, presence of fistula,
status of hearing overtime, time of intervention and efficacy of intervention, associated
syndrome/conditions and socioeconomic condition of the family.

Management strategies

Recently, the focus of assessment and treatment of young children has shifted from
Rehabilitative Model to Prevention Model and effective participation – ICF perspective. Studies
have reported that early language and phonological intervention program are effective in
facilitating both speech production and language performance (i.e.) vocabulary development of a
child (Pamphona et al., 2004). An awareness of the developmental course of normal speech and
language and of communication disorders associated with cleft palate adds important
information for clinicians as they make treatment plans over the long-term course of cleft care
The focus of the therapy should be to achieve intelligible speech and improve quality of life of
the client. For effective management, the speech-language pathologist (SLP) must be able to
identify the specific articulatory, resonatory and language deficits. They should make effort to
correct the errors by using appropriate therapeutic techniques. They must also be creative and
intuitively decide prognostic success.

Grunwell (1992) notes that essence of speech therapy is to facilitate change in person’s
communication ability, the change furthermore towards progression. Following are few of the
therapy techniques generally used for developing/correcting speech and language.

Phonetic placement Approach

Phonetic placement approach is used for correct production of targeted phoneme. One At a time.
In this initially the clinician makes the child aware of the phonetic placement of the target sound
/p/ and facilitates to produce it in nonsense syllables. For eg, pa, pi, pu, po, ip, up, op, ap. This
would be followed by production in words and sentences.

Linguistic Approach/Phonological Approach

The study of phonology identifies the meaningful patterns of sounds in a language and how
these sounds are organized in the mind. Bowen points out that phonological development in
children involves three components: the way a sound is stored in the child’s mind; the way the
sound is actually said by the child; and the rules that connect these two processes.The primary
focuses has been to (a) established sound and feature contrast and (b) replace error patterns with
appropriate phonological patterns. In this case, the target behavior is usually based on the
phonological process that describes the error. Following phonological process identification,
individual sounds are chosen that are likely to facilitate from the target sound to other sound
related to a particular error process.

A sequence of four processes are required (Grunwell 1992) to bring about a positive
phonological change: destabilization, innovation, stabilization and generalization. To achieve a
new speech output pattern (process), the child’s current inaccurate and stable pattern must be
destabilized first. This would enable subsequent introduction of the correct pattern into the
child’s speech. The new patterns, thus learnt, should be generalized to new context. such
strategies would lead to gradual stabilization and to spontaneous speech, ultimately.

Modeling

This technique can be used for correcting articulation, resonance errors and in enhancing
language as well. Using this technique the SLP models the correct speech and language behavior
that the child has to learn. In modeling the child is not expected to achieve the target sound/
behavior immediately rather the child is encouraged slowly to approximate the target sound
using visual or auditory prompts. Immediate reinforcement of target behavior is very important.
Stimulability

This is a strategy which uses multisensory stimulation (i.e.) a sound is taught using visual,
auditory and or tactile cue. For example to teach the production of a stop consonant ‘t’ , clinician
provide visual feedback using the mirror, tactile feedback by making the child feel the burst of
air, auditory feedback by discriminating between correct and incorrect production. This also
helps in reducing the nasal emissions and phoneme specific nasal emissions. There are softwares
available like speech trainer 3, nasometer which provides visual feedback.

Focused Stimulation

This procedure is used to increase children’s vocabulary and language use. The rationale is that,
the more number of times one uses a target word while playing or communicating with the child,
it is more likely that the child will start using the target word. During the interaction the clinician
reinforces the intended response and also provides visual and auditory cues wherever necessary.

Auditory discrimination training

To help the child the child to become aware of his incorrect production and also enables the child
to self-monitor.

Oro-motor exercises

Generally oro motor exercises are carried out for achieving range of movement, strength of the
muscles, and speed of the movement of the articulator. Exercise like blowing, puffing the cheek,
which even though not associated directly with the movements required for speech, it can be
used to show the correct flow of the air stream and building up of intra oral breath pressure.
For any of the therapy technique to be effective, it is very important to empower the parent or
significant other by teaching them few simple techniques or observing the therapy session and
facilitate the child in practicing the new learnt behavior at home.

The specific speech and language problems and management strategies for different age groups
are given below:

Toddlers (1-3 years)

Speech therapy is usually initiated anywhere between 18 months to 2 years, if the child shows
• Inconsistent intra-oral breath pressure
• Deficits in the size and nature (composition) of their early sound production. Their
babbling usually consists of the sounds like /m/ , /n/, /w/ and /y/ which are low breath
pressure sounds.
• May show glottal stops and laryngeal growls.
 • Delay in emergence of expressive language skills

For the child to learn good speech habits, parents should be trained in recognizing the oral and
compensatory articulation, techniques for eliciting correct oral consonant production and
techniques for stimulating expressive language.

Morris (1984) suggests that there are two major subgroups of children with marginal
velopharyngeal dysfunction. These two groups can be easily distinguished by their response
to short-term therapeutic intervention. The first is the “almost-but-not-quite” (ABNQ) subgroup.
This group tends to present with mild consistent nasalization of speech that is highly consistent
among and within tasks. Morris suggests that speech therapy is not likely to be successful with
this group. A brief period of therapy for the young child with inconsistent VP function should
reveal whether further improvement is possible. The second diagnostic group of marginal
velopharyngeal function described by Morris is the “sometimes-but-not always” group (SBNA).
Children in this group generally show marked inconsistency in velopharyngeal function. Some
children in this group will show improvement in VP function with training and some will not. It
is essential to consider the children in this group who do not improve.

Preschoolers (3 – 5 years), School age Children and Adolescents (5+ years)

• These groups of children generally have residual compensatory errors and/or
compensatory maladaptive errors due to faulty learning.
• There may be persistent hyper nasality/nasal emissions.
• 30% of these children are at risk for language learning or learning disability.

After the cleft surgery the child’s articulation pattern should be monitored and appropriate
articulatory placement and air flow for correct production of speech sounds must be taught to the
child if needed. In therapy, the category of sounds will be targeted based on the child’s
stimulability and the sounds that will have the biggest ability on child’s speech intelligibility.
Initially anterior sounds are targeted as they are more visible with voiceless cognate then
followed by voicing.

When velopharyngeal symptoms persist, it is critical to establish an aggressive or intensive

monitoring or management plan to normalize the child’s speech as soon as possible in order to
avoid social and psychological concerns. The most notable risk for deterioration in
velopharyngeal function during this period and later relates to changes in the dimensions of the
pharyngeal cavity caused either by adenoid involution or maxillary advancement which requires
appropriate referrals.

Conclusion
It is well known that the presence of a cleft palate may have negative impact on individual’s
ability to communicate effectively. Speech is shaped by many dynamic linguistic processes that
are active and that should be taken into consideration long before the first words emerge in a
child’s communication. Thus, the evaluation and management of communication disorders
associated with cleft palate is a critical component. It is emphasized that speech therapy is
required at different developmental period. Clinician can use strategies in isolation or
combination. The strategies used by the clinician should have the potential to improve speech
quality, language, communication skills and overall the speech intelligibility to improve the
quality of life.

References

Bowen C. Children’s Speech Sound Disorders. 1998, Retreived on 7/22/2006. From

http://tripod.com/Caroline Bowen/phonol-andartic.htm

Morris HL. Types of velopharyngeal incompetence. In Winitz H (ed). Treating Articulation

Disorders: For Clinicians by Clinicians.Baltimore: University Park Press, 1984, pp. 211–222

Morris H, Ozanne A. Phonetic, phonological and language skills of children with a cleft palate.
Cleft Palate-Craniofac J 40(5):460–470,2003.

Chapman K, Hardin-Jones M, Halter KA. Relationship between early speech and later speech
and language performance for children with cleft lip and palate. Clin Linguist Phon 17(3):173–
197, 2003

Golding-Kushner K. Therapy Techniques for Cleft Palate Speech and Related Disorders. San
Diego, CA: Singular; 2001.

Pamplona MC, Ysunza A, Espinosa J. A comparative trial of two modalities of speech

intervention for compensatory articulation in cleft palate children, phonologic approach versus
articulatory approach. Int J Pediatr Otorhinolaryngoly. 1999;49:21–26.

Pamplona MC, Ysunza A, Ramirez P. Naturalistic intervention in cleft palate children. Int J
Pediatr Otorhinolaryngoly. 2004;68:75–81.

Salas-Provance MB, Kuehn D, Marsh J. Phonetic repertoire and syllable structure characteristics
of 15-month-old babies with cleft palate. J Phonetics. 2003;31:23–38.

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