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References
American Cleft Palate-Craniofacial Association (ACPA).
Parameters for evaluation and treatment of patients with cleft
lip/plate or other craniofacial anomalies (revised). American Cleft
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Broen PA, Dever MC, Doyle SS, et al. Acquisition of linguistic
and cognitive skills by children with cleft palate. J Speech
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Brothers M, Scherer NJ. Parent-implemented parent training for
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Hardin-Jones MA, Chapman KL. The impact of early
intervention on speech and lexical development for toddlers
with cleft palate: a retrospective look at outcome. Language,
Speech, and Hearing Services in Schools. 2008;39:89–96.
Hardin-Jones MA, Chapman KL. The significance of nasal
substitutions in the early phonology of toddlers with repaired cleft
palate. [Poster presented at the American Cleft Palate-
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Hardin-Jones MA, Chapman KL, Scherer NJ. Early
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early palatal obturation on consonant development in babies
with unrepaired cleft palate. Cleft Palate Craniofac J.
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Kanter CE. Diagnosis and prognosis in cleft palate speech. J
Speech Disord. 1948;13:211–222.
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Konst EM, Tietveld T, Peters HF, Kuijpers-Jagtman AM.
Language skills of young children with unilateral cleft lip
and palate following infant orthopedics: a randomized
clinical trial. Cleft Palate Craniofac J. 2003;40:356–362.
Lohmander A, Lillvik M, Fried H. The impact of early infant-
jaw orthopaedics on early speech production in toddlers
with unilateral cleft lip and palate. Clin Linguist Phon.
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Scherer NJ. The speech and language status of toddler with
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Scherer NJ, D'Antonio LL, McGahey H. Early intervention for
speech impairment in children with cleft palate. Cleft Palate
Craniofac J. 2008;45:18–31.
Schwar R, Leonard L. Do children pick and choose: an
examination of phonological selection and avoidance in
early lexical acquisition. J Child Lang. 1982;9:319–336.
Stoel-Gammon C, Cooper JA. Paerns of early lexical and
phonological development. J Child Lang. 1984;11:247–271.
Suzuki K, Yamazaki Y, Sezaki K, Nakakita N. The effect of
preoperative use of an orthopedic plate on articulatory
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Vihman MM, Macken MA, Miller R, et al. From babbling to
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Speech Therapy for Cleft-Related
Misarticulations
The emphasis in this chapter is on the “treatable” articulation errors
associated with repaired cleft palate with or without cleft lip. For schoolage youngsters (5 to 6 years and older), the assumption is made that if
the child had a cleft or a noncleft velopharyngeal (VP) problem, physical
management of the VP closure mechanism has been successfully
accomplished before you begin therapy. Audible nasal air escape
through a fistula (yet to be repaired) in preschoolers (3 to 5 year olds)
and early school-age youngsters is not treatable through speech therapy.
Some preschoolers may warrant diagnostic therapy to determine the
adequacy of VP function or the presence of VP inadequacy (VPI) and
the need for secondary surgery. This is especially the case for the child
who presents with nonoral compensatory articulations (CAs) and
hypernasal resonance and whose treatment will require collaborative
interaction between the treating speech-language pathologist (SLP) and
the team-based SLP. Of course, children with learned nasal emission
paerns such as phoneme-specific nasal emission (PSNE) may never
have had physical intervention because it is well known that children
without any physical problems of the VP system can exhibit this paern
(Peterson-Falzone and Graham, 1990; Trost-Cardamone, 1993, 2004,
2009, 2013). In addition, there is always the likelihood that a child with
an undiagnosed submucous cleft palate or noncleft VPI may present in
your caseload and require referral to a team and collaborative
management for speech (Grames, 2004; Grames et al., 2015).
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Deciding What Is “Treatable” and What
Is Not
At its most basic level, the job of treating cleft-related speech sound
disorders in children with repaired cleft palate starts with deciding (1)
what speech problems are likely to be amenable (eradicated or at least
lessened in severity) to behavioral therapy versus (2) what types or
combinations of problems are not appropriate targets for therapy. For
children in the laer category, the SLP usually decides, “Speech therapy
alone cannot correct or adequately modify these particular speech
problems; a physical change in the oral or pharyngeal structures is
needed.” Yes, speech therapy may be able to bring about less distorted
or “improved approximations” of sibilant or dental fricatives, affricates,
or other misarticulations in the child with a malocclusion. However, in
our collective experience, lile can be accomplished with the following
physically based types of problems, all of which fall into the broad
category of obligatory errors (as described Chapter 5):
Physical management approaches that are necessary to benefit speech
are addressed in Chapters 3 and 10.
• Audible nasal emission and hypernasality caused by ongoing VP
insufficiency (e.g., “short” or immobile repaired cleft palate,
excessively deep pharynx)
• Audible nasal air emission caused by one or more oronasal fistulas
• Adaptive oral misarticulations that have resulted from oral structural
abnormalities such as misplaced (ectopic) teeth or severe malocclusion
requiring physical management
Box 12-1 summarizes what we can treat and what we cannot treat
through speech therapy.
Box 12-1
It Cannot
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NOT TREATABLE TREATABLE
Obligatory or passive errors Learned or active errors
Hypernasality* ——————
Audible nasal emission (fistula, VPI) Audible nasal emission (phoneme-specific) ingressive
airflow (no VPI)
Weak pressure consonants (fistula, VPI) ——————
Consonant distortions caused by oral structural
deviations
Compensatory articulations
• Nonoral placements
• Backed oral placements
• Nasal fricatives
*
Cleft-related hypernasality typically is physically based and is not amenable to
behavioral therapy. Hypernasality may also occur in some speakers as a result of
glottal stop and pharyngeal articulations that keep the velopharyngeal port open.
VPI, Physically based velopharyngeal inadequacy.
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Deciding on the Treatment Approach
In your graduate training and associated clinical practicums, you may
have spent time learning the differences between articulation therapy
and phonological therapy: how each intends to change the child's
speech sound production skills but with a different theoretical basis and
using different techniques and criteria for goal achievement.
“Traditional” articulation therapy is exemplified by the long-standing
motor-phonetic approach (and one that was born before any of the
authors!) to correcting speech sound errors that dates back to the works
of Van Riper (1939a, 1939b, 1963, 1978), Wini (1975, 1984), Morley
(1970), and others and that dominated speech therapy approaches for
much of the twentieth century. Although the approach is “old,” it is not
outdated and in fact is included in most recent textbooks on articulation
and phonological disorders (e.g., Bauman-Waengler, 2015; Bernthal et
al., 2013; Bleile, 2004). Perceptual training that emphasizes target sound
identification and discrimination from the error and from other sounds
is usually a component of this approach, as are self-monitoring and the
ability to self-correct. In traditional therapy, target sounds are taught
one at a time, in contrast to more contemporary phonological
approaches that focus on sound feature contrasts (e.g., minimal pairs
therapy) and eliminating phonological processes. Hodson's Cycles
Approach (2004, 2006) incorporates elements of both traditional and
linguistic approaches and was developed specifically for children who
are unintelligible. In the traditional approach, once the target
production is established, the sound is then practiced and stabilized in a
hierarchical progression of increasingly complex speech contexts. Practice
typically begins at the syllable level (with the target in prevocalic,
postvocalic, and intervocalic positions: consonant-vowel [CV], vowelconsonant [VC], vowel-consonant-vowel [VCV], consonant-vowelconsonant [CVC]) and progresses to words (with target sounds in wordinitial, word-medial, and word-final positions and moving from
monosyllabic to multisyllabic word structures), target sound words in
phrases and sentences, and finally to carryover into spontaneous speech.
In this chapter, the focus is on the articulatory placement and airflow
direction errors that are the predominant features of “cleft palate
speech” and that result in the nonoral and backed oral misarticulations
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and learned nasal emission paerns. Articulation therapy that
emphasizes phonetic placement and shaping techniques is the initial
approach for modification and “unlearning” of cleft palate speech errors
and learning new placements, although it is understood that “one size
does not fit all.” At some stage in their speech sound development,
children with a history of cleft or noncleft VPI may indeed benefit from
a phonological approach (sometimes called a phonemic-linguistic
approach). This is because these misarticulations are deviant productions,
learned in response to a physical inadequacy and whose persistence
often has caused significant inventory constraints. Cleft palate
misarticulations are not developmental; they are not the result of delayed
phonological development, in which misarticulations and error paerns
reflect linguistic delay and learning of phonological rules. For these
youngsters with phonological delays, the problem is learning how to use
the target sounds correctly in what may be a fairly complete inventory. For
the child with CAs that reduce the phonetic inventory, the primary
problem is learning how to make the missing target sounds and enter them
into the inventory.
In phonetic placement therapy, the clinician models the target and
teaches the child where and how to place the articulators for production
of the target sound. Placement instructions emphasize the visual and
tactile features of the target—how it looks and how it feels.
The choice of therapy approach depends on the child's phonetic
inventory and the compensatory error paern consistency. This
underscores the importance of an adequate speech sample and a careful
analysis of the recorded sample.
The child who is highly consistent in his or her compensatory
substitution paerns benefits from traditional therapy, with heavy
emphasis on teaching the missing oral targets. The child who sometimes
(in some contexts) produces a correct target but at other times replaces
the target with a compensatory production may benefit more from a
phonological approach because there may be no or few inventory
constraints. At this time, we have no data to support one approach over
another. A systematic review that examined therapy approaches
(linguistic versus motor) for children with cleft palate, with or without
cleft lip, found “… lile evidence to support any specific intervention.”
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(Bessell et al., 2013, p. e1). The emphasis in this chapter is on the
application of procedures and techniques tailored to teach correct
articulatory (phonetic) placement and oral direction of airflow and
eliminate cleft palate misarticulations. Some children do well with a
strictly motor-phonetic/traditional therapy approach, whereas others
may need a phonological approach. Youngsters who present with
inventory constraints resulting from compensatory substitutions and
developmental error paerns may benefit from a combination of both.
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Initiating Treatment
When to Start Treatment
For most school-age children with repaired clefts, speech therapy is not
new. Rather, it may be a continuation of treatment begun in the
preschool years, the ideal time to initiate direct speech therapy. For
others, this may be the first speech therapy experience. In either
instance, you will want to determine whether the child is under team
care and communicate with the team, especially the team SLP, before
starting treatment. Before embarking on treatment, you will want to
understand the hearing status, the functional status of the VP closure
mechanism, and any oral structural hazards to speech progress, as well
as plans for ongoing team care. If the child is not under team care, you
will want to find out why and then initiate the process of a referral, as
appropriate. Additional comments regarding the value to patient and
clinician of collaborative interaction with the team are included at the
end of this chapter.
Frequency and Duration of Sessions
Ideally, speech therapy sessions should take place on a daily basis.
Because this rarely is feasible, a more realistic schedule is at least twice
weekly for individual sessions of at least 30 minutes supplemented by
daily speech homework, a home practice program. This combination of
frequency and duration is easier to accomplish in an outpatient medical
center seing, in private practice, or in another free-standing clinic than
in the public schools where caseloads are heavy and brief sessions of
group therapy may be the only option. To the extent that your teaching
time with the youngster is shorter, the home program may need to be
more extensive.
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