Theresa M. Snelling, MA, CCC-SLP Pediatric Speech-Language
Pathologist Clinical Coordinator Rose Cleft Palate and Craniofacial
Center Denver, Colorado Slide 2 REFERENCES: Peterson-Falzone SJ,
Hardin-Jones MA, Karnell MP, Trost-Cardamone JE. (2006). The
Clinicians Guide to Treating Cleft Palate Speech. St. Louis, MO,
Mosby. Kummer AW. (2008) Cleft Palate and Craniofacial Anomalies:
Effects on Speech and Resonance (2 nd ed.). Englewood Cliffs, NJ:
Thomson Delmar Learning. Hardin-Jones, M., Chapman, K., and
Scherer, N.J. (2006, June 13 th ). Early Intervention in Children
with Cleft Palate. The ASHA Leader. American Cleft
Palate-Craniofacial Association (2009). Parameters or the
Evaluation and Treatment of Patients with Cleft Lip/Palate or Other
Craniofacial Anomalies. Available from www.acpa-cpf.org. Slide 3
LUKE LUKE- Diagnosis - Unilateral Complete Cleft Lip and Palate
Services Early Intervention; Individual Private speech therapy from
3- 4 ; Child Find Preschool 3-5 years.(NO SPEECH THERAPY
CURRENTLY); GOOD PALATAL CLOSURE. Surgeries: INITIAL LIP REPAIR
FOLLOWING NASO-ALVEOLAR MOLDING- 3 MONTHS; PALATE REPAIR 11 MONTHS;
3 SETS PE TUBES. Slide 4 Paige- cleft of soft palate only Palate
repair- 12 months /developed fistula; second repair pharyngeal flap
and fistula repair /developed fistula; ongoing speech therapy,
pervasive HYPERNASALITY and nasal emission. Advanced language
skills!! Wore obturator Recent re-repair 2012 = palate closure and
NORMAL resonance ! Slide 5 INFANT WITH CLEFT PALATE- early concerns
Feeding Speech sound development Open palate- cant create negative
pressure for sucking Liquid and food leak in to nasal cavity
ADAPTATIONS Feeding positioning (upright) Adapted bottle to control
for lack of suck Limit feeding sessions to 20-30 minutes to limit
calorie burn Open palate cant create oral pressure for speech
sounds Sounds needing oral pressure result in nasal airflow or
nasal resonance SPEECH ADAPTATIONS Nasal sound substitutions for
oral consonants (m/b, n/d) Increased glottal sound play Nasalized
vowels Slide 6 Oral structures for SPEECH AND FEEDING SOFT PALATE
and HARD PALATE CREATE CLOSURE BETWEEN ORAL CAVITY AND NASAL CAVITY
Slide 7 (Primary) RESONANCE DISORDERS ARTICULATION DISORDERS
***This is what Ill cover during this first half of our
presentations! (Secondary) LANGUAGE DISORDERS OR DELAY VOICE
DISORDERS (Laryngeal) Slide 8 HYPERNASAL-excessive nasal resonance
during production of VOWELS- VOWELS!!!!! HYPONASALITY- a reduction
in normal nasal resonance resulting from a partial or complete
blockage of the nasal airway by any number of sources.
HYPER-HYPONASALITY (MIXED NASALITY)-the simultaneous occurrence of
hypernasality and hyponasality in the same speaker usually as a
result of VPI in the presence of high nasal resistance that is not
sufficient to block nasal resonance completely. Slide 9 NASAL
EMISSION (articulation) Nasal emission- nasal air escape associated
with consonants requiring high oral pressure. May or may not be
audible- often seen in conjunction with hypernasality on vowels.
NASAL SUBSTITUTIONS (Articulation may overlap with hypernasal
resonance and be secondary to VPI or unrepaired cleft palate!) /m/
and /n/ substitutions for consonants For example: m/p, b, w, r; n/
t, d, l, sh; ng/n, k, g Slide 10 AVOID THE TERM- NASAL S/He sounds
nasal does not differentiate hypo and hypernasality. Slide 11
ARTICULATION PLACE, MANNER, AND VOICING Most errors related to
cleft palate have to do with PLACEMENT errors while manner is
maintained! ATTEND TO PLACEMENT!!! Usually BACKED! Slide 12 Glottal
stops, nasal snorts PLOSIVES /b, p, t, d, k, g/ AFFRICATES /tS, dZ/
Slide 13 Pharyngeal Fricatives, Nasal Fricatives Fricatives- s, z,
sh, v, th, f Affricates- ch/tS/, j/dZ/ Slide 14 Most common
articulation errors related to palatal clefts- GLOTTAL STOPS
PHARYNGEAL FRICATIVES NASAL FRICATIVES NASAL PHONEME SUBSTITIONS
Slide 15 COMPENSATORY MISARTICULATIONS Compensatory
misarticulations related to cleft palate are usually errors in
PLACEMENT OF PRODUCTION. They are learned articulatory postures or
placements that typically persist even after successful surgery or
appliance management of the pharyngeal port and therefore co-exist
with an adequate closure mechanism. They tend to be BACKED
ARTICULATIONS relative to the target place of production. Slide 16
VELOPHARYNGEAL INSUFFICIENCY Velopharyngeal Insufficiency (VPI) is
a resonance disorder associated with a natural pressure valve in
the back of the mouth that does not maintain air pressures that are
needed in typical speech production. The disorder may be structural
or functional or results in inadequate separation of the oral and
nasal cavities. ***JEFF WILL COVER THIS MORE IN PART II Slide 17
Slide 18 In therapy setting MIRROR TEST**(great with little
ones!!!) STRAW ASSESSMENT**(older children =biofeedback) In
team/clinic: (JEFF will cover) VIDEOFLOUROSCOPY
NASOENDOSCOPY/VIDEOENDOSCOPY NASOMETRY Slide 19 Goals: TO CORRECT
THE PLACEMENT ERRORS (often will improve/correct hypernasal
resonance.) Improve hypernasal resonance (if its structural
secondary surgical management is needed- but therapy should be
tried first especially in the presence of articulation errors.)
Slide 20 Therapy techniquescontinued Target high pressure- oral vs.
nasal. LABEL air flow- windy sound, lip popper for direct feedback
even with little ones (15-18 months old.) TARGET strong and varied
vowels and glides /w, l, r, j, h/ if not present or weak-Children
will often produce glides even in the presence of VPI. Slide 21
BACKING reduction TARGET BACKING ERRORS- move sounds anterior!!!
vowels (anterior round vowels /u/ /oe/) glides /w, r/not /j/
substitution mid-dorsal IS NOT the goal but may be the process of
moving sounds forward (from /k/ placement, to mid-dorsal placement,
to tip alveolar) use lips to encourage ANTERIOR airflow- rounded
lips help move air forward. Slide 22 BACKING reduction TRY
OVERPLACEMENT of articulators to decrease backing ***/t/- produced
as a /k/I often start with tongue between lips rather than on
alveolar ridge- then pull it back in mouth once they can produce
plosive with tongue tip! (Sarah) Family was given /t/ to work on-
Child produced glottal stop + vowel and in all word attempts- this
was given as homework BEFORE child could produce a /t/! Approach-
targeted /p/moved to overplacement for /t/. Slide 23 KEY POINTS:
Determine PLACE of articulation error and target with emphasis on
manner, voicing and PLACE classifications. Start with PLACEMENT-
even pending surgery. IF YOU EMPHASIZE MANNER (plosive, fricative)
with VPI- likely to teach/encourage compensatory articulation
patterns. Slide 24 VIDEOS E- th, t, d- GOAL eliminate Backing Slide
25 Stella 2 years Speech Therapy in the presence of Velopharyngeal
Insufficiency (VPI ) Slide 26 IN presence of Velopharyngeal
Insufficiency IF you teach STRIDENCY for s or sh in the presence of
VPI or unrepaired palate, child will create stridency in back of
throat = PHARYNGEAL FRICATIVE! (TARGET ONLY ORAL, ANTERIOR
AIRFLOW!!!! IF you teach PLOSIVES in presence of VPI- child may use
GLOTTAL STOP. Target light contact, anterior airflow,
overplacement,.strategies. DONT TEACH OR REINFORCE COMPENSATORY
ARTICULATION ERRORS!! Slide 27 KEY POINTS: Rule out obvious
structural issues such as a palatal fistula that does not allow for
a build up of oral pressure even in the presence of a functional
soft palate; may need obturator to cover fistula in the hard
palate. OBTURATORS ARE POSSIBLE FROM ABOUT 3 YEARS OLD
(REMOVEABLE); NON-REMOVEABLE ATTACHED TO BRACKETS ON TEETH AT ABOUT
3 YEARS OLD Slide 28 KEY POINTS: Encourage strong productions-Use
Your Big Strong Mouth. Patients frequently will try to control
nasal escape related to VPI by decreasing oral strength, pressure,
and volume. This does NOT contribute to optimizing VP closure.
Although increasing pressure and volume may increase audible nasal
emission, it may be a stepping stone allowing for contrast, and/or
improved outcome even following secondary surgery (fistula repair
or pharyngeal flap.) Slide 29 KEY POINTS: Use visual and tactile
feedback pop cotton, feel airstreams on your hand, see the tongue
hump in the back, see air on a mirror or with SeeScape, etc LUCY
p-final Slide 30 Slide 31 PROBLEMChild doesnt imitate words
IMITATION DEVELOPMENT. Eye contact/Smile Motor imitation
(pat-a-cake, peek-a-boo, SO BIG!) Vocal imitation (reciprocal
vocalization of vowels, grunting, giggling.) INFLECTION!! Easier to
imitate- thus UH OH!!! OH *#@!* MOTOR paired with sounds (BYE BYE,
UH OH) (BABY sign!) SOUND IMITATION easier developmentally than
words!!! TARGET SOUNDS if they are not yet imitating sound play!
WORDS, word combinations, phrases, sentences ESTABLISH IMITATION
LEVELBUILD FROM STRENGTH!!! Slide 32 PROBLEMChild doesnt imitate
words ESTABLISH WHAT THE CHILD IMITATES(motor movements, joint
attention, feeding the baby) BUILD ON THAT LEVEL!! Dont make WORDS
the target when child doesnt imitate motor actions in play- START
WITH IMITATION!! IMITATION, IMITATION, IMITATION- IN PLAY!! Childs
play, follow their lead, introduce new play schemes by playing them
yourself, limit questions and commands. Slide 33 PROBLEMChild
doesnt imitate words When Motor Imitation occurs in play- add
sounds, noises, facial expressions Stirring food SH, SH, SH, SH
Knock on doll house door knock, knock at same time as motor. SH,
SH, SH baby is sleeping when putting doll to bed. UH OH!! Hand to
your face-EVERYTIMEwhen they imitate putting hands to face- it
increases chance theyll pair it with approximation of UH OH! Slide
34 PROBLEMChild doesnt imitate words WHAT ABOUT INFLECTION?
Whatever BO BO! No! (yelling at dog was model) I LOVE YOU! (3
syllables approximated) Inflection is why kids say uh oh! Early!
START IMITATION WHERE THEY ARE SUCCESSFUL- THATS THE STRATEGY!!!
Slide 35 SUMMARY of Indirect Language Stimulation Reduce
questionsespecially yes/no responses. (choice questions increase
the chance of a verbal response) Dont use commands in play- model
the activity! INSTEAD: Follow childs lead Model play skills Use
self talk, parallel talk, modeling, expansion. Use exaggerated
inflection (UH OH! Oh NO!) Encourage turn-taking.2 year olds will
sit in a chair and take turns- it can still be play. Slide 36
INFANTS: Make sure parents know that sounds infant pre-palate
repair CAN make are M, N, NG, vowels, gurgles Talk and imitate
childs sound playdont push sounds they CANT make (plosives,
fricatives, affricates.) ****** Good sounds to target during play
in EARLY INTERVENTION- vowels (increase variety), /w, r/, /l/,/m,
n/. Slide 37 USE INDIRECT LANGUAGE TECHNIQUES BUT HAVE SPECIFIC
SOUND AND RESONANCE GOALS! EATING/CHEWING SOUNDS to get lip smacks!
Stacking blocks- Put block to face- make BIG OPEN VOWEL SOUNDSyou
put block onthen give block to child your turndont tell them to say
it at firstFIRST get the game of turn-taking (motor) then add
soundthen modify soundPOP IT! BIG MOUTH! Animal sounds, car sounds,
CHOOSE HIGH PRESSURE PHONEMES IF PALATE IS REPAIRED!!!! Slide 38
BOOKS CHOSE BOOKS AND TARGET WORDS TO FACILITATE HIGH PRESSURE
SOUND DEVELOPMENT Wheres Spot? BOOK = NO PUPPY! Childs response to
tell mommy dogNO PUPPY! DID YOU FEEL THE AIR POP? PUPPY!! Pop air
on their hand- let them pop it on your hand This is a great
combined language and articulation goal= 2 word combinations AND
high pressure (plosive) sound production!! Slide 39 STRIDENCY
Dolls: sh! for sleeping- targeting fricatives! FOOD/KITCHEN play-
HOT! Big open air on /h/ to work towards stridency in sh SNAKES-
Snake sounds!! ssss Shwoosh- paired with other sounds.
Paper/markers- make long lines or circles to represent continuant
feature of /s/, sh, /f/pair sound with the motor. Slide 40 HIGH
PRESSURE PHONEMES Coloring paper/markers- P, B- lip poppers- pair
sound with any motor activity. Tap marker on paper for /p/ or /t/
Train setch, ch, ch Target pop component of the ch (the /t/). /k/ =
back scraper; /t tongue tapper; /p/ popper- and feel the air on
your hand!! Slide 41 WHAT IF PALATE IS UNREPAIRED OR CHILD HAS VPI?
Target BIG OPEN vowels!!! Target anterior lip movement on vowels
(oh, oo, ow) Target Glides- yes even /l/!! Many 2 years olds CAN
make an /l/, and if theyre stimulable it will usually not result in
a compensatory articulation error. Target Glides- I work on both
/w/ and /r/ when they are backed or omitted altogether in words-
ROUND ANTERIOR LIPS move the glide forward through the mouth- THIS
IS HOW YOU IMPROVE ORAL MOTOR LIP AND TONGUE AND CHEEK STRENGTH!!
IN WORDS AND SPEECH! NOT blowing exercise! Slide 42 WHAT IF PALATE
IS UNREPAIRED OR CHILD HAS VPI? DONT teach glottal stops,
pharyngeal fricatives or nasal fricatives on accident! If palate is
open or too short, but not yet ready for surgery be very aware of
your targets!! To get good lip use, target /m/ words and tread
lightly with a STRONG /b/- will get a paired glottal stop! (Chu
Chu) Slide 43 WHAT IF PALATE IS UNREPAIRED OR CHILD HAS VPI? TARGET
Glides and BIG vowels to increase intelligibility! More accuracy on
vowels with improve intelligibility even in the presence of VPI!
VOICELESS plosives /p,t, k/are easier to approximate if VPI is
present and less likely to be paired with a glottal stop than
VOICED cognate /b,d, g/. Target voiceless, with light contact Slide
44 PRIOR TO PALATE REPAIR: Target IMITATION!! Not necessarily
specific sounds, but the GAME OF IMITATION! This goal lays the
ground work for speech therapy post palate repair. Target more than
just receptive language skills- expanding play skills and motor
imitation. Reciprocal vocalizations- develop between 6-9 months-
play with vowels and inflection and facial expressions. Slide 45
AFTER palatal repair: Teach the contrast of oral vs. nasal by using
terms like- that was in your mouth! Uh Oh, that was in your nose!
(my nose too!) Target- big, open vowelsand high pressure consonants
(plosives, fricatives and affricates) IN THE CONTEXT OF PLAY!!!
Slide 46 GOALS AND OBJECTIVES: HAVE specific targetsrelated to
resonance, articulatory placement, and compensatory articulation
patterns: High pressure phonemes (even with 18 month olds).
Stridency (sh, s) in sound play or words. Glides (w) using lip
rounding. Develop big open vowels to reduce Hypernasality. If
connected speech is mumbled with poor intelligibility- target use
your big, strong mouth. Slide 47 GOALS AND OBJECTIVES: PROGRESS
reports should include information about: Resonance. Articulatory
placement patterns. Strategies that worked to address goals.
Compensatory articulation errors. GOAL: will use plosives /p, t, k/
in single words BE SURE to document error pattern as glottal stop,
or nasal substitution or omission of consonants with vowels only
sound used Slide 48 REPORTS! INCLUDE DETAILS RELATED TO CLEFT
PALATE IN YOUR REPORTS ITS CRITICAL TO THE DECISIONS THE CLEFT
PALATE TEAM HAS TO MAKE OVER TIME! TO DETERMINE IF SECONDARY
SURGICAL MANAGEMENT IS NECESSARY- ITS IMPORTANT TO KNOW WHAT HAS
BEEN TARGETED IN THERAPY!! Slide 49 HAVE GOALS! More than just
language stimulation with young children (birth to 3) have specific
goals for articulation and resonance development related to cleft
palate. Speech therapy is still appropriately play based but that
does not mean you avoid articulation and resonance goals *BIG OPEN
MOUTH *STRONG,VARIETY OF VOWEL *SOUNDS, PAIRED WITH MOTOR
IMITATION, TO INCREASE VARIETY OF VOWELS AND CONSONANTS PRODUCED.
Slide 50 REMEMBER BLOWING AND SUCKING EXERCISES DO NOT IMPROVE
CLOSURE FOR SPEECH (they might improve blowing and suckingbut the
goal?????) No clinical, scientific research to support the benefit
to cleft palate speech error patterns for isolated blowing and
sucking exercises! SPEECH/SOUND correlation needed for speech
improvement Slide 51 Blowing, suckingwhen to use it If they have
poor lip closure and you pop cotton balls to get lip
pressureQUICKLY work into speech/sound context- Thats a lip
popper!! My lips popped- PAH! Pooh, etc. BLOWING to get oral air
because all air is in nose- QUICKLY work to a sound WHOA! (/hw/) or
HAH /h/ FOR EXAMPLE To work towards sh BLOW AIR OUT MOUTH, CLOSE
TEETH, BLOW AIR AGAIN through teeth and will approximate sh!
