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you repeat the [s] sound 10 times” or “Let's place this in front of your
mouth to make sure air escapes only from your mouth when you repeat
the [s] sound 10 times.” The See-Scape can also be used to teach control
over oral versus nasal airflow by having the child intentionally make
paired oral versus nasal productions (e.g., 10 sets of [s]-[
]) with the
olive placed either in a nostril or in front of the mouth). This intentional
contrast can also be taught using simple oral versus nasal blowing; for
example, “Let's blow air through our mouth and then through our
nose” (“silly blowing”). Video 12-1
illustrates use of the See-Scape to
monitor for intentional turbulent nasal fricatives.
The See-Scape is available through Pro-Ed (www.proedinc.com). You
can also purchase coiled
-inch diameter polyethylene tubing from
stores such as Home Depot and cut it into 18-inch lengths. Nose clamps
are standard material used in respiratory testing and spirometry in
medical seings. So if you are a hospital or team speech language
pathologist, these devices likely are available in house.
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Therapy for Cleft-Related Speech Errors
Objectives
The therapy objectives (general outcome goals) for the treatable cleft
palate speech errors are as follows:
For Compensatory Articulations
1. Teach new motor paerns to replace and eliminate nonoral CAs
(doing so may improve VP closure).
2. Teach correct oral target place and establish oral pressure buildup and
release in that place using motor-phonetic therapy.
3. Bring backed oral articulations forward; modify or eliminate oral
backing paerns.
For Learned Nasal Emission Problems
1. Teach and establish oral airflow for speech and oral pressure buildup.
2. Eliminate intentional nasal direction and pathway of speech airflow.
For Ingressive Airflow Problems
1. Verify adequate VP closure; some youngsters with ingressive airflow
have physically based VPI or VPD (e.g., undiagnosed submucous cleft
palate).
2. Establish egressive or pulmonic airflow for affected target sounds.
As mentioned earlier, with some youngsters, there may be an
additional diagnostic therapy goal: to evaluate speech adequacy of the
physical repair. This is particularly pertinent in youngsters who present
with nonoral CAs, few to no oral pressure consonants, and some degree
of hypernasality with or without audible nasal emission. With this
subset of youngsters, the determination of VP adequacy can be made
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more reliably by observing their response (and that of the VP
mechanism) to speech therapy. Speech therapy to modify aberrant,
nonoral placements can be effective even if more surgery is needed to
correct a fistula or VP insufficiency. Many oronasal fistulas do not
interfere with placement therapy, but when they do, an obturator
appliance can be constructed, provided it is not at odds with dental
eruption and shedding of teeth or with ongoing orthodontic treatment
(e.g., maxillary expansion).
A multimodality teaching approach (auditory, visual, tactilekinesthetic) with the focus on oral placements and airflow is essential to
cleft palate speech therapy (auditory bombardment alone does not
work). This is true whether the task is to eliminate CAs, modify backed
oral productions, or treat learned nasal emission or ingressive airflow.
In the following pages, we first address treatment of nonoral
compensatory errors (targets realized as substitutions and
coproductions) and backed oral productions in which the key error is in
place of production. We then address treatment or the “undoing” of
learned nasal emission errors and paerns in which the key error is
direction of airflow.
Treatment Components
Regardless of the specific types of errors the child presents, certain
treatment components can be applied to all therapy for eliminating
nonoral CAs and backed oral productions. They include the following:
• Establish a “place map” for consonants.
• Select appropriate (initial) treatment targets.
• Get the target sound(s) into the speech sound inventory.
• Teach correct oral target versus error sound contrasts.
• Establish reliable self-monitoring for carryover and generalization.
The ultimate goal is to establish accurate sound production and
usage. Children vary in the amount and detail of phonetic placement
and discrimination teaching they need to produce a sound. Some
youngsters may need all the steps and techniques discussed in this
chapter; others will not. We expect that you will approach this material
as you would approach any multiple-choice situation: select and use
whatever works for you and the child. As so aptly stated by Bleile (2004,
p. 356), “Phonetic placement and shaping techniques are guidelines
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rather than rigid procedures. The clinician should pick and choose
among treatment techniques, keeping what works, discarding what
does not, and (most often), modifying a technique to beer suit the
clinician's style and client's needs.”
1. Establish a “Place Map” for Consonants
An example of the place map for high pressure consonants is shown in
Figure 12-5 (reproduced in color on the inside front cover of this book). It
is a lateral diagram of the speech mechanism that includes all the high
pressure consonants and can be color coded for place of production
categories: yellow for labials (bilabials and labiodentals), green for
interdentals, red for alveolars (tip and blade), blue for palatals, and
black for back velars. The gloal fricative /h/ (in pink) also has been
included because of the use of /h/ and whispered speech in breaking up
gloal stop paerns. Low pressure consonants /l, r/ and the nasal /n/ can
also be pictured on the place map for work on articulatory backing
paerns, such as backed to velar place as in nasal replacement of /n/
with [
], /l/ with [ ].
FIGURE 12-5 “Place map” for high pressure consonants.
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Anterior, middle, and posterior regions of the tongue dorsum are
shown in Figure 12-6 (reproduced in color on the inside back cover of this
book).
FIGURE 12-6 Color-coded anterior, middle, and posterior
tongue dorsum in relation to anterior palate, midpalate, and
posterior palate.
Color coding sounds according to place of production is helpful
because puing the colors together shows the child where the contact
points (articulatory placements) and corresponding pressure buildup
points are for making the sounds. For example, the child learns that a
specific color always means, “I use both lips (yellow to yellow) for this
sound” and that another color or colors means “I use the front of my
tongue to touch the bumps behind my top teeth for this sound” (red to
red), and so forth. This conceptual learning can then be applied to tactile
cueing in phonetic placement teaching. For example, in teaching
placement for /k/, you can review “black-to-black” and then stimulate
the articulator points (using a tongue blade) while giving instructions,
such as “Get the back of your tongue, this back part, up to the back of
your mouth—here in the back, top part of your palate.”
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To recap, use a tongue blade to tactilely identify the target areas. This
helps the child with target place learning. Divide up the oral cavity into
different (color-coded) areas that you then can label “back of the
tongue,” “front of the tongue,” “middle of the tongue,” “back of the
palate,” “lips,” and so forth. This facilitates the placement instructions.
Phonetic placement teaching for back velar /k/ is demonstrated in Video
12-2
. Video 12-3 shows phonetic placement teaching for tip alveolar /t/
using homorganic /l/ and /n/, which the child produces well, to facilitate
/t/ placement.
2. Select Appropriate (Initial) Treatment Targets
In general, in deciding where you want to start treatment, you want to
target (1) compensatory errors that have the greatest impact on speech
understandability and acceptability even if this means going out of
developmental sequence and (2) sounds on which the child will most
quickly show improvement so the child is motivated to continue.
Sometimes, however, these two factors may be at odds with each other.
It may be appropriate, for example, to deviate from maturational norms
and work on “s” with a 3-year-old child who is using rampant gloal
stops for all high pressure consonant targets. If, however, the “s” proves
too difficult, you may need first to treat “f” or perhaps “sh.”
The “th” is rarely affected by compensatory substitution but if it is, it
too would be a good alternate starter sound.
Additional guidelines for target selection include the following:
• Stimulability. Select stimulable sounds (i.e., sounds the youngster can
make in some contexts).
• Visibility. Start with the more visible targets.
• Place of production. Teach anterior sounds first (remember, children
with clefts tend to avoid alveolar place).
• Voicing. Teach voiceless targets before voiced, especially with gloal
stops to break up the paern of gloal stopping, or use whispered
productions and intrusive /h/.
• Manner of production. In establishing placement for oral pressure
targets, fricatives generally are easier than stops, especially for children
who replace many oral targets with gloal stops.
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• Developmental schedule. Within a place category or a manner class,
consider the normal acquisition sequence (e.g., “p” before “t” before
“k”). In addition, feel free to deviate from that schedule as
intelligibility/understandability issues may warrant.
Some youngsters may do beer starting with voiced targets that require
less oral pressure and have a shorter voice onset time, which may
lessen the potential for producing an intrusive gloal stop as in “pea”
→ [pʔi] or a coproduced gloal stop as in “pea”
.
3. Get the Target Sounds Into the Speech Sound
Inventory
When a sound is not in the inventory (not stimulable in any context), the
first order of business after you have made your target sound selection
is to teach the child how to produce the target sound in “isolation” and
then to practice it in structured drill until it is a stable, automatized
production. This enters the sound into the inventory; it ensures that the
youngster can make the target sound reliably. For nonoral CAs, this
requires new (correct) place learning, acquiring a new motor paern
and facilitating correct manner and voicing associated with the new oral
target. With youngsters who have no obligatory nasal airflow problems,
the new target can now be normally produced. For those who have
obligatory nasal emission (e.g., caused by fistulas or persisting VP
insufficiency), the sound may be distorted by nasal air emission and
weak oral pressure but will at least be orally placed. For learned nasal
emission errors, geing the sound into the inventory requires learning
oral direction of airflow for the target and elimination of the learned
habit of nasal direction of the airflow.
Isolated production is possible with fricatives (and nasals, glides,
liquids), but achieving a truly isolated production with stops and
affricates is not possible; for these plosives, “isolated” target production
becomes a consonant-vowel (CV) syllable, even when whispered or
produced using strong aspiration as in “ph,” “bh,” or “th.”
Once the child can produce the target in isolation, you are ready to
move on to production in syllable contexts, and traditional articulation
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therapy (or phonological therapy approaches, if necessary) can be
applied. For most youngsters who have compensatory substitutions that
are consistent and frequent, traditional articulation therapy is
appropriate and effective. That is, once the target sound production is
stabilized in “isolation,” a contextual hierarchy can be followed
progressing from target sound in syllables to words, to structured
phrases, to sentences, and to carry over into spontaneous speech.
4. Teach Correct Oral Target Versus Error Sound
Contrasts
The lateral diagram can be used to visually represent and explain to the
child (and parents) the compensatory placements (e.g., gloal and
pharyngeal) that you want to change or eliminate. These placements can
be visually compared to the desired articulatory valving points or
placements. The place map previously described provides a visual
representation of the target place and allows you to contrast this with
the faulty place or airflow direction and pathway. The desired place can
be color coded or highlighted, and the faulty place can be “Xed out,” as
shown in Figure 12-7, in which the pharyngeal stop is contrasted with the
target velar stop /k/.
A blank lateral diagram has been included as Appendix 12A for your
use in this therapy. It is also useful in explaining velopharyngeal
closure, secondary surgical procedures, airway problems, tonsil and
adenoid interactions with closure, and so forth to parents and patients.
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FIGURE 12-7 Place contrasts for /k/ “mouth sound” versus
pharyngeal stop “throat sound.”
The place map can also be used to visually enhance auditory
discrimination training, in which the clinician produces the contrasting
pair of target versus error sounds. For example, the child is instructed,
“Tell me whether I am making this sound in my mouth or in my throat.”
You can use schematic picture contrasts and pair them with the
production contrasts. Also, keep in mind multimodality teaching. In the
production, it is important to instruct the child to watch where and how
the sound is made and listen to how the production sounds, as well as to
feel how the sound is made. It is important that the child understands
these features of both the desired target and the error production, so all
elements of the placement and airflow contrasts are fully learned.
Understanding these production contrasts facilitates intrinsic feedback
and self-monitoring and correction, and ultimately benefits carryover
and generalization.
Younger as well as older children can benefit from lateral diagram
illustrations. For example, if the child is using gloal stop for /b/:
• Show the child where the /b/ should be made (pointing to both the
diagram and your lips).
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• Demonstrate how it should be made (bringing both lips together to
stop the airflow).
• Point to the place of the error substitution (the gloal stop) on the
diagram and on your lower neck and the child's lower neck.
• Then X out that gloal place on the diagram.
Admiedly, producing the error sound for contrasts requires practice
on your part as the clinician, and some compensatory productions are
easier to produce than others. Our advice is to work at it and do the best
you can.
5. Establish Reliable Self-Monitoring
Ideally, we would like our patients to be able to do a production task in
which they intentionally produce the differences between gloal (or
pharyngeal) and oral placements (or oral versus nasal airflow) so that
they can build internal targets for self-monitoring. As we all know, most
youngsters cannot intentionally make their error sounds, especially once
they have learned the correct target production. However, we want
them able to benefit from feedback and to self-monitor for their own
error versus correct target production. To do this, they will need to draw
on the tactile, kinesthetic, and auditory understanding of target versus
error differences learned early in therapy during the acquisition of new
motor paerns for oral targets and elimination of compensatory
placements. Practice in self-monitoring is critical to building internal
targets that will serve the speaker reliably in conversational and other
connected speech. Therefore, it should be an integral part of therapy,
starting at the syllable production level and proceeding through
connected speech practice. If the child's only monitor is the speech therapist,
the child will not be able to internalize the sound contrasts in order to selfmonitor and self-correct.
Treating Nonoral Compensatory Articulations
We are now ready to consider specific therapy procedures and
techniques for eliminating nonoral CAs and replacing them with correct
oral targets. Remember that CAs are errors in place of production and are,
for the most part, nonoral articulations that use pharyngeal and gloal
articulatory valving.
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