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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_33_библиотеки_им_акад_М_И_Перельмана
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A Protocol for Assessing Cleft Palate
Speech
The protocol presented here is outlined in Table 8-1 and consists of four
steps: (1) obtain an adequate speech sample, (2) analyze the speech
sample, (3) correlate the perceptual speech data with the orofacial
examination findings, and (4) interpret the clinical data and make
recommendations.
This protocol incorporates the guidelines presented in the article titled
“Universal Parameters for Reporting Speech Outcomes in Individuals
with Cleft Palate” (Henningsson, et al., 2008) and is compatible with
the protocol developed for The Americleft Speech Project (Chapman et
al., 2016). The protocol for the Americleft project includes elements of
both the universal parameters system (UPS), as presented in the
Henningsson et al. article, and the Cleft Audit Protocol for SpeechAugmented (CAPS-A) (John et al., 2006) that is used throughout the
United Kingdom and in Ireland. It therefore can yield speech data for
routine clinical assessments and quality improvement or audit
evaluations and for speech outcomes research involving intercenter
comparisons.
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TABLE 8-1
A Protocol for Assessment of Cleft Palate Speech
I. Obtain an adequate speech sample.
A. Use several speech sampling contexts:
1. Conversational speech
2. Other connected speech (automatic or memorized material; e.g., counting, days of week)
3. Special or controlled sampling contexts (sensitive to cleft-type speech errors)
4. Published sound inventories, articulation tests
5. Stimulability testing
B. Record the speech sample.
II. Analyze the speech sample.
A. Document phonetic inventory (size, variety, constraints, age-appropriate).
B. Rate or document the following:
1. Speech understandability and speech acceptability: severity
2. Hypernasality: severity
3. Audible nasal emission, nasal turbulence, or both (WNL/none, or present, and frequency)
4. Hyponasality (WNL/none, or present)
5. Voice disorder (WNL/none, or present)
6. Consonant production errors: error types (compensatory [nonoral], backed oral, dental and occlusal,
developmental)
C. Describe cleft type error paerns:
1. Hypernasality (pervasive, intermient)
2. Nasal emission paern (obligatory/passive or learned/active)
3. Nonoral compensatory articulations
4. Backed or retracted oral productions
5. Other oral misarticulations (dental, occlusal, adaptive)
6. Paern consistency (error affects target in all contexts and positions of occurrence or inconsistently affects
target relative to context or position)
III. Correlate perceptual speech data with orofacial exam findings.
A. Determine relationships between speech articulation errors and oral structural deviations (e.g., class III
malocclusion or underbite and inverted labiodentals).
B. See Chapter 7 and Appendix 7C for overview of the orofacial examination.
IV. Interpret the clinical data and make recommendations.
A. Make a definitive diagnosis and determine need for referral and/or treatment.
B. Make a tentative diagnosis with follow-up recommendations:
1. Pending instrumental assessment findings
2. Pending outcome of “diagnostic therapy”
Modified from Peterson-Falzone, Trost-Cardamone, Karnell MP, Hardin-Jones MA:
The clinician's guide to treating cleft palate speech. St. Louis: Mosby, 2006. Sections
I. and II. are based on Henningsson GE, Kuehn DP, Sell D, et al.: Universal
parameters for reporting speech outcomes in individuals with cleft palate. Cleft Palate
Craniofac J 45:1-15, 2008.
Obtain an Adequate Speech Sample
An adequate speech sample is a sample that will yield the necessary
data for reliable and accurate analysis and speech diagnosis and that
also informs us regarding treatment planning. For team-based SLPs, a
sample that also yields data for quality improvement and clinical audit
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evaluations and for reporting of speech outcomes (Chapman et al.,
2016; John et al., 2006; Henningsson et al., 2008) is desirable and time
efficient. The sample provided in this protocol meets the above
objectives. It has both clinical and research utility.
Because speech is a complex behavioral task and because speakers
can show variation in what the SLP's ears will identify as errors or
deviations across different speech contexts and tasks, a speech sample
structured to facilitate the identification of specific cleft palate error
types and error paerns is recommended. Put another way, we could
say, “The more generic or ‘uncontrolled’ the speech sample, the more
likely that the identification of speech errors will be inaccurate and
incomplete, and thus the more likely that the treatment decisions can
be wrong.”
Many authors have emphasized the importance of sampling speech
in varied contexts, including controlled speech samples (e.g., Chapman
et al., 2016; Henningsson et al., 2008; John et al., 2006; Peterson-Falzone
et al., 2006; Peterson-Falzone et al., 2010; Trost-Cardamone, 2009, 2013;
Trost-Cardamone and Bernthal, 1993). Essential ingredients of an
adequate speech sample are shown in the first section of Table 8-1.
Conversational Speech
Conversational speech provides the most representative sample of
natural speech and provides the only valid basis for judging speech
understandability (Henningsson et al., 2008). It is recommended that
the conversational speech sample be a minimum of 2 to 3 minutes in
length and that it be elicited using a standard set of questions (e.g., see
Table 8-2).
Speech understandability and acceptability are considered global
speech parameters. Speech understandability may be defined as the
degree to which the listener understands the speaker. Although speech
understandability is closely related to intelligibility, it is more easily
scaled using descriptors. Speech acceptability may be defined as the
degree to which speech calls aention to itself and away from the
message. Acceptability is a separate global parameter because speech
can be understandable but not acceptable; for example, the speaker
with good articulation but significant hypernasality has speech that is
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understood but is not pleasing or acceptable (Henningsson et al., 2008;
Whitehill, 2002; Wiel, 1995).
TABLE 8-2
Eliciting the Conversational Speech Sample
The conversational speech sample should focus on questions where the answer is not easily predetermined.
Yes or no questions should be avoided. For example, the following elicitation questions may be helpful and
will help to standardize the stimulus questions:
• Tell me about your brothers and sisters.
• Tell me about your favorite movie.
• Tell me about your favorite TV program.
• Tell me about your favorite place to go.
• Tell me about what you like to do on your birthday.
• Tell me what you like to do on vacation.
From the Americleft Speech Outcomes Project Protocol, Section 9 of the Americleft
Project Study Guide, 2015. http://www.acpa-cpf.org/uploads/site/americleft-study-
guide.pdf
Although speech understandability should be judged or rated based
only on the conversational speech sample, conversation can be used to
rate other cleft-related speech parameters shown in section II of the
protocol (see Table 8-1). The conversational speech sample is the most
valid way to judge speech understandability because the intended
phonemic targets are not known to the clinician. However, it may not
sample the speaker's full phonetic inventory. The additional contexts
described in the following paragraphs can ensure sampling of the full
phonetic inventory of the language and also include special sampling
contexts that are phonetically controlled to capture cleft- and VPIrelated speech deviations.
Other Connected Speech Tasks
For patients, especially younger children, who will not participate in
conversation, other connected speech samples can be collected, for
example serial counting (1 to 10, 1 to 20), recitation of the days of the
week, and memorized material. Some younger children may recite
nursery rhymes and sing familiar songs. Connected speech samples
also can be collected from the controlled sampling contexts presented
here.
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Special and Controlled Sampling Contexts
At this time in the United States, there is no standard speech protocol, not
even a single set of sentences, commonly used for cleft palate speech
assessment. Many clinicians simply resort to generic speech tests and
protocols. Although generic single-word and sentence articulation tests
can provide information on atypical speech errors associated with cleft
palate and VPI or VPD, they are not structured to do so. For the teambased SLP especially, the standard use of special and controlled sampling
contexts and tasks is recommended, including articulation stimuli
specifically designed to reveal cleft palate speech errors (Henningsson et al.,
2008; John et al., 2006; Peterson Falzone et al., 2006; Trost-Cardamone,
2004, 2009, 2012; Trost-Cardamone and Bernthal, 1993). The American
English Word Sample (AEWS) (Trost-Cardamone and Kuehn, 2009)
and the American English Sentence Sample (AESS) (Trost-Cardamone,
2012) were developed in response to the call for a universal system for
reporting speech outcomes in individuals with clefts (Henningsson et
al., 2008). These word and sentence samples are compatible with other
international protocols used in research on speech outcomes in
speakers with cleft palate, for example, the Americleft Speech
Outcomes Project (Chapman et al., 2016), the Cleft Audit Protocol for
Speech-Augmented (CAPS-A; John et al., 2006), and the Spanish UPS
(Cleves et al., 2009). They also offer a standard assessment tool for use
at the local team level. Both the single-word and sentence samples can
be used to identify the key characteristics of cleft palate speech:
hypernasality, audible nasal emission and nasal turbulence, consonant
production errors (compensatory articulations and others), and
hyponasality (as may be observed following secondary surgery).
Because these materials focus specifically on eliciting cleft speech
characteristics, they provide a clinically efficient sampling protocol that
can be used with other standardized tests for comparison to normative
data. In some instances, the conversational speech sample and special
tests and procedures may constitute the sole assessment baery used
by the team SLP. This is often the case in busy cleft palate and
craniofacial clinics, where most patients receive focused speech
articulation and resonance evaluations.
For routine clinical use, the American English Word Sample (AEWS) is
useful in that it expands the number of stimuli for assessing cleft-
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p g
related errors and therefore the number of opportunities for error
productions. This facilitates error paern analysis. Given time
constraints, a published articulation inventory, although less well
controlled for cleft-related errors, also expands the number of
opportunities for errors and serves as a developmental measure at the
same time. To our knowledge at this time, as with the American
English Sentence Sample (AESS), the AEWS is the only available
controlled single-word sample for American English.
Table 8-3 presents a description of special sampling contexts and
procedures and their purposes in assessing for cleft palate speech
errors.
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TABLE 8-3
Special/Controlled Sampling Contexts and Speech Tasks for
Diagnosing Cleft Palate Speech Errors
CONTEXT PROCEDURE PURPOSE(S)
Single words: cleft focused
assessment
American English Words Sample
(AEWS)
*
Elicit in repetition or picture naming
Phonetically transcribe target sound
errors
Assess for audible nasal emission
[ANE] and/or nasal turbulence [NT]
on high pressure consonants
Assess for cleft type CAs and
backing of oral targets
Assess for adaptive oral
misarticulations
Assess for other common
misarticulations (e.g., omissions,
distortions, substitutions)
Sentences: American English
Sentence Sample (AESS)
†
Elicit by repetition
Phonetically transcribe target errors
(1) Oral pressure consonants
(stops, fricatives, affricates);
no nasals; one target type per
sentence (e.g., /p/, /t/, etc. in
all positions)
(1) Assess for ANE and/or NT, CAs,
and backed or retracted oral
productions; detects adaptive oral
misarticulations and other common
misarticulations
(2) Nasal consonants; no oral
high pressure consonants
(2) Facilitates detection of
assimilation nasality; detects
hyponasality
(3) Sonorants/low-oral-
pressure consonants only /w,
j, l, r/; avoid nasals
(3) Assess for hypernasality and
backed or retracted oral
productions
Paragraph: Zoo Passage‡ (no
nasal consonants)
Oral reading preferred Assess for hypernasality
CV syllables: ordered from
anterior to posterior place of
production; includes all
English consonants ordered
through
Syllable repetition with a dental
mirror/reflector held beneath nostrils
(optional); e.g.
,
, , ,
Detect NE, mirror fogging on
affected high pressure consonants
Document consonant phonetic
inventory
Detect CAs (substitutions,
coproductions)
Detect backed or retracted oral
productions
Serial counting:
from 60 to 70
from 50 to 60 or 30-40
Elicited counting (dental mirror or
reflector held beneath nostrils is
optional)
60-70 detects PSNE on /s/
ANE/NT on 60-70 with absence of
ANE/NT on 50-60 or 30-40 can
confirm PSNE
Sustained isolated high vowel
production: [u, i]
Elicited, sustained [u] and [i] with
alternate “gentle” cul-de-sac
technique/occluding nostrils
Resonance shift suggests atypical
oronasal coupling (hypernasality); a
very gross test
*
Trost-Cardamone and Kuehn (revised 2009).
†
Trost-Cardamone (2013, 2012), Chapman et al., (2016)
‡
Fletcher (1972).
ANE, Audible nasal emission; CAs, compensatory articulations; CV, consonant-vowel;
NE, nasal emission; PSNE; phoneme-specific nasal emission; NT, nasal turbulence.
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Modified from Peterson-Falzone SJ, Trost-Cardamone JE, Karnell MP, Hardin-Jones
MA: The clinician's guide to treating cleft palate speech. St. Louis: Mosby, 2006.
As can be seen, these include the following:
Single words
Sentences
Paragraph: Zoo Passage
Consonant-vowel (CV) syllables
Counting from 60 to 70, 50 to 60
Sustained high vowel production
Now watch a few video clips that illustrate some of these sampling
contexts.
Video 8-1
illustrates both the resonance shift in sustained vowel
production using nasal occlusion, and confirmation of nasal air
emission using the dental reflector.
Video 8-2
shows the usefulness of comparing the quick task of
counting from 60 to 70 with counting from 50 to 60 (or 30 to 40) in
distinguishing or verifying phoneme-specific nasal emission.
This same counting task can be used to document pharyngeal
fricatives that are used to replace the fricative /s/ as you heard in Audio
5-12. You may want to relisten to it here.
The child in Video 8-3
is the same child you saw in Video 5-6 and
who uses ingressive airflow (clicks). Here you will again hear her
counting and then repeating sentences from the AESS. Note how the
sentences reveal more sounds affected by clicks as well her nasal
grimace.
At first glance, the task of assembling the speech stimuli may seem
overwhelming; it is not. A conversational speech sample, one set of
sentences and one set of single words, both structured phonetically to
sample for hypernasality, nasal emission and nasal turbulence, and
consonant production errors, provides a basic adequate sample.
Repetition of CV syllables (see protocol forms in Appendix 8-A) is
especially useful with younger children who may not or cannot engage
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in some of the other tasks (e.g., sentence repetition, counting from 60 to
70). The Zoo Passage (see Appendix 8-B) and serial counting are easy
add-ons to this basic baery. To our knowledge, at this time the only
available American English controlled sentence sample for cleft palate
speech is the AESS. The AEWS and AESS protocol forms are provided
for your use in Appendices 8-C and 8-D, respectively. The Spanish UPS
single-word and sentence protocol (Cleves et al., 2009) is provided in
Appendix 8-E.
The American English Sentence Sample (AESS) is the sentence sample
protocol used in the Americleft Speech Outcomes Project. As data is
forthcoming from this project, it is hoped that more speech-language
pathologists based in cleft and craniofacial centers will consider
adopting the protocol.
The AEWS, the AESS, and the Spanish UPS are administered by
having the child repeat the word or sentence stimuli after the
examiner. Well-defined scoring protocols are in place when these
samples are used for speech outcomes research. Detailed scoring is not
necessary for routine clinical assessments. Rather, the data can be used
describe error types and paerns and for treatment planning, and a
simple count of the percentage of target consonants correct (PCC) can
be obtained with each administration to document change and
treatment progress.
Published Sound Inventories and Standard
Articulation Tests
For younger patients especially, an articulation inventory that provides
normative data for determining the child's developmental articulation
and phonology status is recommended. Many such standard
inventories are available, for example, the Goldman-Fristoe Test of
Articulation 3 (GFTA-3) (2015) or later edition, the Kahn-Lewis
Phonological Analysis (KLPA-3) (2015) or later edition, the BanksonBernthal Test of Phonology (BBTOP) (1990), and the Clinical
Assessment of Articulation and Phonology (CAAP-2) (Secord and
Donohue, 2014). The focused cleft palate speech assessment uses such
inventories as supplemental to the task of diagnosing cleft palate or
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noncleft VPD speech errors and predominantly for documenting
speech sound developmental status in younger children.
A full assessment baery that includes cleft-focused speech assessment
as well as published articulation inventory cannot be accomplished
during a team visit day. Often, because of work schedules, it is difficult
for families to return to the clinic. This is where a collaborative
relationship between the team SLP and the treating SLP (school- or
community clinic-based) is a valuable resource. The detailed cleft
palate speech assessment can be done by the team SLP, and the more
generic and extensive speech and language assessments can be done by
the community- or school-based SLP. And importantly, these
assessments begin the collaborative care relationship.
Stimulability Testing
This testing is an integral part of all articulation assessment.
Stimulability testing with isolated sounds or CV syllables informs us of
the speaker's motor phonetic ability and is a key means of
documenting his or her phonetic inventory (i.e., the consonant and
vowel targets the speaker can produce, whether or not these sounds are
actually used in spontaneous or elicited connected speech). Data from
stimulability testing guides us in determining starting points in
therapy. For example, as applied to cleft palate speech, substitution of a
gloal stop for an oral stop may or may not represent an inventory
constraint: If stimulability testing demonstrates that the speaker can
produce the target for which the gloal stop is substituted, for example,
then therapy can begin by practicing the target in syllable contexts or
meaningful speech contexts. By contrast, if the sound cannot be elicited
in any context through stimulability testing, then therapy must start at
the motor learning level of teaching, with a strong emphasis on
teaching place of production and automatizing target productions.
Video 8-4
illustrates speech sound modeling and stimulability with a
youngster (EC) who uses pharyngeal fricatives for a number of
fricatives and stops. You saw this child in Video 5-4 and you will see
and listen to more of him later in this chapter.
For more on stimulability testing, see Bernthal et al. (2013) and
Peterson-Falzone et al. (2010, Chapter 9).
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