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expand her or his consonant inventory and begin producing consonants
from all early sound classes (if the child is not already doing so). The
absence of stop consonants combined with the persistence of nasal and
gloal substitutions approximately 6 months following surgery is a red
flag that should lead you to examine the child's phonological
development carefully.
Videos 4-1
and 4-2 show how early physical constraints can affect
both phonemic and phonological development in toddlers. In Video 4-1,
you see a child age 2 : 11 with limited knowledge of the sound system
of his language. At an even earlier age, his inadequately repaired cleft
prevented those around him from understanding his early speech
aempts. These failures led to frustration (still obvious in this video)
and limitations in phonological development. At 2 : 11 he does not even
discriminate /m/ from /n/. His use of gloal stops is so pervasive he
does not aempt an oral gesture for most high pressure consonants.
Video 4-2 shows a child of the same age (2 : 11) who needed a
functional VP system before she got it. This child is a bright lile girl
exhibiting a limited sound inventory for her age. Note that she can
produce normal oral pressure consonants inconsistently and that
consistency of good pronunciations increased with modeling by the
examiner.
Early Lexical Development
The early lexicon of toddlers with cleft palate has been examined by
several investigators (Table 4-2), and delays have been reported in both
size of expressive vocabulary and rate of word acquisition. Word
inventories completed by parents routinely demonstrate that toddlers
with cleft palate produce fewer words than do their noncleft peers from
14 to 30 months, and those findings have been supported by direct
observation of expressive vocabulary in this group. Lexical selectivity is
also evident, with these toddlers targeting more words that begin with
sonorants than with obstruents. Several investigators have reported that
as a group these toddlers are several months behind noncleft toddlers in
onset of first words, are slower to acquire words (Estrem and Broen,
1989; Hardin-Jones and Chapman, 2014), and have a low rate of word
use in communicative interactions (Scherer et al., 2013).
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TABLE 4-2
Early Expressive Language Findings for Toddlers With Cleft Palate
MAJOR FINDINGS AUTHORS
Smaller expressive vocabulary Broen et al., 1998
Chapman et al., 2003
Lu et al., 2010
Scherer and D'Antonio, 1995
Scherer et al., 2008
Slower rate of word acquisition Broen et al., 1998
Hardin-Jones and Chapman, 2014
Preference for words beginning with sonorants Estrem and Broen,1989
Hardin-Jones and Chapman, 2014
Broen et al. (1998) reported similar findings regarding word
acquisition for the children they studied but made an important
observation. These investigators noted that differences in rate of word
acquisition between their cleft and noncleft groups were no longer
statistically significant when hearing and velopharyngeal function were
added as covariates in their statistical model. Their findings suggest that
early differences in language acquisition may be related to hearing and
velopharyngeal function in some children and provide yet another
reason to argue for routine monitoring of hearing and middle ear status
in these children. Unfortunately, early identification of velopharyngeal
inadequacy in toddlers with cleft palate is more problematic because
the assessment process depends on changes in speech production (e.g.,
the addition of pressure consonants) that occur over time.
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Implications for Age at Time of Palatal
Surgery
Historically, it was assumed that a cleft of the palate would not have a
significant impact on speech until a baby began to talk. During the early
1980s, concerns about speech led many surgeons to begin repairing the
palate at approximately 12 months of age. Even as surgeons began
appreciating the need to repair the cleft before the onset of speech,
SLPs, psychologists, and linguists were discovering a relationship
between early vocal development and later speech-language
development. We now know that a cleft palate affects the developing
sound system of a child much earlier than 12 months of age. To ensure
the best possible speech outcome, the ideal time to repair the palate
appears to be before the onset of canonical babbling, at approximately 6
months of age (but confirmation through clinical research findings is
needed). Of course, other factors related to the cleft (e.g., size or width
of cleft) and the child's health may not permit palatal repair at such an
early age. The SLP on the cleft palate team will advocate for early
surgery when feasible to promote early phonological and lexical
development. You should recognize, however, that as an
interdisciplinary team member, the SLP must always be open to
changes in the treatment plan when common sense dictates a different
approach.
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Summary
Babies with unrepaired cleft palate demonstrate delays in early
phonological development. They produce a smaller consonant
inventory than do their noncleft peers and tend to avoid production of
pressure consonants. Although these early delays may explain the slow
rate of growth frequently seen in their expressive vocabularies, we still
do not know why some of these toddlers slowly “catch up” to their
noncleft peers in phonological performance by the preschool years,
whereas others go on to demonstrate significant phonological delays
and deviant misarticulations. Factors such as middle ear disease, age of
surgery, and the presence of other congenital anomalies (if any)
undoubtedly play a role.
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References
Broen PA, Dever MC, Doyle SS, et al. Acquisition of linguistic and
cognitive skills by children with cleft palate. J Speech Hear Res.
1998;41:676–687.
Chapman KL, Hardin-Jones MA, Halter KA. The relationship
between early speech and later speech and language
performance for children with cleft lip and palate. Clin Linguist
Phon. 2003;17:173–197.
Chapman KL, Hardin-Jones M, Schulte J, Halter KA. Vocal
development of 9-month-old babies with cleft palate. J Speech
Lang Hear Res. 2001;44:1268–1283.
Estrem T, Broen PA. Early speech production of children with cleft
palate. J Speech Hear Res. 1989;32:12–23.
Grunwell P, Russell J. Vocalisations before and after cleft palate
surgery: a pilot study. Br J Disord Commun. 1987;22:1–17.
Grunwell P, Russell J. Phonological development in children with
cleft lip and palate. Clin Linguist Phon. 1988;2:75–95.
Hardin-Jones M, Chapman KL. Early lexical characteristics of
toddlers with cleft lip and palate. Cleft Palate Craniofac J.
2014;51:622–631.
Hardin-Jones M, Chapman KL. The significance of nasal substitutions
in the early phonology of toddlers with repaired cleft palate. Poster
presented at the American Cleft Palate-Craniofacial Association
Annual Conference, Palm Springs, Fla. 2015.
Huers B, Bau A, Bronsted K. A longitudinal group study of
speech development in Danish born with and without cleft lip
and palate. Int J Lang Commun Disord. 2001;36:447–470.
Jones CE, Chapman KL, Hardin-Jones MA. Speech development
of children with cleft palate before and after palatal surgery.
Cleft Palate Craniofac J. 2003;40:19–31.
Moller K, Starr C. A parent's guide to cleft lip and palate. University
of Minnesota Press: Minneapolis; 1990.
Lohmander A, Olsson M, Flynn T. Early consonant production in
Swedish infants with and without unilateral cleft lip and palate
and two-stage palatal repair. Cleft Palate Craniofac J. 2011;48:271–
285.
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Lu Z, Ma L, Luo Y, Fletcher P. The effects of unrepaired cleft
palate on early language development in Chinese infants. Cleft
Palate Craniofac J. 2010;47:400–404.
Russell J, Grunwell P. Speech development in children with cleft
lip and palate. Grunwell P. Analysing cleft palate speech. Whurr
Publishers: London; 1993:19–47.
Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP. Cleft palate
speech. 4th ed. Mosby: St Louis; 2010.
Scherer NJ, Boyce S, Martin G. Pre-linguistic children with cleft
palate: growth of gesture, vocalization, and word use. Int J
Speech Lang Pathol. 2013;15:586–592.
Scherer NJ, D'Antonio LL. Parent questionnaire for screening
early language development in children with cleft palate. Cleft
Palate J. 1995;32:7–13.
Scherer NJ, Williams AL, Proctor-Williams K. Early and later
vocalization skills in children with and without cleft palate. Int J
Pediatr Otorhinolaryngol. 2008;72:827–840.
Stoel-Gammon C. Role of babbling and phonology in early
linguistic development. Wetherby AM, Warren SF, Reichle J.
Transitions in prelinguistic communication. Paul H. Brookes:
Baltimore; 1998:87–110.
Willadsen E, Albrechtsen H. Phonetic description of babbling in
Danish toddlers born with and without unilateral cleft lip and
palate. Cleft Palate Craniofac J. 2006;43:189–200.
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Effects of Cleft and Noncleft VPI
on Speech
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What Is VPI?
VPI stands for velopharyngeal inadequacy and is used in this text as
the generic term for faulty velopharyngeal closure. As such, VPI
encompasses the many causes or contributors to impaired
velopharyngeal function, that is, to the velopharyngeal closure problem
that results in hypernasality and nasal emission during speech.
In the literature, the acronym “VPI” and the associated terms
“velopharyngeal inadequacy,” “velopharyngeal insufficiency,” and
“velopharyngeal incompetence” are used interchangeably to denote any
type of velopharyngeal (VP) closure problem. In other words, the terms
typically are used with lile or no regard for the underlying cause of the
problem (Trost-Cardamone, 1989). Both in research and in clinical
management, it is beneficial to go beyond the nonspecific descriptor
“VPI” and to explain the cause of the presenting closure inadequacy. In
research, being more specific about the cause facilitates valid and
reliable comparisons of data. In clinical management, we know that
different causes call for different treatment approaches. Although we
prefer the term inadequacy, it does not really maer whether we use
“inadequacy” or the other often used term, “dysfunction.” The
important issue is specifying the cause of the faulty velopharyn geal
closure to ensure appropriate diagnosis and management.
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Understanding the Causes of Cleft and
Noncleft VPI
Although cleft palate is the most familiar cause of VPI, many other
causes exist (Trost-Cardamone, 1989; Peterson-Falzone, et al., 2006;
Peterson-Falzone, et al., 2010). Both for accurate diagnosis and for
appropriate treatment, it is important that structural causes, neurological
causes, and causes related to speech (sound) mislearning be distinguished from
one another (Trost-Cardamone, 1989).
Figure 5-1 presents a classification of cleft and noncleft etiologies of
VPI. In the cleft VPI group, all the causes are structural; they result from
some type of tissue insufficiency. Note that this group includes both
unoperated clefts and persisting insufficiency following surgical repair.
Noncleft VPI can have a variety of causes that can be subgrouped into
three distinct categories, as follows:
1. VP insufficiency, which includes structural causes other than clefting
2. VP incompetency, which encompasses neurogenic causes (dysarthria,
affecting the mobility of the VP port; and apraxia of speech, affecting
motor speech programming for VP closure)
3. VP mislearning, in which VPI exists despite an anatomically sufficient
and physiologically capable mechanism.
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