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Management of children with cleft palate and related speech disorders
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Treatment of VPI / cleft palate speech

Treatment planning guidelines

  • What can I treat – active vs passive speech errors
  • Where to start?
  • Planning goals
  • Phonological or articulation therapy
  • Diagnostic therapy

Treating cleft type speech errors

  • Treating Specific Speech Sounds
    • Articulation approach
    • Overcoming phonological processes
    • References and film clip examples
  • Therapy considerations for specific age groups
    • Infants and toddlers
    • Preschool-age children
    • School age children
    • Adolescent

Resonance treatment guidelines

Nasal Airflow Disorders

  • Audible nasal air emission and nasal turbulence
  • Phoneme Specific Nasal Air Emission
  • Nasal Grimace

Modes of service delivery for speech disorders related to cleft lip and palate – what is most effective?

  • Intensive or weekly therapy?
  • Phonological or articulation therapy?
  • Early intervention

Useful websites

Case studies

 

Treatment planning guidelines

Where to start?

The question of where to begin with treatment planning for cleft-type speech characteristics has the same answer as for any articulation or phonological disorder:

  • Analyse the speech sample to determine patterns of errors.
  • Document the phonemic repertoire.
  • Consider stimulability.

Planning goals

Harding and Grunwell (1998) in their article about active vs passive cleft-type speech characteristics give some specific advice about planning therapy targets (pp347-350).Target selection for therapy:

  • Consider which targets are most stimulable in isolation.
  • Consider which sounds will have the most impact on intelligibility.
  • Developmentally early sounds can be a good starting point, however:
    • Target selection might not follow normal developmental patterns.
    • For children with very limited phonemic inventories, increasing the meaningful contrasts the child can produce is the goal: select the sounds that are easy to elicit.
    • It can be helpful to target an entire class of affected consonants.Voiceless plosives and voiceless fricatives can be easier to work on than voiced sounds.

Golding-Kushner (2001, pp70-1) also suggests:

  • Ensure the client and parent understand the problem.
  • Sound selection: start with whispered /h/ to discourage glottal articulation, then target front sounds before back sounds.
  • Build a core vocabulary in which all sounds are correctly produced.

 

Further reading

 

Diagnostic therapy

Diagnostic therapy can be particularly helpful for children with very limited phonemic repertoires, to establish whether oral production of phonemes is possible once oral articulatory placement has been taught.

 

Treating cleft type speech errors

Treating active cleft type speech errors is very similar to treating any other phonological disorder, something with which paediatric speech pathologists have extensive experience.

Some general principles which have been recommended in the literature are:

  • Emphasise minimal articulatory effort and pressure in the demonstration model.
  • Target voiceless consonants first, then add voicing. Voiced sounds require higher intra-oral pressure.
  • Teach word final consonants first. Word final plosives require less intra-oral air pressure than word initial, and the preceding vowel helps to establish oral airflow.
  • Consonants in other word positions may then be able to be taught using a chaining technique, for example "back" "backing" "king".
  • Fricative targets may be easier than plosives, even though this does not follow the usual development order of acquisition.
  • Work from the front of the mouth to the back. Anterior sounds tend to be easier as they are the most visible.
  • Defer /k,g/ until late in therapy.
  • Exaggerate oral placement of the target, eg interdental /t/, gradually shaping to desired alveolar placement.
  • It may be useful to change one feature at a time when moving from one sound to the next sound.
  • If using an articulation approach, work in a hierarchy of single sounds to syllables, words, sentences and spontaneous speech for correct placement and manner.
  • It may help to give the target sound a new (invented) name, as the child does not then associate the target with their habitual error, for example, calling /s/ "the train slowing down sound" (Harding & Grunwell, 1998).
  • Increasing the child’s phonemic repertoire will result in an increase in speech contrasts, and therefore speech intelligibility and language development.
  • Plan for multiple repetitions of targets.
  • For words lists for therapy, refer to Blockcolsky et al (1987), which provides very specific word lists grouped according to sounds and blends.

Click here for:

Click here for tips on therapy considerations for specific age-groups:

 

Further reading

 

Nasal airflow disorders

Audible nasal air emission and nasal turbulence can be the result of:

    1. A phonological process, wherein excessive nasal airflow accompanies or replaces the target phoneme. In this case, the child is physically able to close to velopharyngeal port, but has adopted the inappropriate nasal airflow as part of the phonological system. This is an active cleft type speech error and can be treated with speech therapy. The same sort of pattern can occur in non-cleft children for isolated phonemes, most commonly /s, z/. This is called Phoneme Specific Nasal Air Emission (PSNE).
    2. Inability of the velopharyngeal mechanism to achieve closure. In this case, the excessive nasal airflow is likely to be present consistently on most pressure consonants. An instrumental assessment at the tertiary hospital may be indicated to confirm VPI. At John Hunter Children’s Hospital this assessment may include palatal videofluoroscopy and / or nasendoscopy. This is a passive cleft type speech error and will not respond to speech therapy.

Nasal grimace is quite commonly observed accompanying nasal air emission. 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, of include the forehead.

Click here for more detail about treatment of nasal airflow disorders.

 

 

Disclaimer

This webpage pertains to management of children by the John Hunter Children’s Hospital Cleft Palate Team.  The resource information is aimed at qualified speech pathologists working within the geographical area of the Northern Child Health Network. It assumes a working knowledge of articulation and phonological processes in paediatric populations.

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