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begins babbling and producing consonant sounds. Babies with cleft
palate who have a limited consonant inventory appear to produce
growls more frequently than their noncleft peers and these
productions persist for longer periods. Growls are of concern in this
population because, as with gloal stops, they involve excessive
laryngeal or pharyngeal muscular activity. Some children with
severe delays in speech sound development learn to produce these
behaviors early on as a substitute for oral articulations.
Whenever possible, we want to circumvent the persistence of
these behaviors by having parents ignore the behavior and model
an appropriate oral consonant instead. Unfortunately, growling is a
cute behavior that parents often reinforce. You want to discourage
parents from reinforcing these behaviors, preferably before they call
your aention to this “cute thing” that their child does.
In addition to increasing the frequency of vocalizations, other
goals of phonological intervention during the early stages of speech
and language development should be to expand the baby's
consonant inventory and range of syllable shapes (Paul and
Norbury, 2012). Both goals can be easily addressed in simple
babbling games. It is best for the parents' learning if you first
describe, and then demonstrate, a turn-taking game.
• Instruct the parents to wait until their baby vocalizes or babbles,
and then imitate what the baby says.
• Wait for the baby to repeat the vocalization, and then say it again.
• Once the baby begins to participate actively by vocalizing back and
forth with the parent, a new consonant can be introduced into the
babbling. Similarly, vowels can be practiced by increasing their
duration in isolated production and in consonant-vowel (CV)
productions.
• Before palatal surgery, you should advise parents to initially
encourage CV syllables that the baby can easily produce, such as
those containing vocalic and nasal consonants (e.g., wawa, mama,
nænæ, lili).
• If oral stops such as /b/ are present prior to palatal surgery they can
be reinforced as well. Parents should be informed, however, that
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oral stop consonants may sound nasal. Advise parents to ignore the
nasal quality and reinforce the baby's aempts to produce these
consonants.
If the baby does not readily imitate vocalizations, it may be
beneficial initially to engage him or her in an activity that involves
body movement (e.g., hand clapping, jumping, dancing). Performing
these movements in front of a mirror where the child can see both
himself or herself and you (or the parent) will likely enhance the
child's interest in the activity.
• Once the baby imitates large body movements, encourage
imitation of different facial expressions (e.g., happy, sad, silly).
• Gradually introduce different lip and tongue movements for
imitation.
• Pair sounds with different movements (e.g., kissing), and
encourage the child to imitate both the facial movement and the
vocalization.
It is important to stress to the parent that the goal is not to have
the baby imitate the exact sound the adult produces. The goal of
babbling games during this stage of language development is to
establish imitative speech sound behaviors and facilitate expansion
of both the consonant and syllable shape inventory. It does not maer
if the parent models one sound and the baby produces another.
Some babies with an unrepaired cleft produce a gloal stop when
vocalizing or aempting to imitate an oral stop consonant. Because
we always want to reward a baby for vocalizing or participating in
babbling games, you should advise the parent to model an
acceptable consonant when gloal stops are produced. It is
important that the parents and family not reward other deviant
speech productions, such as nasal fricatives and pharyngeal growls,
by modeling these sounds back to the baby (Box 11-2).
Box 11-2
Do Palatal Obturators Facilitate Early
Consonant Production?
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Some clinicians have questioned whether anterior palatal obturators
(covering the hard palate) could be used as a treatment to facilitate
early speech sound development. Theoretically, obturation of the
hard palate could provide an advantage in early speech sound
development because it provides the baby with an anterior
articulatory surface for production of lingual consonants. HardinJones et al. (2002) found no difference in size of consonant inventory
or in place of consonant production between 9-month-old babies
who had worn an anterior palatal obturator and those who had not.
These investigators argued that although an anterior palatal
obturator may cover the hard palate, the loss of air pressure through
the posterior portion of the cleft in the soft palate may have a
dominant effect on the baby's consonant development. Similar
findings were subsequently reported by Lohmander et al. (2004) for
18-month-old babies. We should point out, however, that two
studies have reported more favorable phonological performance in
older children (ages 2 to 3 and 5 to 6 years) who wore these
appliances (Konst et al., 2003; Suzuki et al., 2006). Currently, palatal
obturators are not routinely recommended in the United States and
Canada to promote early speech sound development. This is
unlikely to change unless future clinical studies can demonstrate a
direct impact of these appliances on speech development.
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Parents' Expectations of Palatal
Surgery
As the time for palatal surgery approaches (typically a time that
parents have both eagerly awaited and dreaded), parents will need
to know what to expect. Most parents want to know about feeding
and what restrictions will be imposed immediately after surgery.
Because such information will differ depending on their surgeon,
such a discussion should involve the surgeon, the surgeon's nurse, or
the team SLP who should be familiar with the surgeon and the
protocols. Parental expectation for speech is another issue that
should be addressed before palatal surgery to ensure that parents
have realistic expectations. Many children with palatal clefts
undergo surgery before they begin saying words. Parents frequently
assume that their child will begin talking once the surgery has been
performed and that any delays previously observed will simply
disappear. Unfortunately, this typically is not the case. It is
important for parents to know the following:
• Frequency and variety of vocalizations may decrease immediately
after surgery. It may take several weeks for the toddler to resume
normal production levels, and so parents should be forewarned to
maintain good interaction levels during this time.
• Provided the initial palatoplasty does the job of providing an intact
palate and a velopharyngeal (VP) mechanism capable of closure,
many toddlers begin adding new consonants to their phonetic
inventory that were not produced before surgery (e.g., stop
consonants that require oral pressure). These consonants will be
evident in both babble and early words. Other toddlers may begin
adding words to their expressive vocabulary but show lile, if any,
growth in their phonetic inventory. Early intervention would be
appropriate for this laer group of children both for diagnostic
purposes (of monitoring the adequacy of the VP mechanism) and to
facilitate expansion of the child's speech sound inventory.
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Lexical and Phonological Growth
Following Surgery
After the repaired palate has had sufficient time to heal and the baby
has recovered from the trauma of the hospitalization, parents should
be advised to keep a diary of new words and consonants that their
child produces. The types of consonants that the child begins
producing after palatoplasty may dictate for some children whether
early intervention is needed.
• Toddlers who begin adding oral stops to their inventory are
demonstrating the type of phonetic growth expected after surgery,
but they should be monitored periodically to ensure that their
consonant inventory and expressive vocabulary continue to expand
appropriately.
• Toddlers who persist in using nasal substitutions or gloal stops
and those who have developed nasal fricatives should be carefully
monitored. These behaviors are transient for some toddlers and
disappear as their lexical and speech sound inventory expand. The
persistence of these types of consonants and the absence of oral
pressure consonants and stops may be early indicators of
velopharyngeal inadequacy (VPI) in some children. In other
children, nasal substitutions and gloal stops persist as learned
behaviors and are not necessarily indicative of VPI; in these
children, the abnormal productions serve as important predictors of
subsequent phonological deviation and perhaps delay.
Although gloal stops are the predominant gloal productions
heard in children with cleft palate, some children use /h/ as a
substitute for oral pressure targets. This gloal substitution,
although atypical, is not as difficult to remediate as the gloal stop.
• Determining the adequacy of the VP mechanism is not possible
immediately following palatal surgery. Assessment occurs over
time as the toddler's language expands and increasingly more
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consonants are added to the phonetic inventory. For some children,
evidence of VP adequacy is apparent early on as the child begins
producing short sentences. For other children, assessment of VP
adequacy is a long-term process that extends into the preschool
years or beyond, depending on the presence and specific types of
maladaptive compensatory misarticulations.
The toddler in Video 11-1 was seen by one of the authors on a trip
to China. Despite receiving palatal surgery at 13 months, this
child's phonetic inventory was limited to nasals, glides, and gloal
stops at 2 years, 10 months. Although the initial clinical impression
was VPI, stimulability testing revealed that he was able to blow
bubbles and produce a “raspberry” following an auditory and
visual model. After a brief period of intervention (twice a day for 4
consecutive days), the child was able to produce oral stops and an
oral /f/. Parents observed each session and were encouraged to
work with the child at home. When the child was seen for followup at 4 years of age, a complete inventory of obstruent consonants
was evident and speech was judged to be normal. This case
underscores two important points: (1) adequacy of velopharyngeal
function cannot be assessed until a child is aempting to produce
obstruent consonants and (2) absence of obstruent consonants does
not in and of itself imply VPI.
• It is important to evaluate the child's developing phonology in
relation to (not independent of) the child's developing lexicon. We
do not have the same phonological expectations for a child with a
limited expressive vocabulary as we do for a child with a large
expressive vocabulary. Children with small expressive vocabularies
tend to have a small phonetic inventory. Paul and Jennings (1992)
found that the typical 18- to 24-month-old child produces
approximately 14 different consonants in a 10-minute interaction
sample. In contrast, same-age peers with small expressive lexicons
produce an average of 6 different consonants (Box 11-3).
Box 11-3
The Value of a Good Assessment
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An SLP cannot design a good treatment plan for toddlers when an
adequate assessment has not been performed. We know from many
years of research that young children with cleft palate have far more
difficulty with speech sound production than they do with
expressive language. However, it is not uncommon for SLPs to
administer a language test and call the assessment good if the child
is too young for an articulation test. Although parents can provide a
lot of useful information about the sounds their toddler produces,
the information they provide is usually limited to the inventory of
sounds and perhaps the type of error they have heard their child
produce. They cannot provide you with information about the
frequency of the error (which will dictate in part the impact on
intelligibility) or the nature of the error paern (is it developmental
or cleft-related?), and that information is critical to customizing a
good treatment plan for a child. If you plan to initiate articulation or
phonological treatment, you need to administer an articulation test
or obtain an adequately long speech sample and analyze it.
Finally, not every error that a child with a cleft produces is cleft
related. Be alert to errors associated with the cleft or VPI, but do not
let the cleft become such a “distraction” that you lose sight of the
developmental aspects of the child's speech and language.
Expanding the Phonetic Inventory
Toddlers with severely limited vocabularies frequently demonstrate
impaired phonological skills as well. When delays are evident across
all areas of language, intervention typically focuses on the lexical,
syntactic, semantic, and pragmatic aspects of language. It is assumed
that as positive changes occur in these aspects of language, positive
changes will follow in phonology. For many children with cleft
palate, however, delays in phonological development far exceed
delays in other areas. These delays result primarily from restricted
consonant inventories that often make it difficult to identify
intelligible words in the early lexicon. If careful analysis of
spontaneous uerances suggests that the child's expressive
vocabulary is developing appropriately, then a primary goal of
intervention will be to expand the consonant inventory. It is likely
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that some nasals and glides will already be present in the inventory.
Developmentally, the addition of early developing voiced stops (e.g.,
/b/ and /d/) would make sense. However, you should not feel
constrained by developmental considerations when selecting
consonants to target in therapy with these children. Some of these
children find fricatives easier to produce than stops. Because the goal
is to increase the variety of consonants that the child produces (so
the child has more sounds to aach meaning to), you should feel free
to focus initially on any consonants that are easy to elicit. Table 11-2
offers a summary of contexts that can be used to facilitate consonant
production during the early stages of speech development. Activities
that either a parent or a clinician can use to stimulate new
consonants include the following:
• Model lip and tongue movements in a mirror while siing side by
side with the child in front of a large mirror, and encourage
imitation:
— Puff up your cheeks with air, and then tap the
cheek repeatedly to release air through lips in
small bursts.
— Pucker or protrude your lips while producing /u/,
and then pat your mouth repeatedly to generate
/w/.
• Model specific speech targets in CV syllables, as in “pa,” “da” to
encourage imitative production. A good way to draw the child's
visual aention to your mouth (in the mirror) is to bring a block or
peg to the side of your mouth as you produce the target sound. The
child's aempted response can then be rewarded or reinforced by
puing the block in a bucket or the peg in a pegboard, which tells
the child that he or she has succeeded in the task. This activity is
illustrated in Video 11-2
. Note that the clinician is also training the
parent for home practice in this activity.
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• Use specific play activities to stimulate specific sounds:
— Blow bubbles and use “bilabial language” within
this task. For example, say “Bubbles. Blow
bubbles.” (Clinician blows bubbles.) Again,
“Bubbles, POP, POP.” (Clinician pops bubbles and
encourages child to do same.) “More bubbles??
Blow bubbles!” (Repeat several times, gradually
engaging the child in blowing as well as popping
the bubbles.) If one parent is present, “Mommy
(Papa) blow, Mommy (Papa) pop, Mommy (Papa)
blow,” and so forth.
— Sing “lalala” to a simple song.
— Feed a baby doll, and say /mmmm/ each time a
bole or spoon is brought to her mouth.
— Say “shhhhhhhhhh” while making the gesture for
the “be quiet” sound.
— Play with toys and animal figures, and use specific
sounds to represent the sounds they make (e.g.,
say “ssssssss” each time the snake appears; say
“rrrrrrrr” each time you move the car, “baaa” for
the goat or lamb, “bzzzz” for bee). It is a good idea
to collect toy animal figures in identical pairs (one
for you, one for the child) to facilitate imitation
and turn-taking games. Holding the animal to
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your mouth will direct the child's aention to the
speech gestures as well as to the sounds.
TABLE 11-2
Contexts for Facilitating Consonant Production in Early Speech
GOAL ACTIVITY
To increase length and
rhythm of productions
Use simple repetitive motor activities (e.g., bouncing on a large ball) while
modeling repetitive syllables in time with the child's movement (/ba ba ba/)
To connect sounds with
meaning
Use songs like “The Wheels on the Bus” that include verses with simple
sounds (e.g., “the wipers on the bus go whoosh, whoosh, whoosh,” “the
babies on the bus go wah, wah, wah”)
To encourage expression of
emotion with conventional
vocalizations
Use games and routines to incorporate exclamations such as “yeah,”,
“wow,” “uh-oh,” “haha,” and “whee”
To facilitate consonants Use stressed syllables (baby to facilitate /b/)
To facilitate velar
consonants
Use words with velars at the end of syllables (talk to facilitate /k/) and
words with velars preceding back vowels (good to facilitate /ɡ/)
To facilitate alveolar
consonants
Use words with alveolars preceding a front vowel (tea to facilitate /t/)
To facilitate production of a
consonant at a new place of
articulation
Use a word that contains another consonant at the same place of
articulation (toss to facilitate /s/)
To facilitate first fricatives Use words with fricatives between vowels (taffy to facilitate /f/)
To facilitate voicing
distinctions
Use beginning contexts to facilitate production of voiced consonants (dough
to facilitate /d/) and ending contexts to facilitate production of voiceless
consonants (eat to facilitate /t/)
Adapted from Paul R, Norbury CF: Language disorders from infancy through
adolescence (4th ed). St. Louis: Mosby, 2012; Bleile K, Miller S: Infants and
toddlers. In Bernthal J (ed): Articulatory and phonological disorders in toddlers with
medical needs. New York: Thieme, 1993, pp. 81-109; DeThorne LS, Johnson CJ,
Walder L, Mahurin-Smith J. When “Simon says” doesn't work: alternatives to
imitation for facilitating early speech development. Am J Speech Lang Pathol
18:133-145, 2009.
Facilitating Early Words
If the toddler's consonant and syllable shape inventories appear
significantly delayed and the early lexicon also appears restricted,
you may want to begin expanding the child's vocabulary as well.
Focused stimulation and enhanced milieu training are intervention
strategies that are commonly used during the earliest stages of
speech-language acquisition to facilitate vocabulary expansion and
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