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association with certain target sounds or phonetic
contexts.
• Nasal emission heard sporadically on some or all
pressure consonants may prove remediable by
therapy, especially if it has a learned basis. This
needs to be verified with trial diagnostic therapy to
determine whether the patient can eliminate it.
Referral for instrumental assessment and possible
physical management of the VP mechanism is
indicated if a short period of trial therapy is not
successful.
Weak High Pressure Consonants (Oral Pressure Problem)
1. Are high pressure consonants (stops, fricatives, affricates) in the
inventory produced with weak oral pressures?
• This tends to be easier to hear on stops and affricates
than on fricatives because fricatives are continuants
and normally require lower oral pressures than stops
and affricates.
• This suggests a physically based VP closure problem.
• Weak oral pressures are always evident when nasal
emission and continuous/pervasive hypernasality
are heard in the same speaker. Their combined
presence provides unequivocal evidence of
physically based VP inadequacy.
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2. Is there reduced vocal loudness?
• Reduced oral (supragloal) pressures associated with
physically inadequate VP closure affect subgloal
pressure; reduced subgloal pressure results in
reduced vocal intensity.
Nonoral Compensatory Articulations Assessment
In listening for nonoral compensatory articulations (CAs), remember
their cardinal features: They are learned errors, most often in place of
production. As a group, they are characterized as backed articulations,
predominantly backed to the pharynx and glois. There are, however,
a few exceptions. CAs are learned articulatory postures that often persist
even after successful physical management of the VP closure mechanism. In
other words, what was learned when the VP system was not capable of
closure persists after adequate closure is made possible.
Diagnostic questions and possible answers:
1. Are CAs present?
• At this first level of analysis, this is a binary decision:
yes or no.
2. If the answer is “yes,” ask the following sequenced assessment
questions:
• What types of CAs are present? This draws upon the
clinician's perceptual skills and experience in
hearing and transcribing these types of errors.
— List the types observed.
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— Be careful not to mistake a gloal stop for a
consonant omission.
— Be careful not to mistake a pharyngeal fricative for a
lateralized sibilant.
• How are these compensatory articulation types used
or revealed?
— Do they occur as substitutions, as coproductions, or
both?
— Are paerns consistent? For example, are voiced
stops always replaced by gloal stops? Are all oral
fricatives replaced by pharyngeal fricatives, or is this
paern limited to sibilants or sibilants plus
affricates?
— Answers to these questions will guide you in
treatment planning.
Too often, the notation that compensatory articulations are used and
the types observed is the only information provided in the team report.
Although this information is of some use diagnostically, it is of
minimal use for planning speech remediation. Conversely, if a
nonspecialist clinician is making a referral to a team, this is an initial
body of information that should be useful to the team SLP. To make an
accurate and reliable diagnosis and to plan appropriate treatment,
more in-depth assessment and analysis is usually necessary. Often this
can be done collaboratively by the team SLP and the community- or
school-based SLP.
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• Are persisting nonoral CAs causing velopharyngeal
inadequacy (VPI)?
— You want to identify VPI that is caused by (rather
than the cause of) pharyngeal and gloal CAs.
Remember, a velopharyngeal mechanism that is fully
capable of closure may be bypassed if the speaker
substitutes CAs such as gloal stops and pharyngeal
fricatives for oral consonants. Rampant gloal stop
substitutions and many pharyngeal fricative
substitutions in a speaker who is also hypernasal
should alert you to this possibility. If gloal or
pharyngeal CAs, or both, are suspected to be having
this adverse effect on VP closure, it is important to
document any normal pressure consonant
productions and in what contexts they occur.
— Habitual use of gloal or pharyngeal articulations as
a possible cause of VPI is best revealed through
imaging studies such as videofluoroscopy and
videonasendoscopy (Henningsson and Isberg, 1986,
1991). In such cases, if the speaker has some normal
oral placements, an imaging study will show that the
VP port closes with normal, orally placed pressure
consonant articulations but stays open, or may even
open more, during gloal stop and pharyngeal
fricative articulations.
— When compensatory articulations are the cause of
velopharyngeal inadequacy, speech therapy to
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replace the gloal and pharyngeal articulations with
normal oral targets should correspondingly improve
or normalize velopharyngeal closure.
Backed Oral Productions Assessment
Diagnostic questions and possible answers:
1. Are backed or retracted oral articulations present?
• At this first level of analysis, this is a binary decision:
yes or no.
2. If the answer is “yes,” what types are present?
• List types (e.g., /t, d/ → mid-dorsum palatal stop; /s,
z/ → mid-dorsum palatal fricative; tip alveolars /t/ or
/d/ or /n/ or /l/ are velarized; /k/ or /ɡ/ are backed but
not to pharyngeal place).
The arrow (→) means “becomes” or “is replaced by.”
Although some speakers with repaired cleft palate (with or without
cleft lip) may present with backed oral production on one or two
sounds, be alert to more extensive articulatory backing that may affect
many or most intraoral targets and may also coexist with the nonoral
compensatory articulations. This information will help you in
treatment planning because a major focus will be on bringing backed
articulations forward and not just on specific sound correction.
Adaptive Oral Misarticulations Assessment
Adaptive oral misarticulations are differentiated from CAs because
they have a current (existing) physical cause and are thus obligatory.
The most commonly encountered examples are sibilants and affricates
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adversely affected by dental and occlusal deviations. For example,
ectopic teeth in the anterior hard palate can lead to backed /s/
production that causes the sound to be produced as a palatal or even
velar fricative. Other examples are provided in Chapter 7. Adaptive
oral misarticulations may also be etiologically based in motor control
problems as seen in the dysarthrias.
Assessing Effects of Dental Deviations on Speech
Diagnostic questions:
1. Are there missing teeth?
• Missing anterior teeth can encourage frontal lisping.
• Missing buccal teeth can encourage lateralization of
sibilants.
2. Are there rotated, misaligned, or ectopic teeth in the maxilla?
• Any of these can cause distortion of sibilants and
affricates.
• In severe cases (e.g., several rotated teeth) tongue
placement for /s, z/ can be palatalized and for /t, d, n,
l/ can be backed (i.e., the tongue tip or blade contacts
a point on the hard palate that is more posterior than
normal).
3. Are there diastemas?
• Diastemas are spaces between teeth, especially the
maxillary incisors. They are normal during the
mixed dentition stage and therefore transient. Do not
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be quick to aribute diffuse production of sibilants
to diastemas.
Assessing Effects of Occlusal (Dental Arch Form) Deviations on
Speech
Diagnostic questions:
1. Is there maxillary collapse resulting in crossbite?
• Crossbite (unilateral or bilateral) can, but does not
necessarily, contribute to lateralization or other
distortion of sibilants.
2. Is there a protrusive premaxilla? This is found in true class II
malocclusions, but may also be seen in “pseudo-class II” in which only
the premaxilla, rather than the entire maxilla, is protruded. This can
lead to:
• Production of bilabials with the lower lip articulating
with the upper teeth rather than the lower lip
meeting the upper lip. This results in “dentalized”
bilabials
• Backed production of tip-alveolars /t, d, n, l/
• Diffuse sibilant productions
3. Is there a retrusive maxilla? (This is most often seen in skeletal class
III malocclusions.) Or a retrusive premaxilla? (This is a “pseudo-class
III” malocclusion, so-labeled because it is only the premaxilla that is
retropositioned, not the entire maxilla.) Potential effects on speech
include:
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• Interference with labiodentals, specifically “inverted”
placement for /f, v/ (lower teeth articulate against
upper lip)
• Labiodental contact, instead of bilabial contact, for
/p, b, m, w/ (again with lower teeth articulating
against upper lip)
• Interference with tip alveolars because the tongue
has to “reach back” to accomplish correct placement.
(Or, the tongue may just “not care” and protrude
anteriorly on these consonants.)
Assessing the Effects of Upper Lip Structural Deviations on
Speech
Diagnostic questions:
1. Is the upper lip deficient in length?
• A short upper lip, much like an upper lip that is
positioned too far posteriorly (as in a severe class III
malocclusion), may not make consistent contact with
the lower lip for intended bilabial productions.
2. Is the repaired lip tight and immobile, as a result of excessive
scarring and abnormal muscle alignment?
• Production of /w/ (and some vowels) may be
adversely affected by the reduced ability to round
the lips.
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• In some rare cases, scar tissue may be so excessive
that the lip is actually overly long (rather than
foreshortened), in addition to being immobile. In
these cases, the speaker may not be able to avoid
bilabial contact (i.e., bilabial fricatives) for what
would otherwise be labiodental articulations.
Developmental Articulation and Phonological
Errors
Although developmental articulation errors and phonological
processes are not the focus of this chapter or text, a brief mention is in
order. The team SLP should assess for these types of errors and
paerns or refer for more comprehensive assessment, as is the protocol
for any speech assessment with preschool and early school-age
children.
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Diagnostic Outcomes: Case Examples
The following scenarios are presented as instructive examples of
common speech diagnoses in speakers with cleft palate. For obvious
reasons, we have not included the many children with repaired cleft
palate who have normal speech and those who have predominantly
developmental disorders. Also, there will be some children who
present with small phonetic inventories, gloal stops, and hypernasal
resonance. Such children require diagnostic therapy to (1) explore what
improvement can be brought about in their speech and (2) determine
whether physical management is necessary. To make the information
presented in this chapter clinically and developmentally meaningful
and to provide continuity between chapters, the material is presented
in three age groups: baby or toddler, preschool, and school-age.
As you read this material, be aware that we are not talking about the
same child through each of these developmental stages. The material is
derived from prior case records of the authors.
Baby/Toddler: Age 8 to 10 Months
Clinical Findings/Presenting Problems
1. Unoperated left unilateral cleft of the lip and palate.
2. Has recently begun to babble; no anterior stop consonants in the
babbling inventory; babbles using /m, j,
, h/.
3. Sporadic individual CV uerances include above sounds plus /h/
and what parents describe as a “grunting sound from deep in his
throat” that is “prey funny”!
4. His vowel inventory appears to be emerging and expanding
appropriately.
Speech Diagnosis
“Bobby” presents with delayed onset of canonical babbling, and a
reduced phonetic inventory that includes only the nasal /m/ the glide
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