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increase consonant inventories in young children (Table 11-3).
Focused stimulation involves the use of intensive modeling and
expansion to facilitate functional language. With enhanced milieu
training, the child's natural environment is arranged so that he or she
must request or comment on an object to receive it. Research by
Scherer and her colleagues has demonstrated that these naturalistic
approaches can be successfully implemented by parents and are
effective in increasing expressive vocabulary and facilitating
consonant inventories in toddlers with cleft palate (Brothers and
Scherer, 2002; Scherer, 1999; Scherer et al., 2008).
TABLE 11-3
Models of Early Language Intervention
PROCEDURE DESCRIPTION KEY COMPONENTS
Enhanced
milieu
Arranges environment to promote child engagement and
requesting
Environmental
arrangement
Modeling
Teaches functional language using prompts, recasts, mandmodels, expansions in natural contexts
Mand-model
Incidental teaching
Models developmentally appropriate language in response
to child communication
Responsive interaction
Modeling and expansion by
parent
Focused
stimulation
Facilitates functional language using intensive modeling
and expansions
Following the child's lead
Facilitating conversation
through games, books
Intensive modeling and
expansion
Responsive interaction
From Scherer N, Kaiser APL: Early intervention for children with cleft palate.
Infants Young Child 20:355-366, 2007.
When working with young toddlers who have a restricted
expressive vocabulary, you should select training words with care.
Bear in mind the following:
• Any words chosen for this task should begin with consonants and
syllable shapes already in the child's inventory. Considerable
research evidence has demonstrated that children are more likely to
learn new words when they contain initial consonants that are
already in the child's inventory (see Schwar and Leonard, 1982;
Stoel-Gammon and Cooper, 1984; Vihman et al., 1985).
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• Consonants heard in the babbling of most young toddlers with
repaired cleft palate typically include at least /m, n, w, j, h/. Initially,
appropriate words to target for these children could include
mommy, no, more, night-night (“nii-ni”), and hi because these
words make no demands on the VP system and they begin with
consonants the child has already practiced.
• As the child's phonetic inventory expands to include early
developing stops (/b/, /d/, /ɡ/), words containing these consonants
can be added (e.g., ball, bye-bye, up, daddy, doggy, go). Note that
babies who avoid production of stop consonants in the initial
position of words can frequently be stimulated to produce them at
the end of simple vowel-consonant (VC) words.
• Select relational words as well as nouns. Relational words allow a
child to express communicative functions other than naming, such
as rejection (e.g., no), recurrence (e.g., more), and locative action
(e.g., up).
• Words should be functional and serve a range of communication
purposes.
If you need additional guidance in this area, a more
comprehensive account can be found in Paul and Norbury (2012)
(Box 11-4).
Box 11-4
Nasal Substitutions
Developmental or Atypical Errors (or Both)?
The development of nasal substitutions was examined by HardinJones and Chapman (2015) in the developing lexicons of 34 toddlers
with and 20 toddlers without cleft palate. This research revealed
that although a large percentage (76%) of toddlers with repaired
cleft palate produced word-initial nasal substitutions in their early
lexicon, these substitutions were also noted in the early words of
40% of the toddlers who did not have cleft palate. The use of nasal
substitutions decreased over time for both groups and was
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eliminated by 33 months for most of the children. This finding was
consistent with that of Broen et al. (1998), who found that the
absence of stops and persistence of nasal substitutions beyond 30
months discriminated children with repaired cleft palate who
required secondary surgery for VPI from those who did not. In the
study by Hardin-Jones and Chapman, only 38% of the cleft group
who produced nasal substitutions in their early lexicon was later
diagnosed with VPI.
These findings support a cautious approach to early diagnosis of
VPI. Phonological development is a process that unfolds over time.
A child's early performance does not always reflect his or her
capabilities, either linguistically or physically. Although nasal
substitutions may be a potential early indicator of VPI for some
children, the transient nature of these substitutions in the early
lexicons of toddlers with and without cleft palate suggests that the
diagnostic utility of this information is questionable, at best, in the
young child.
Teach Oral Versus Nasal Airflow
If the toddler is avoiding production of stop consonants following
surgery, activities that teach the concept of oral airflow can also be
introduced. These activities will be most productive if they
incorporate the intended consonant and are followed up by the
consonant stimulation activities just described.
• Use a “raspberry” (i.e., a prolonged /p/) to move a coon ball
across a table surface. You can increase the child's interest in the
activity by puing “eyes” on a coon ball or pom-pom to create a
bug and have a bug race (Hardin-Jones et al., 2015). For older
toddlers and preschoolers, you can also blow through a straw on a
small ball of coon.
If you also have to teach the difference between oral and nasal
airflow, Hardin-Jones et al. (2015) recommend sequencing activities
so that an airflow activity (using a low-resistance blowing toy) is
followed by a sound production activity (e.g., producing a
raspberry to stimulate /p/), followed by an activity that allows the
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child to put the sound in a word (e.g., blowing bubbles and saying
“pop, pop, pop”).
• Put a piece of paper or a feather in your hand, hold your hand in
front of your mouth, and whisper “pa” to move the object.
• If the child is directing airflow through his or her nose on blowing,
such as in the aempt to blow out a candle (the extreme case is the
child who “blows” with his lips closed), use lightweight blowing
toys (toys that do not present significant resistance to airflow) to
provide feedback regarding the direction of airflow. Demonstrate
the difference between nasal direction of the airflow by alternately
holding the toy (e.g., a lile plastic helicopter with a rotor blade
that moves easily) in front of your nose and mouth as you blow
(nasally, then orally). Then, hold it in front of the child in the same
positions. To assist the child in directing the airflow orally, you
may initially have to close off his nares with your hand, using only
gentle force in doing so (do not “squeeze”).
A good resource for SLPs and parents working with older toddlers
and preschoolers is the Articulation Books for Cleft Palate Speech series
by Kristi Chamberlain (www.linguisystems.com). The six books in
this series address the problems that a chipmunk named “Chippy”
has in producing oral airflow and pressure consonants. His sister
“Twitch” teaches him how to direct airflow orally and produce the
consonants /h, p, b, t, d, k, g, f/.
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Oral Motor “Exercises”: A Warning
Much controversy surrounds the use of oral motor exercises in
speech therapy. Advocates of these activities have argued that they
can strengthen muscles and thus improve range of motion.
Unfortunately, despite a lack of supportive evidence, some SLPs
have “jumped on the oral motor bandwagon” and have capitalized
on this trend by marketing simple blowing and sucking toys and
devices. When an SLP is working with a toddler who has a cleft, the
primary question is “Why does a delay in consonant development
exist?” Toddlers (cleft and noncleft) avoid production of specific
types of consonants for many reasons. A true oral motor deficit or
mobility problem is only one of many possible explanations for
limited consonant development, and it is a highly unlikely one for
most babies. Do not invest time or advise a parent to invest time and
money addressing a muscle strength problem that may not (and
probably does not) exist unless a problem has actually been
documented. It is very frustrating to see clinicians working on
“exercises” to strengthen the lips and tongue tip when bilabial and
lingua-alveolar sounds are already evident in babble, or when
bilabial and lingual functions are completely intact for feeding and
other nonspeech motor behaviors.
In a retrospective study, Hardin-Jones and Chapman (2008)
compared early intervention outcomes of 10 toddlers with repaired
cleft palate with a comparable group of toddlers who had been
referred for intervention but did not receive it. Lile difference in
speech production was evident between the groups on 10-month
follow-up, a finding suggesting that the intervention was not as
effective as expected. The authors questioned whether the parents
had been actively involved in the intervention and speculated that
the limited improvement may have been influenced by treatment
goals. In addition to increasing sound production, 7 of the toddlers
were working on increasing oral motor awareness and strength in
therapy. Because all the toddlers were already producing all bilabial
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consonants and all but one were producing alveolar and velar
consonants at the onset of intervention, the authors questioned what
the oral motor goal was supposed to accomplish.
Most toddlers with cleft palate whom you will see with delays in
articulation or phonological development are demonstrating the
following:
• General delays in speech sound development
• Faulty learning (e.g., gloal stops and nasal substitutions
frequently produced during the early linguistic period have
become integrated into the child's developing phonology)
• Early lexical acquisition strategies that have persisted well beyond
the first word period and now interfere with general intelligibility
(e.g., favorite sound substitution, severe phoneme collapse)
Having a repaired cleft does not mean that a child will lack the
muscle strength needed to produce consonant sounds adequately.
When you encounter toddlers and young children with clefts, bear
in mind the following:
• The presence of a cleft palate (repaired or unrepaired) has no
bearing on tongue strength or function (why would it?).
• Most young children who demonstrate VPI do so because their
palate is too short to achieve VP closure, and palatal exercises will
not change that.
• Muscle strength or lack thereof is not a primary causal factor
associated with phonological delays in this population.
SLPs have been discussing the use of oral motor exercises to
strengthen the VP mechanism as far back as the 1940s. Although
originally supportive of their use, Kanter (1948) was the first to
point out that palatal exercises are a “waste of time” when the
palate is short and the velopharyngeal gap is large. He also noted
that it does not maer whether a child can blow up a balloon or not
(a task that requires strong, sustained muscular effort). Speech
requires the velopharyngeal port to open and close with minimal
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effort and so “the only real test of palatal adequacy for speech is
adequacy in speech” (p. 218).
Parents and SLPs should always focus on facilitating sound
production through babbling games and later through conventional
articulation or phonological strategies. As mentioned previously,
simple “low-resistance” blowing toys can be used to demonstrate
forward-moving oral airflow with older toddlers, but blowing
should never be used to “strengthen” labial or soft palate
musculature; it does not work. Children who appear to get beer
over time in therapy when using these tools are likely demonstrating
improvement related to maturation and to learning correct motor
speech paerns. Had therapy focused only on speech sound
development, these children probably would have shown progress
much sooner.
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Looking Ahead
The strategies and procedures employed to treat speech sound
disorders that persist into the preschool years depend on the nature
of the errors that are produced. Children with a limited phonetic
inventory and those with compensatory articulations may benefit
from a traditional articulation approach that relies on imitation,
contextual utilization, phonetic placement instruction, or shaping to
establish correct production of a target sound. Children with an ageappropriate phonetic inventory who produce developmental (and
even atypical) substitutions may benefit from a phonological
approach that uses word pairs to create meaningful contrasts
between a target sound and a child's error. In reality, both types of
intervention may be needed at different stages of intervention as the
child's articulation abilities and error paerns change.
When planning treatment for young children with cleft palate, it is
important to remember that although many speech sound
substitutions (compensatory articulations and developmental errors
alike) reflect errors in placement, the frequency of the error often
dictates the type of intervention that should be initiated. A child who
consistently (or frequently) substitutes a gloal stop for a labial,
lingual, or velar stop in all positions of a word needs articulation
therapy that focuses on placement of the articulators. A child who
correctly produces /ɡ/ in the medial and final position of a word but
substitutes a gloal stop in the word initial position portrays a very
different picture. So, too, does the child who substitutes a gloal
stop for a /ɡ/ in the initial position of words 40% of the time and
correctly produces /ɡ/ at all other times. In these laer two examples,
the children clearly have knowledge of /ɡ/ (and its placement), but
the first has a rule that dictates a change in production of that sound
in certain conditions (word positions). Both children could benefit
from a phonological approach that focuses on sound contrasts.
As a general rule of thumb, frequently occurring compensatory
articulations and other nondevelopmental errors such as initial
consonant deletion and severe phoneme collapse (using one
consonant to replace multiple other consonants, such as /ɡ/ replacing
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p p p g
/b, p, d, t, f, s, sh, ch/) are considered a priority for treatment because
of their significant impact on speech intelligibility. As developmental
sound substitutions are introduced for treatment, however,
remember that the best treatment strategy for these errors may not
always be the same as that used for the nondevelopmental errors.
Specific strategies for addressing speech sound errors in
preschoolers and school-age children with cleft palate or VPI, or
both, are described in Chapter 12.
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Summary
• SLPs should meet with parents as soon as possible, but certainly no
later than when the child is 3 months of age, to provide information
regarding speech and language development and to discuss the
impact of a cleft palate on that development.
• Appropriate phonological goals during the early stages of speech
and language development include increasing the baby's rate of
vocalization and expanding his or her consonant inventory (and
vowel inventory when indicated) and range of syllable shapes.
• The frequency and variety of vocalizations may decrease
immediately after palatal surgery. It may take some toddlers
several weeks to resume presurgical production levels.
• Definitive assessment of the VP mechanism is not possible
immediately after palatal surgery but occurs over time as the
toddler's language expands and consonants are added to the
phonetic inventory.
• Early intervention should be considered for those toddlers who do
not begin adding new consonants (particularly oral stops) to their
phonetic inventory after palatal surgery. Intervention typically
focuses on facilitating growth of the toddler's expressive
vocabulary or phonetic inventory, or both.
• Expansion of a child's consonant inventory should be facilitated
using conventional articulation and phonological strategies. Lowresistance blowing toys can be used to demonstrate oral airflow,
but blowing activities are typically nonproductive when used to
strengthen the labial or soft palate musculature in this population.
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