Assessment of cleft palate speech at the community level

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Information to include in reports for the cleft palate team

• What is the child's phonemic inventory?
• What phonological processes are present?
• Which specific sounds are affected by nasal air emission or hypernasality?
• Information about oral musculature function and the appearance of the hard and soft palate.
• Details about therapy progress to date if applicable.
• Any relevant medical history, eg removal of tonsils and adenoids, cardiac problems, syndrome diagnosis.
• If referring a child for a second opinion, it would be helpful to send a copy of the articulation test form raw data and any analysis.

Articulation tests

There are a number of specific articulation tests that have been developed for the assessment of cleft palate speech.

The GOS.SP.ASS (Great Ormond Street Speech Assessment) is widely used throughout the U.K. and a set of GOS.SP.ASS pictures is available for loan from JHCH. The GOS.SP.ASS also provides a means of recording resonance, nasal airflow, speech error patterns, and oral musculature assessment.

The GOS.SP.ASS sentences can be viewed in Appendix 2, pp. 29-30 of the article:
Sell, D., Harding, A. & Grunwell, P. (1999). GOS.SP.ASS'98: an assessment for speech disorders associated with cleft palate and / or velopharyngeal dysfunction (revised). Int. J. Language & Communication Disorders, 34(1), 17-33.
http://web.ebscohost.com/ehost/detail?vid=1&hid=7&sid=9dc4736d-3c65-47b7-ba87-f59a217ec68a%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&AN=1999017885
Access to this website on computers that are not on the NSW Health network is available by using your Gardiner Library membership number as the password.

The test used by JHCH speech pathologists is a draft version of the Rhinocleft®, which is an Australian test that is currently under development, and is expected to be available for wide spread use in the near future.

The most practical option for community based therapists, however, is to use a standard articulation or phonology test which is available in their own clinic. An informal survey of Hunter New England speech pathologists during the development of this website indicated that the following articulation tests were in frequent use:

• DEAP
• Goldman Fristoe
• Daz Roberts
• Caroline Bowen screener
• Articulation survey.

When using a standard articulation test, pay particular attention to:

1. The child's phonemic inventory.

• Is there an appropriate range of sounds for the child's age?
• Is there a preference for nasal sounds /m n ?/ and glides?
• Is there a lack of high pressure consonants, for example /p,b,t,d/?

2. High pressure consonants (plosives, fricatives and affricates) - is there reduced oral air pressure (speech might sound soft or muffled)?
3. Sibilants, particularly /s/ - is there any nasal air emission? Does it accompany the sound or replace the sound?
4. Vowels - is there any perceived hypernasality?
5. Any unusual phonological processes, eg, backing plosives or fricatives to pharyngeal sounds, backing to glottal stop.
6. Stimulability testing. Test for all phonemes, not just age-appropriate phonemes. Stimulability for later-developing phonemes may lead you to target those in therapy. Golding-Kushner (2001, pp 96-102) go into specific detail about stimulability testing.

Further reading

Golding Kushner, K. (2001) Therapy Techniques for Cleft Palate Speech and Related Disorders. Cengage Learning, Chapter 7.

Assessment of velopharyngeal function

A short speech sample combined with some simple screening techniques can be effective in assisting the speech pathologist to make perceptual judgements about resonance and nasal airflow, which in combination with case history information will allow the speech pathologist to make inferences about velopharyngeal function. Note that the tasks suggested below use single words or short phrases, as this will help the listener to focus on the target sounds. However, it is important to also evaluate connected speech, as achieving and maintaining velopharyngeal closure during connected speech is generally more difficult. For further information about speech sampling, refer to:

Henningsson, G., Kuehn, D.P., Sell, D., Sweeney, T., Trost-Cardamone, J. E., Whitehill, T. L., Speech Parameters Group. (2008). Universal parameters for reporting speech outcomes in individuals with cleft palate. Cleft Palate-Craniofacial Journal, 45(1), 1-17. Nasal air emission p. 7
http://www.cpcjournal.org/doi/full/10.1597/06-086.1

For a detailed explanation and definitions of hypernasality and hyponasality go to Resonance. See also nasal airflow disorders.

Nasal flutter test (wmv) 2.8MB). Tests for hypernasality on vowels.
Ask the child to phonate a vowel and alternately occlude and let go of their nose with your fingers. If resonance is normal, then the vowel should sound the same whether the nares are occluded or open. If the vowel is hypernasal, then it will sound different when the nose is blocked. High vowels such as /i/ will be more vulnerable to hypernasality.

References for nasal flutter test:

• Weiss, C., (1974). The speech pathologist's role in dealing with obturator-wearing school children. J. Speech Hear. Dis., 155-162. Cited in Rampp, D. L., Pannbacker, M., Kinnebrew, M.C., (1984). Velopharyngeal Incompetency: A Practical Guide for Evaluation and Management. Austin, TW: Pro-Ed.
  Hess, D., (1976). A new experimental approach to assessment of velopharyngeal adequacy: Nasal manometric bleed testing. J. Speech Hear. Dis., 41, 427-443. Cited in Rampp, D. L., Pannbacker, M., Kinnebrew, M.C., (1984). Velopharyngeal Incompetency: A Practical Guide for Evaluation and Management. Austin: Pro-Ed.

Hypernasality (wmv) 13.9MB). Tests for words or phrases that are loaded with voiced oral consonants, eg /b/.

For examples of words/ phrases see:

• Community Developed VPI screener (pdf 40K)
• Kummer (2008) Table 12-3 (p. 325) and 12-4 (p. 327)
• Bzoch Error Pattern Diagnostic Articulation Test. Bzoch, K. (1979). Measurement and assessment of categorical aspects of cleft palate speech. In Bzoch, K. (Ed.), Communicative Disorders Related to Cleft Lip and Palate, 2nd ed., Austin, TX: Pro-Ed, 161-191. Cited in Rampp, D. L., Pannbacker, M., Kinnebrew, M.C., (1984). Velopharyngeal Incompetency: A Practical Guide for Evaluation and Management. Austin, TX: Pro-Ed.

Test for hypernasality

Hyponasality (wmv) 7.9MB). Test with single words or phrases that are loaded with nasal consonants, eg /m/.

For examples of words/ phrases see:

• Community Developed VPI screener (pdf 40K)
• Kummer (2008) Table 12-5, p. 327.
• Bzoch Error Pattern Diagnostic Articulation Test. Bzoch, K. (1979). Measurement and assessment of categorical aspects of cleft palate speech. In Bzoch, K. (Ed.), Communicative Disorders Related to Cleft Lip and Palate, 2nd ed., Austin, TX: Pro-Ed, 161-191. Cited in Rampp, D. L., Pannbacker, M., Kinnebrew, M.C., (1984). Velopharyngeal Incompetency: A Practical Guide for Evaluation and Management. Austin, TX: Pro-Ed.

Test for hyponasality

Having the child count from 90-99 is a useful short sample when listening for hyponasality, as this sequence of numbers is loaded with nasal consonants.

Nasal airflow

Speech samples for testing for nasal airflow should be loaded with high pressure consonants. The nasal emission test (wmv) 8.2MB) used at JHCH is from the Bzoch Error Pattern Diagnostic Articulation Test, and contains words loaded with bilabial plosives.

• Bzoch, K. (1979). Measurement and assessment of categorical aspects of cleft palate speech. In Bzoch, K. (Ed.), Communicative Disorders Related to Cleft Lip and Palate, 2nd ed., Austin, TX: Pro-Ed, 161-191. Cited in Rampp, D. L., Pannbacker, M., Kinnebrew, M.C., (1984). Velopharyngeal Incompetency: A Practical Guide for Evaluation and Management. Austin, TX: Pro-Ed.
• An alternative suggested by Kummer (2008) is having the child count from 60-70 (or repeat "60 60 60 60" if this is easier), as this sample is loaded with high vowels, sibilants and plosives, which require the velopharyngeal port to maintain oral air pressure.
• The GOS.SP.ASS tests /papa, pipi, kaka and kiki/ and /s/. Sell, D., Harding, A. & Grunwell, P. (1999). GOS.SP.ASS'98: an assessment for speech disorders associated with cleft palate and / or velopharyngeal dysfunction (revised). Int. J. Language & Communication Disorders, 34(1), 17-33.
  http://web.ebscohost.com/ehost/detail?vid=1&hid=7&sid=9dc4736d-3c65-47b7-ba87-f59a217ec68a%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&AN=1999017885
  Access to this website on computers that are not on the NSW Health network is available by using your Gardiner Library membership number as the password.

Perceptual methods to help detect nasal air emission

Using a mirror will help perceptual assessment by giving a visual indication of nasal air emission. Note that nasal air emission can be audible or inaudible.

• Positive S mirror test (wmv) 3.5MB)
• Negative S mirror test (wmv) 17.8MB)

The mirror test can be conducted with the speech samples above.

For younger children who are unable to produce /s/, an alternative fricative to try is /f/.

• Place the mirror under the child's nose.
• Have the child repeat the target sound/s.
• If the mirror fogs up, this indicates nasal air emission. Note whether the nasal air emission was audible or inaudible.Note that the mirror will fog up when the child breathes out at the end of the phrase - try to remove the mirror just before this happens.

Clean your mirror with alcohol wipes. Do not use Liv-Wipes (common in hospitals) as these appear to prevent the mirror from fogging at all. You may need to check your equipment before you start.
If you do not have a mirror in your clinic, then use the back of a metal teaspoon.

Test for nasal air emission

Further reading

Bzoch Error Pattern Diagnostic Articulation Test. Bzoch, K. (1979). Measurement and assessment of categorical aspects of cleft palate speech. In Bzoch, K. (Ed.), Communicative Disorders Related to Cleft Lip and Palate, 2nd ed., Austin, TX: Pro-Ed, 161-191. Cited in Rampp, D. L., Pannbacker, M., Kinnebrew, M.C., (1984). Velopharyngeal Incompetency: A Practical Guide for Evaluation and Management. Austin, TX: Pro-Ed.
Test for nasal air emission: p. 295

Nasal air emission can be:

• Consistent: occurs on most pressure-sensitive phonemes.
• Inconsistent: occurs occasionally on most pressure-sensitive phonemes.
• Phoneme specific: occurs consistently only on some phonemes.

Nasal air emission is more likely to be present in connected speech - it may not show up in short phrases, as there is less demand on the velopharyngeal system. In some cases, nasal air emission may only be present in transitions between oral and nasal sounds. For example, lunch, handy, snow, winter, rainbow, hamster, Humpty Dumpty. In these types of words, the nasal air emission will occur on the high pressure consonant which is immediately before or after the nasal sound.

Nasal air emission trouble shooting examples

Is nasal air emission noted (either audible or visible) on all pressure consonants? Is it accompanied by hypernasality?		Consider a physical inability to close velopharyngeal port.
Is the nasal air emission noted on only some sounds? Are these sounds in the same place of articulation as each other?		1. Consider whether a fistula is responsible. Look in the mouth and think about the place of articulation of the affected sounds in relation to the location of the fistula. Estimate the size of the fistula. The possible effects on speech are as follows (Kummer, 2008, Blakeley, 2000) Small fistula: might have minimal effect on speech >5mm diameter: NAE on production of pressure-sensitive consonants 2. Consider whether it is a phonological pattern.
Is the nasal air emission noted on only some sounds? Are these sounds the same manner of articulation?		If occurring in a particular sound group (commonly fricatives or affricates) despite apparent ability to correctly direct oral airflow for other sounds, think about phoneme specific nasal air emission.
The child's NAE occurs inconsistently on different sounds, and appears to be more evident on longer or more phonemically complex utterances. Phonological errors are inconsistent.		Consider incoordination of velopharyngeal mechanism, such as in childhood apraxia of speech. Assess diadochokinetic rate (Kummer, 2008).

Kummer (2008), p. 337, goes into further detail about differential diagnosis of the cause of hypernasality and nasal air emission.

Nasal grimace

Nasal grimace is quite commonly observed accompanying nasal air emissions. This is a behavioural response wherein the child attempts to inhibit the nasal air emission by constricting the nose to reduce the air escape. Nasal grimace can involve just the nares, or can extend to the bridge of the nose, or include the forehead. This may be called facial grimace.

During the articulation and phonology assessment, note if any sounds are accompanied by nasal grimace, and whether it is consistent or inconsistent. See GOS.SP.ASS for a rating scale to describe the extent of nasal / facial grimace.

Further reading

• Sell, D., Harding, A. & Grunwell, P. (1994) A screening assessment of cleft palate speech (Great Ormond Street Speech Assessment). European Journal of Disorders of Communication, 29, 1-15.
  Nasal grimace, p. 6.
• Sell, D., Harding, A. & Grunwell, P. (1999). GOS.SP.ASS'98: an assessment for speech disorders associated with cleft palate and / or velopharyngeal dysfunction (revised). Int. J. Language & Communication Disorders, 34(1), 17-33.
  Nasal grimace, p.20.
  http://web.ebscohost.com/ehost/detail?vid=1&hid=7&sid=9dc4736d-3c65-47b7-ba87-f59a217ec68a%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&AN=1999017885
  Access to this website on computers that are not on the NSW Health network is available by using your Gardiner Library membership number as the password.

Stimulability Testing

Like any speech assessment, it is useful to conduct stimulability testing to help with treatment planning. In addition, stimulability testing of velopharyngeal function provides some differential diagnostic information.

Once you have determined which sound the child is producing with hypernasality or nasal air emission, test if the child can eliminate the hypernasality or nasal air emission. Stimulability for correct production indicates that the child is likely to be capable of achieving adequate velopharyngeal closure for speech. Consider whether the error is a feature of the child's phonological system, rather than a physical inability to achieve velopharyngeal closure. Prognosis for therapy is good if the child is stimulable to eliminate the hypernasality or nasal air emission.

Ideas for stimulability testing:

• Model oral airflow and placement.
• Try gently holding the child's nose during sound production.
• Emphasise mouth opening, and overarticulate consonants.
• Minimise articulatory effort and pressure (use a soft breathy voice in the model).
• Try voiceless consonants.
• Try word final consonants, as oral resonance is established by the preceding vowel.
• Test for all phonemes, not just age-appropriate phonemes. The child may be stimulable for correct oral production of a later-developing high pressure sound, even though they may habitually produce earlier developing sounds in a non-oral manner (for example, pharyngeal or nasal realisations). Correct oral production of a later-developing sound would give an indication that the child is capable of adequate velopharyngeal function for speech. This oral manner and placement skill may be used as a starting point in therapy.

Further reading

• Blakeley, R. W. (2000) Palate Dysfunction and Speech Disorders: Evaluation and Treatment Planning Program for Children and Adults. Austin, TX: Pro-Ed.
• Kummer, A.W. (2008) Cleft Palate and Craniofacial Anomalies: Effects on Speech and Resonance (2nd ed.). New York: Thompson Delmar Learning, Chapter 12.
• Kummer, A. W. Resonance Disorders & Velopharyngeal Dysfunction: Simple Low-Tech and No-Tech Procedures for Evaluation and Treatment
  http://www.speechpathology.com/articles/article_detail.asp?article_id=332
• Peterson-Falzone, S., Trost-Cardamone, J.E., Karnell, M. & Hardin-Jones, M. (2005). The Clinician's Guide to Treating Cleft Palate Speech. NY: Mosby, Chapter 6 provides some valuable guidelines in how to interpret the assessment results.

Oral musculature assessment

Watch an oral musculature assessment being conducted:

• bifud uvula (wmv) 17.8MB)
• restricted range of movement (wmv) 17.8MB)

For an oral musculature assessment proforma, see:

• "GOS.SP.ASS'98: speech profile for children with cleft palate and / or velopharyngeal dysfunction (revised)"
  which is in Appendix 1, pp. 28-29 of:
  Sell, D., Harding, A. & Grunwell, P. (1999). GOS.SP.ASS'98: an assessment for speech disorders associated with cleft palate and / or velopharyngeal dysfunction (revised). Int. J. Language & Communication Disorders, 34(1), 17-33.
  http://web.ebscohost.com/ehost/detail?vid=1&hid=7&sid=9dc4736d-3c65-47b7-ba87-f59a217ec68a%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&AN=1999017885
  Access to this website on computers that are not on the NSW Health network is available by using your Gardiner Library membership number as the password.
• Rampp, D. L., Pannbacker, M., Kinnebrew, M.C., (1984). Velopharyngeal Incompetency: A Practical Guide for Evaluation and Management. Austin, TX: Pro-Ed.

Oral Musculature Assessment Practical Tips

• Be mindful of PPE (personal protective equipment) such as gloves.
• Introduce the OMA in a fun way, for example "How many teeth have you got? Let's count them".
• Very young children may become upset during the OMA. It may be advisable to leave the OMA to the end of the session so that the other assessment tasks are completed first whilst the child is settled.
• For very young children, an effective method of conducting an oral examination to view the palate is to lay the child on the mother's lap. (wmv) 9.3MB)

Observations to make during the OMA

Watch a film clip (wmv) 3.8MB) of a 3.5 year old child with a normal intact palate and normal palatal movement.

Compare structure and function with the photos below of an 8 year old boy with abnormal palatal presentation.

At rest	During phonation

Click here to read this boy's case study.

Further reading

• Kummer, A.W. (2008) Cleft Palate and Craniofacial Anomalies: Effects on Speech and Resonance (2nd ed.). New York: Thompson Delmar Learning, Chapter 13.
• Peterson-Falzone, S., Trost-Cardamone, J.E., Karnell, M. & Hardin-Jones, M. (2005). The Clinician's Guide to Treating Cleft Palate Speech. NY: Mosby, Chapter 6.
• Rampp, D. L., Pannbacker, M., Kinnebrew, M.C., (1984). Velopharyngeal Incompetency: A Practical Guide for Evaluation and Management. Austin, TX: Pro-Ed.

Listening skills

Listening to cleft type speech errors and making perceptual judgements about resonance is a skill that improves with practice. When listening to speech errors and trying to transcribe an unusual sound, it may be useful to try to imitate the sound yourself and note your tongue placement, manner of production and whether the sound is voiced or voiceless. Refer to the chart below for phonetic symbols for some of the speech sounds often present in cleft palate speech. (Reproduced with kind permission from David Fitzsimons, Marilyn Heine, and Maeve Morrison.)

This chart shows a representation of the place of articulation for English speech sounds and many cleft palate compensatory articulations.

Click on this link to click on the phonetic symbol and hear the sounds being produced.
http://www.phonetics.ucla.edu/course/chapter1/chapter1.html

Note JHCH has a CD-rom for loan: The Sounds of the International Phonetic Alphabet

Note the GOS.SP.ASS DVD has a section in which you can rate typical cleft speech errors.

For those interested in more extensive listening practice, the Cleft Palate International Speech Issues website http://clispi.org/ may be of interest. It is necessary to apply for an account to gain full access to this website.

Transcription activities

23 month old toddler

This 23 month old toddler was born with a complete right sided cleft lip and palate. His lip was repaired at 5 months of age, and his palate was repaired at 12 months of age. He had grommets inserted at the time of his cleft palate repair. His grommets are now thought to be out. He is due for repeat hearing test and review by ENT. His mother feels he is not hearing well.

This toddler continues to have some feeding difficulties, particularly transition to textured solids. He sees a speech pathologist and a dietitian via Feeding Clinic on a regular basis. He drinks from a bottle with a pigeon cleft palate teat, but no longer requires the valve in the teat.

Watch the film clip (wmv) 12.6MB)

of the speech pathologist obtaining a speech and language sample in a play activity. Transcribe the child's responses.

• What is the child's phonemic inventory?
• What phonological processes are operating?
• Comment on the child's resonance and nasal airflow.

6 year old

This 6;6 year old boy has VPI but does not have a cleft palate. He has a diagnosed syndrome and developmental delay. He had a pharyngoplasty performed at 6 years of age. His mother feels that his speech has improved since this surgery.

Watch the film clip (wmv) 19.2MB)

which shows a speech sample with single words and brief conversation.

• Based on this sample, what sounds does he appear to have in his phonemic inventory?
• What phonological processes are operating?
• Comment on the child's resonance and nasal airflow.

10 year old

Watch the first film clip (wmv) 20.6MB)

which shows a Rhinocleft® speech sample of a girl with a bifid uvula and sub-mucous cleft palate which was diagnosed at age six years by an ENT and has not been repaired. This girl attends annual reviews at the cleft palate clinic.

• Is hypernasality present or absent based on perceptual judgement?
• Is nasal air emission present or absent based on perceptual judgement?

Watch the second film clip (wmv) 8.2MB) and see whether this confirms your thoughts.

Read a recent assessment report (pdf 28K) from the JHCH Speech Pathologist to find out about this child's full clinical picture.

Click here to read a case study of this girl.

Note the GOS.SP.ASS DVD has a section in which you can rate typical cleft speech errors.

For those interested in more extensive listening practice, the Cleft Palate International Speech Issues website may be of interest. It is necessary to apply for an account to gain full access to this website.