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ASSESSMENT OF CLEFT PALATE SPEECH IN THE UK

Anne Harding-Bell MRCSLT PhD

De Montfort University, Leicester, Addenbrookes Hospital, Cambridge

Abstract
In the UK, GOSSPASS ’98(Great Ormond Street Speech Assessment) (Sell Harding and Grunwell 1994
and 1999) is a widely used, detailed assessment of cleft palate speech. It was revised in 1998 alongside the
development of a complementary audit protocol, CAPS (Cleft lip and palate Audit Protocol for Speech
1996).
The parameters assessed in both GOS.SP.ASS and CAPS are nasal resonance, nasal emission, nasal tur-
bulence, grimace, voice, and cleft-type characteristics affecting consonant production. Cleft-type character-
istics (CTCs) are categorised in a hierarchical order:
a) anterior oral CTCs: dentalisation, lateral/lateralisation, palatal/palatalisation,
b) posterior CTCs: backing to velar, backing to uvular,
c) non-oral CTCs: pharyngeal/glottal articulation, active nasal fricative and
d) passive CTCs: weak nasalised realisations, nasal realisations of plosives, nasal realisation of frica-
tives, and absent pressure consonants.
The prevalence of each characteristic can be indicated. In addition, the CAPS protocol rates intelligibility
and GOS.SP.ASS records details about appearance of speech, oronasal structure and aetiological factors.
All patients should be video and audio recorded at audit; 3;0, 5;0, 10;0, 15;0 yrs. Replicable speech sam-
ples are elicited through spontaneous speech, counting and sentence imitation. Consonant targets included
are nasals, plosives, fricatives, affricates and lateral approximants. Vowels are not specifically targeted but
vowel distortions are noted. Realisations of consonant targets are transcribed (IPA 1993, Extensions to the
IPA 1990, a Note on describing types of nasality 1996). The stimulus sentences include target sounds in 3
word positions and exclude distracting pressure consonants.
For analytical purposes the broad categorisation of anterior, posterior, non-oral, and passive CTCs have
been found to achieve high levels of listener agreement. These categories may well be applicable to cross
linguistic studies.

Acknowlegements
The fact that Speech and Language Therapists in the UK can present an approach to speech assessment
which is recommended for nationwide use is a tribute to the gracious nature of many in our profession. We
have shared a desire to make valid assessments and to be able to compare results which we are able to do
now. Key people to thank are Roz Razzell for her work comparing the speech protocols, Kim Harland for
her inspiration in creating CAPS, Debbie Sell and Pam Grunwell for collaboration in revising GOS.SP.ASS
’94 and the SIG committee for initiating the speech assessment project. To all my valued colleagues who
have contributed to listening exercises and rated speech samples, thank you.
Protocols for speech assessment are essential for future audit and research. Without collection of core
data outcomes of sugery cannot be evaluated and intercentre comparisons are impossible. The Goteborg
Congress provides an opportunity for consideration of current UK speech assessment protocols in an inter-
national context. This paper presents a method of speech assessment; some issues relating to specific pa-
rameters; and an example of data analysis and interpretation.
In 1993 there was growing awareness of the need to measure speech outcomes but no protocol existed
for data collection. Various centres expressed an interest in identifying an optimal protocol in order that it

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could be recommended for nationwide application. The Cleft Palate SIG supported a study to compare ex-
isting protocols (Razzell and Harding 1995, Harding Razzell and Harland in preparation) and 6 centres sub-
mitted their protocol for comparison. The optimal protocol chosen 12 expert raters was GOS.SP.ASS (Sell,
Harding and Grunwell 1994) however the comparative process revealed some ambiguities and omissions
in GOS.SP.ASS which needed to be addressed before it could be recommended for national use. Revised
GOS.SP.ASS ’98 (Sell Harding and Grunwell 1998) was developed simultaneously with an audit protocol
Cleft Audit Protocol for Speech (CAPS). (Harding, Harland and Razzell, 1998). As a result of close collab-
oration in their preparation, the two procedures can be used concurrently and their results are comparable.
The parameters assessed in both protocols are hyper nasal resonance, hyponasal resonance nasal emis-
sion, nasal turbulence, grimace, voice, and consonant production. GOS.SP.ASS has a more detailed analysis
of nasality and consonant production but does not include an intelligibility rating.
Application of both assessments is facilitated by the availability of a video containing definitions and ex-
amples of each parameter on GOS.SP.ASS. CAPS uses simplified rating scales in the nasality section. The
video also illustrates transcription symbols and diacritics. Whilst there are no absolute rights and wrongs in
transcription of speech the GOS.SP.ASS video provides a yardstick for interrater training and outcome
measurement.
Speech assessment is based as far as possible on a replicable sample of speech which includes counting,
sentence repetition and a spontaneous speech sample. The consonants targeted in sentence repetition are bi-
labial nasal and plosives / m p b /; labiodental and dental fricatives / f v / , / / ; alveolar plosives, fricatives
and nasals / t d s z n /; lateral / l /; post alveolar fricative and affricates / /; velar / /; and glottal
/ h /. The purpose of sentence repetition is to elicit the target consonant within a speech stream. The sentence
context is manipulated to eliminate distracting sounds which might influence both production and percep-
tion of the target sound. Each sentence includes the target consonant in word initial, word final and medial.
Transcription is made off realization in word initial and word final position. Vowels are not specifically tar-
geted but vowel distortions are noted and assessed separately. It is important to recognise vowel distortion
because vowel disturbances seriously disrupt intelligibility and may indicate hearing problems. Picture
Stimuli for eliciting sentence repetition are distributed with CAPS.
Rating Hypernasality [ ]
Since hypernasal resonance is most easily perceived on vowels ratings of hyper nasal resonance are best
made on words without nasal consonants such as the number string, “ 2 3 4 5”. The GOS.SP.ASS scale for
rating resonance has been extended to a 4 point scale because the previously recommended 3 point scale
was not thought to be sufficiently sensitive to minor changes in resonance. With specific training and lis-
tening tasks it is possible to achieve a high level of interrater agreement on this scale (Sell et al, personal
communication 1996). However routine audit may not permit this level of preparation so CAPS has includ-
ed a broader scale.
Various phenomena in speech can restrict the validity nasal resonance ratings.
1. Voice quality: if, after making a resonance judgement the voice is subsequently rated as dysphonic,
then the resonance judgement is to some extent invalidated. With reduced voice the resonance quality
will be temporarily distorted and not representative of the normal quality.
2. Judgements of resonance are elevated by a predominance of nasals such that the string “Mum came
home early” will, inevitably, have more nasal resonance than the sentence “Gary’s got a bag of lego”.
Hence ratings of hypernasal resonance on speech samples containing a predominance of nasal reali-
zations may be inflated by the predominance of nasals.
3. Excessive nasal emission present on pressure consonants can distort one’s perseption of nasal reso-
nance. It is difficult to make an accurate perceptual judgement of nasal resonance when pressure con-
sonants are affected by excessive nasal emission.
4. Prevalent pharyngeal and glottal articulation may involve the base of tongue approximating the pha-
ryngeal wall. This tensing of the vocal tract must modify the both vocal quality nasal resonance.
5. Complexity of the speech pattern also influences the perception of resonance. There may be consid-
erable variability in which parts of the sample particularly influence resonance and emission ratings.

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Consistent/inconsistent ratings
It is clinically important for users to record whether hypernasal resonance is consistent or inconsistent be-
cause management might be different for cases of consistent hypernasality. Inconsistent ratings suggest a
need for more observation and assessment and consideration of other factors such as hearing loss, environ-
ment, or the speech context. Parents report of resonance changes when a child is tired, miserable or stressed
would contribute to a prediction of inconsistent VPI.

Nasal emission [ ]
Since nasal emission is not related to voice but to airflow, it only occurs when a high volume of air is under
pressure during production of pressure consonants. Production of sentences targeting “p t k f s sh” provide
the most reliable indication of nasal emission. In fact, ratings of nasal emission are only applicable to speech
samples which contain oral pressure consonants. If consonant realizations are restricted to glottal, pharyn-
geal, nasal and approximant consonants, then a nasal emission rating must be deferred.
Inaudible nasal emission can only be perceived by instrumental measure of nasal airflow on production
of an oral pressure consonant or sound. In order to detect inaudible nasal emission the mirror test is included
on the revisied GOSPASS form. A mirror is held under each nostril during production of a few syllables:
[ pa pa, pi pi, ka ka, ki ki ] and sustained [ sssss ]. Production of the velar consonant-vowel syllable
[ ka ka ka ] versus bilabial consonant-vowel syllables [ pa pa pa ], may detect differences in nasal emission
related to an anterior fistula.
Nasal emission ratings can be further confounded by phoneme specific nasality or active nasal fricatives
[ ] because oral airflow has been actively ‘stopped’ by lips or tongue thereby forcing the airglow
nasally. In such cases assessment of nasal airflow during production o plosive consonants “p t k” is likely
to show entirely oral airflow. If oral pressure can be achieved for /p b t d/ then nasal airflow in [ ]
is phoneme specific. Nasal emission on plosives is therefore diagnostically relevant when excessive nasal
emission on fricatives is prevalent.
Nasal turbulence [ ], a distracting nasal quality, is listened for on production of nasal consonats or
pressure consonants as in the sentence “Ben is a baby boy”. Nasal turbulence has been described as a severe
form of nasal emission (McWilliams 1984), but it has been shown that the distracting turbulent noise is as-
sociated with a narrow velopharyngeal gap (Kummer et al 1992) perhaps caused by either irregular shaped
adenoids, mild VPI with nasal congestion, or a constricted nasal airway due to collapsed nasal septum.
Huponasal resonance [ ] is rated on nasal consonants and would be particularly noticed during
counting the numbers 15, 16, 17, 18, 19, 20 and in the sentences for / /. A rating of 1 indicates mod-
erate hyponasality where nasal consonants are slighty denasal. A rating of 2 registers that target nasal con-
sonants are perceived as plosives.
The relevanee of identifying hyponasal resonance is to ensure that children with cleft palate have a patent
nasal airway, that they can sustain lip closure and tongue contact with the hard palate and that they are
healthy, thriving children. It is important to make a rating of hyponasality irrespective of the hypernasality
rating because the two qualities can co-occur in the same speech sample.

Consequences of persistent hyponasality

Sustained open mouth posture limits the contact of the tongue tip with the hard palate which may precipitate
back of tongue articulation. A lack of sustained upward and forward pressure exerted by the tongue to en-
courage growth of the maxilla can affect facial growth. (Oblak and Koselj 1984) Without sustained lip clo-
sure the restraining influence of the upper teeth on jaw growth cannot be maintained and hearing may be
reduced because eustachian tube function is compromised by less frequent and less active dry swallows.
Finally, there are social disadvantages to nasal obstruction because it is has a negative affect on facial ap-
pearance particularly during eating and there may be persistent drooling. It is frequently the speech assess-
ment that identifies hyponasality and alerts the team to the need to manage a nasal airway problem.

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Figure 1. Anterior and Posterior Oral Cleft Type Characteristics (CTCs)

Figure 2. Non-oral, active Cleft-Type Characteristics requiring no velopharyngeal sphincter closure.

Grimace is assessed because it is visually distracting and often signals increased effort to control nasal
airflow. GOS.SP.ASS distinguishes between: nasal flare which involves only the nostrils; nasal grimace
which involves the lower face and facial grimace which includes furrowing of the brow. Grimace can occur
without any audible cleft-type characteristics.

Consonant production
Realizations of consonant production are transcribed phonetically and realisations thought to be typical of
cleft palate (cleft-type) are identified on the hierarchical list of cleft-type realizations. The list was derived
from an extensive literature review (Harding and Grunwell 1996) and the hierarchical order reflects the rel-
ative severity of the characteristics. Severity here refers both to the potential impact of a characteristic on
speech intelligibility and the implications for management. There is no requirement in either GOS.SP.ASS
or CAPS to note fequency of each cleft-type characteristic but recommendation has been made that some
convention such as double ticks, or circle, could be used to identify characteristics which occur frequently.
Those characteristics occuring very occasionally in a sample could be recorded with a dotted circle, or tick,
to indicate that it has occurred only once. Data analysis would then specify whether occasional occurrences
were included in data analysis or whether the most prevalent occurrences were the focus of interest.
A major innovation in revised GOS.SP.ASS and CAPS is categorisation of Cleft-type characteristics
(CTCs) into diagnostically relevant clusters of CTCs: anterior and posterior ‘oral’ CTCs, non-oral CTCs
and passive CTCs. (see Figure 1) Passive characteristics include productions which are apparently the pas-
sive consequence of velopharyngeal dysfunction, or less commonly of fistulae, and reduce potential for
achieving and/or sustaining intra-oral pressure (Harding and Grunwell 1996, Harding and Grunwell 1998).
(see Figure 2)
These 5 descriptive categories are particularly relevant for audit and research because it has always been
a challenge to establish listener agreement on ten parameters which have to be rated almost simultaneously.
Although the terminology and definitions of the ten cleft type characteristics are presented in
GOS.SP.ASS’98, listeners are likely to use different definitions or may apply the same definitions differ-
ently. Clinicians are often unsure about exact transcription particularly when speech patterns are complex.
However unsure a clinician might be about exact phonetic transcription, all cleft type realizations are attrib-
utable to one of the five placement based categories. The descriptive terms for groups of CTCs assist cate-
gorisation and are meaningful to both speech and language therapists and to non-speech and language
therapists in reporting outcome results. They also have potential for cross-linguistic studies.

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Figure 3. Passive cleft-type chracteristics (CTCs) Passive nasal fricatives and absent pressure consonants.

Diagnostically relevant cleft-type characteristic (CTC) categories

– anterior oral cleft type realizations (CTCs). see Figure 1
0. dentalisation which is often associated with class III malocclusion. Although dentalization is com-
monly regarded as a normal immaturity, “fronting” was a noticeable feature in the Eurocleft Study
(Eurocleft Speech Group 1993) where the subjects were over 8 years old.
1. Lateralisation/lateral: [ ] is associated with dental alveolar arch irregularities
2. Palatalisation/palatal [ tj ç ] is associated with dental irregularities and or fistulae. Realizations which
might also be categorised as palatalised are alveolopalatal fricatives [ ] shown on the IPA chart
revised to 1993 in the section headed “Other symbols”.
2/3. Double articulation has been categorised as 2/3 because, like dentalisation, it is additional to the
categories included in CAPS. It can be precipitated by an anterior fistula. The use of a “two num-
bered” rating for this category suggest the unique double place of articulation. [ ]
– posterior oral CTCs see Figure 1
3. backing to velar: / m p b / and or / n t d s / => velar [ ] and possibly / l / => [ j ] and backing
to uvular e.g. / t k s / => [ ]. Backing is synonymous with ‘retraction’ and is associated with an
anterior defect in the hard palate (Lohmander-Agerskov 1995)
– non-oral CTCs: see Figure 2
4. pharyngeal [ ]
glottal [ ]: often precipitated by with VPI (past or present)
active nasal fricative / f s / => [ ] [ ] [ ] also known as phoneme specific nasality (Trost-Car-
damone 1990) and reported to occur in children with no VP dysfunction (Peterson and Graham 1990)
Distinction between oral and non-oral CTCs is diagnostically critical because articulation of non-oral
CTCs does not require VP closure. Hence samples which use a prevalence glottals, pharyngeal and
active nasal fricatives will not be innervating sphincter closure. (Henningsson and Isberg 1986). Na-
sal resonance may be affected by the tense vocal tract and nasal emission ratings cannot be applied.
Non-oral CTCs restrict the findings in assessing velopharyngeal function and prove difficult to mod-
ify in therapy. Given that consonant realizations are likely to be phonologised (Hewlett 1990), assess-
ment of velopharyngeal potential may be facilitated by engaging the child in sound play which might
elicit nonspeech sounds with soft oral airflow (Harding and Grunwell 1998). It is important to be
aware that new consonant productions are dependent on a child being able to generate and execute
new plans. Failure to imitate required sounds could reflect a ‘motor programming’ problem rather
than an articulatory constraint such as VPI.
– passive CTCs Figure 3
There characteristics reflect accurate articulation with limited intraoral air pressure:
8. Weak nasalised consonants e.g. [ ][ ]

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Figure 4. Passive Nasal Fricative [ (s)n]. Tongue tip approximates hard palate as for [s].
Figure 5. Active Nasal Fricative [n]. Tongue tipseals with hard palate forcing airstream nasally.

9a. Nasal realizations of fricatives e.g. / s / => [ ] or [ ]

9b. Nasal realizations of plosives e.g. / b d g / => [ ] voiced pressure consonants are the most sus-
ceptible to reduced intra-oral pressure because of the limited air supply available above the level of
the closed glottis until the glottis opens for the following vowel.
10. Absent pressure consonants: this category suggests a consonant repertoire that consists of nasals, ap-
proximants and [ h ]. It does not include a prevalence of glottal stop because this is a pressure conso-
nant.
11. Gliding of fricatives and affricates / s ∫ / / t∫ / => [ j ]. This may be either an active alternative which
has become phonologised or it may be part of a passive ‘absent pressure consonant’ pattern.

The speech categories which indicate a need for VPI investigation are the non-oral and the passive cate-
gories. If these consonant characteristics co-exist with hypernasal resonance and or excessive nasal emis-
sion then VPI investigations are recommended. It is possible that a period diagnostic of therapy would be
needed before surgery so that the clinician could identify whether normal articulation could be elicited.
Differentiation between active and passive nasal fricatives was first described in 1996 (Harding and
Grunwell 1996, Grunwell and Harding 1996) and was subsequently put into the context of phonological
processes (Harding and Grunwell 1998). The acoustic distinction between active and passive nasal frica-
tives is often imperceptible [ ]. The diagnostic probe for establishing whether a realisation is an
active nasal fricative e.g. [ ] or a passive nasal fricative is occlusion of the nostrils while [ fffff ] is
attempted. If ‘nose holding’ facilitates ‘s’ production then the nasal realisation is passive because target / s
/ had been correctly articulated with approximation of tongue tip to alveolar ridge and passive loss of air
nasally (see Figure 4). If noseholding blocks consonant production, this is a sign that the appropriate oral
airstream was actively ‘stopped’ by tongue sealing at the alveolus thereby imposing exclusively nasal air-
flow for target / s /. (see Figure 5).
Whilst these speech protocols do not attempt to provide a phonological analysis, idiosyncracies such as
unusual vowels, initial consonant deletion or atypical realisations would be noted on the assessment form.
Summary of speech pattern
This summary section of the findings from the cleft-type characteristics categorises the cleft-type errors
anterior oral CTCs (2), posterior oral CTCs (3), non-oral CTCs (4) and passive CTCs (5) as described
above. Speech patterns with no CTCs and normal for age consonant realizations are rated 0. A rating of 0–

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Figure 6.

Figure 7.

Figure 8.

Figure 9.

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Figure 10.

Figure 11.

1 is used to identify a speech pattern which is not completely normal but which contains none of the listed
CTCs.
These categories are not mutually exclusive and hence more than one may occur in any speech sample.
An overview of any speech sample would include information about nasal resonance, nasal emission and
nasal turbulence in addition to the speech summary categorisation.

Data Analysis
A listening exercise at a VCFS workshop provided an opportunity for exploring the analytical interpretation
of CAPS data. 12 listeners with a range of experience in assessing cleft palate speech rated 5 speech samples
(3 VCFS and 2 non-VCFS). On the rating scale for each parameter, a point was identified which distin-
guished an acceptable score from an unacceptable score. An “unacceptable” score indicated that further in-
vestigation would be required whereas an ‘acceptable’ rating indicated no need for further intervention. An
average percent agreement score for ‘unacceptablitity’ was derived from the 12 ratings for each parameter.
This indicated the degree to which listeners agreed that this parameter was unacceptable. Figure 6 illustrates
that all 5 average percent agreement scores for hypernasal resonance were high. Figure 7 shows the agree-
ment that audible nasal emission (ANE) was present. These results were unexpected given that all the sam-
ples showed ‘unacceptable hypernasal resonance’. It is hypothesized that the weak acoustic signals present
in nasal emission cannot be satisfactorily captured on video. The ANE ratings in Figure 7 are shown for
completeness but are not necessarily a reflection of the actual ANE present in the speech samples. Figure 8
illustrates that the percentage agreement showed passive CTCs in 4 out of 5 samples. Figures 9, 10, 11 il-
lustrate that occurrence of oral CTCs (anterior and posterior) was infrequent but four samples contained
non-oral cleft-type characteristics. This data shows since non-oral CTCs are frequently a response to VPI

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(past or present) and passive CTCs are reported to be the direct consequence of VPI, the cleft-type charac-
teristics identified by the listeners are consistent with the nasal resonance ratings in all samples.
Sample S5 illustrates an active response to suspected VPI in which the speaker has adopted non-oral
CTCs in an attempt to compensate for the articulatory restrictions imposed by VPI. The presence of agree-
ment that some anterior and posterior oral CTCs also existed suggests that this speaker was able to achieve
some VP closure.
This analysis indicates that data collected using CAPS and a panel of 12 listeners all with some experi-
ence of rating cleft palate speech, is able to differentiate between types of cleft-related speech problems. For
formal audit or research a training period with a panel of listeners would be expected to achieve a higher
level of agreement.
With regard to listener agreement it is suggested that an element of individual difference is inevitable in
this type of multi-level task where listeners are required to rate 10 parameters from a 5 minute speech sam-
ple.
Differences in rating are particularly likely because cleft specialists have a wide range of different learn-
ing experiences and understanding about cleft palate speech. Although the common reference provided by
the GOS.SP.ASS training video should ensure closer agreement it is recommended that analytical proce-
dures of speech data should be able to absorb individual differences. Average percent agreement applied to
a large group of listeners is a valid approach. It could be used for 3 or more listeners providing that any
pattern of influence from a single listener was exluded.
International speech comparisons may be facilitated by categorising speech results into anterior, posteri-
or, non-oral, and passive CTCs. Use of this system would eliminate the difficulty agreeing cross-linguistic
definitions of 10 or more speech characteristics and yet would clearly identify the most salient information
in measuring speech outcomes.

References
1. Grunwell P. and Harding A. (1996) A note on: describing types of nasality Clinical Linguistics and
Phonetics vol 10, no 2 157 – 161
2. Harding A., Grunwell P. (1996) Characteristics of cleft palate speech. European Journal of Disorders
of Communication Vol 31 No. 4 331 – 358
3. Harding A., Grunwell P. (1998) Active/versus passive cleft-type speech characteristics: research
based proposals for clincial application of this distinction (1998 International Journal of Language
and Communication Disorders vol 33 329 – 352
4. Harding A., Harland K, Razzell R (1998) CAPS Cleft lip and palate Audit Protocol for Speech. Speech
and Language Therapy Department, St Andrews Centre for Plastic Surgery, Broomfield Hospital,
Court Rd, Chelmsford Essex
5. Harding A, Harland K, Razzell R CAPS: Cleft lip and palate Audit Protocol for Speech: its rationale
and application. (submitted to International Journal of Language and Communication Disorders)
6. Henningsson G. and Isberg A.M. (1986) Velopharyngeal movement patterns in patients alternating
between oral and glottal articulation. A clinical and cineradiographicical study. Cleft Palate Journal,
23: 1 – 9
7. Hewlett N (1990) Processes of development and production In Grunwell P (Ed) Developmental
Speech Disorders. Edinburgh Churchill Livingstone
8. IPA (1993) International Phonetic Alphabet Chart, revised to 1993, Journal of International Phonetic
Association, 23
9. Lohmander-Agerskov A Soderpalm E Friede H Lilja J 1995 A longitudinal study of speech in 15 chil-
dren with cleft lip and treated by late repair of the hard palate. Scandanavian Journal of Plastic and
Reconstructive Surgery 29 21 – 31

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10. Kummer A. W., Curtis C., Wiggs M., Lee L., Strife J. L. (1992) Comparison of velopharyngeal gap
size in patients with hypernasality, hypernasality with nasal emission and nasal emission, or nasal tur-
bulence (rustle) as the primary speech characteristic. Cleftpalate-Craniofacial Journal, 29: 152 – 156
11. McWilliams B.J., Morris H.L., Shelton (1990) Articulation and intelligibility Cleft Palate Speech, On-
tario, B C Decker p.246
12. Peterson S J, and Graham M S (1990) Phoneme specific nasal emission in children with and without
physical anomalies of the velopharyngeal mechanism. Journal of Speech and Hearing Disorders 55,
132 – 139
13. Oblak P and Koselj V (1984) Basic principles in the treatment of cleft at the University Clinic for Max-
illo-facial surgery in Llubljana and their evolution in 30 years. In Hotz, WM Gnoinski, MA Perko, H
Nussbaumer, E Hof (eds) Early Treatment of Cleft Lip and Palate. Proceedings of the Third Interna-
tional Symposium. Zurich. Hans Huber.
14. Sell D., Harding A., Grunwell P (1998) GOS.SP.ASS’98 an assessment for speech disorders associ-
ated with cleft palate and/velopharyngeal dysfunction (revised).
15. International Journal of Language and Communication Disorders 1998 vol 33 17 – 35
16. Sell Harding and Grunwell (1999) GOSSPASS Video: Characteristics of cleft palate speech A training
video for assessment of cleft palate speech Dept Medical Illustration, Great Ormond Street Hospital
for Children NHS Trust, London WC1N 3JH
17. Trost-Cardamone J.E. (1990) The development of speech: Assessing cleft palate misarticulations. In
Kernahan D.A. and Rosenstein S.N. Cleft Lip and Palate: A system of management. Baltimore, Wil-
liams and Wilkins

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Appendix 1 GOS.SP.ASS form

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Appendix 2 CAPS Form

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Appendix 3 CAPS Rating scale

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Appendix 4
Sentences elicited for GOS.SP.ASS
Mary came home early
The puppy is playing with a rope
Bob is a baby boy
The phone fell off the shelf
Dave is driving a van
Neil saw a robin in a nest
A ball looks like a balloon
Tim is putting a hat on
Daddy mended a door
I saw Sam sitting on a bus
The zebra lives at the zoo
Shaun is washing a dirty dish
Charlie’s watching a football match
John’s got a magic badge
The bell’s ringing
Karen’s making a cake
Gary’s got a bag of lego
Hannah’s hurt her hand
This hand is cleaner than the other

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REORGANISATION OF CLEFT SERVICES IN THE UNITED

KINGDOM

Jonathan Sandy1, Mark Henley2, Tim Milward3, Alison Williams1

1University of Bristol Dental School, Lower Maudlin Street, Bristol, BS1 2LY, UK
2Nottingham City Hospital, Nottingham, NG5 1PB, UK
3Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 7TF

Purpose
The purpose of this investigation was to examine the process of care and standards of outcome in children
born with a unilateral cleft lip and palate within the United Kingdom (UK).

Methods
Previous studies in the UK had suggested that the majority of cleft teams dealt with a small number of new
cleft patients each year. These low volume teams provide small numbers of different types of cleft and
therefore meaningful comparisons of outcomes are impossible to obtain. With this in mind, the only way
that National standards of care could be established was to sample cleft patients throughout the UK. We
examined two age cohorts, five year olds (born between 1/4/89 – 31/3/91) and twelve year olds (born be-
tween 1/4/82 and 31/3/84). The sample was identified from a search of operating books. In addition, details
of care including surgery, speech, audiology and dental health were also collected. Outcome data was ob-
tained using protocols for audiology, speech, dentofacial appearance, dento alveolar appearance and cranio
skeletal relations.

Results
At the time of the survey there were 57 cleft teams involved in cleft care. There were a total of 75 cleft sur-
geons operating on these children. A total of 647 children (326 five year olds and 321 twelve year olds were
identified) and 601 of these children were invited to attend data collection days. In all we examined 76% of
these children who were invited. The outcomes were extensive, but as a whole, they were disappointing.
Sixteen percent of twelve year olds had not received a secondary alveolar bone graft and of those who had
a graft, only 52% of the grafts were successful. The dental arch relationships were also poor, in 36% of the
five year olds and 39% of the twelve year olds, there was an underlying skeletal III discrepancy. Twenty
percent of the patients had poor lip appearance and 42% had poor nasal appearance. In 19% of five year
olds and 4% of twelve year olds, speech was difficult to understand. Hypernasality occurred, or had oc-
curred in 27% of five year olds and 31% of twelve year olds. There was mild or moderate hearing loss in
21% of five year olds and 16% of the twelve year olds. Remarkably the parents of the twelve year old pa-
tients were generally satisfied with the outcomes and care received. We also noted there were significant
residual treatment needs in surgery, speech, hearing and dental care.

Discussion
The care of children born with oro-facial clefting has been exposed to significant scrutiny and reorganisa-
tion within the last five years in the UK. These children have the most common craniofacial anomaly and
this is seen in about 1:700 live births. Treatment of any facial anomaly in children is emotive, demanding,

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