information on clefting - college of health · cleft palate team approach pediatric ... later...

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Information on Clefting

http:kidswithcleftsutah.blogspot.com

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Myths

1.  Don’t worry about speech or starting intervention until after surgery.

2.  Babies cannot produce stops presurgery. 3.  Don’t encourage vocalizations prior to

surgery. 4.  All babies with CP have feeding problems. 5.  If VPI is present, a child cannot benefit from

intervention.

(Golding-Kushner, 2001)

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Myths

6.  Oral motor exercises will strengthen the VP mechanism. 7.  Children with CP have language delays. 8.  Speech problems of children with CP do not

have a phonological basis.

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Common Facts about Clefting

! Most common birth defect (CDC, 2006)

! Who has a cleft? "  Native American/India 1:250 "  Utah 1:500 "  Asian 1:500 "  Caucasian 1:750 "  African American 1:900/3000 "  CL & P more common in boys "  CP more common in girls

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Cleft Palate Team Approach

Pediatric Psychologist

Prosthodontist

Geneticist ENT Pediatrician

Social worker

Speech-Language Pathologist Orthodontist Speech Surgeon

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A Little About Anatomy

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For Children with CP

! Muscles do not attach normally ! Musculus uvulae may be smaller/absent ! Tensor veli palatini inserted in bony

portion of the cleft

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Issues Related to Surgical Management

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Management

! Surgical -  Lip surgery -  Primary palatal repair

#  1-stage surgery (hard and soft palate) #  2-stage surgery (veloplasty or delayed palate

repair)

-  Issues related to timing -  Secondary surgical management for speech

(Peterson-Falzone, Hardin-Jones, & Karnell, 2010) 10/23/15

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Timing of Surgery: Key Issues

!  Technical considerations !  Facial growth !  Development of velopharyngeal function !  Speech-language development

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Palatal Repair: Timing 12 mts

8-9 yrs

6 mts

2 stage 6

mts

4 yrs

12 mts

1 stage

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The Debate Continues:

Facial

Growth

Speech Development

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Timing: One Stage Repair

1980’s

1990’s

2000’s

!!!18$24!!!months!!

≈12!!months!

6$12!months!

(Peterson-Falzone et al., 2010; Katzel et al., 2009)

!Wardill!(1937)!!“younger!than!

1!year”.!!Holdsworth!(1945)!6!–!9!months.!

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Timing: One Stage Repair

(Katzel et al., 2009) US data

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Timing: Delayed Hard Palate Repair

1980’s

1990’s

2000’s !!!!!!!5.5!years!!!

7$11!years!

!3$4!years!!!!!!!!!!

(Lohmander et al., 2012)

Rohrich et al. (2000)

suggested SPR at 3-6 mts and HPR at 15-18

mts

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What is the Evidence? Systematic Reviews of

RCT

One RCT

Well controlled study - No Randomization

Well designed cohort/intervention comparison (more than one center)

Multiple time series/Single Case Design

Expert Opinion/Case Reports/Clinical Series/Descriptive Studies/Studies with Poor Methodology

Adapted from Joanna Briggs Institute for EBP

!TOPPS!(ongoing)!

!Willadsen!(2011)!

!!

AmericleL!(ongoing)!

Holland!et!al.!(2007)!

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Secondary Surgical Management

!  Secondary surgery to improve speech - 4 – 6 years of age - 3 types

1) Technique to lengthen repaired palate - Furlow double-reversing Z-plasty

2) Pharyngeal flap 3) Sphincter pharyngoplasty

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Secondary Surgery: Pharyngeal Flap

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Secondary Surgery: Sphincter pharyngoplasty

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Impact of Clefting on Communication: Presurgery

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•  Cou.Inability to impound intraoral air pressure

“Avoids” pressure consonants

•  .No surface against which to place the tongue

“Avoids” alveolar sounds

•  .Less practice with with these sounds

Delayed speech,

Reduced intelligibility,

CAs

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Poor Eustachian tube functioning

Conductive hearing loss

Speech and language delays?

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Impact of Clefting on Early Speech: What Does the Research Say?

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Characteristics - Presurgery

! Vocalize as frequently ! Fewer canonical syllables/less complex ! Delayed in onset of canonical babbling ! Smaller consonant inventories

(Chapman et al., 2001; Scherer et al., 1999; 2008)

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! Composition of babbling is different -  Produce fewer stops, glides, velars

-  Prefer glottal place ([h] common)

-  Trends for more nasals but fewer alveolars and palatals

(Chapman, 1991; Chapman et al., 2001; Olson, 1965; Scherer et al., 2008)

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!  Comprehension within normal range (Long & Dalston, 1983; Scherer et al., 2008)

!  Produced a similar number of nonverbal communicative attempts overall

(Long & Dalston (1982a;1982b)

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Why Do We Care About These Things?

Some might say:

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Why Do We Care About These Things?

Others say:

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Relationship Between Early Speech and Later Speech and Language: NCP

!↑!true!consonants!at!1!yr!↑!sound!development!at!3!yrs!!!!

↑!rate!of!vocalizaRon!at!4$6!mts!!↑ language!at!1!yr!

!<!!complex!babbling!in!the!first!yr!↓!rate!of!lexical!development!↓!language!development!at!6!yrs!

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Relationship Between Early Speech and Later Speech and Language: CP

(Chapman et al. 2003) 10/23/15

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Impact of Clefting on Communication: Postsurgery

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What to Expect Postsurgery

! Takes about 6 weeks to see a normal amount of vocalization

! Stop consonants should start to emerge ! Comprehension should continue to be

within normal limits ! Normal resonance

(Chapman, Hardin-Jones, & Scherer, 2013) 10/23/15

Speech Characteristics: Postsurgery

! Variability in speech development post-surgery - Many children with cleft palate have normal speech

after palate repair - Approximately 68% need S/L intervention - 18-25% employ CAs - 25-37% additional surgery for speech - Group studies suggest delays in speech into

adolescents and beyond

(Hardin-Jones & Jones, 2005) 10/23/15

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Impact of Clefting on Speech: “Cleft” Speech Characteristics

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Cleft Palate Speech

Obligatory

VPD

Hypernasality Nasal Emission

Oral Deviations

Dental Deviations

Oral Distortions

Fistula

Nasal Emission

Learned

Phoneme Specific Nasal

Emission

Compensatory Articulations

(CAs)

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Obligatory

VPD

Hypernasality Nasal Emission

Oral Deviations

Dental Deviations

Oral Distortions

Fistula

Nasal Emission

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Learned

Phoneme specific nasal

emission

Compensatory articulations

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Velopharyngeal Inadequacy (VPI) Velopharyngeal Dysfunction (VPD)

VP Insufficiency

VP Incompetence

VP Mislearning

Velopharyngeal Dysfunction

(Trost-Cardamone, 1989) 10/23/15


Resonance Disorders 1.  Hypernasality - too much nasal resonance

during production of vowels and voiced consonants

2.  Hyponasality - too little nasal resonance during production of vowels and nasals

3.  Mixed/Cul-de-sac resonance

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Speech Disorders 1.  Nasal emission – escape of air during

production of pressure consonants -  Audible -  Inaudible

2.  Weak pressure consonants – loss of air during production of pressure consonants

3.  Nasal substitutions - nasal consonants are substituted for oral consonants -  May be phonological or due to VPD

4. 

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4.  Compensatory productions - Place of articulation is moved posteriorly - Not sure why some children produce them - Attempts or meet pressure requirements for

speech - Why are they such a problem??

5.  Voice Disorders ____________________________________

6. Distorted sibilants

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Compensatory Productions

!  Why are CAs such a problem? - Sounds do not appear in most languages - Negatively impacts intelligibility

- Difficult to eradicate in therapy - When child produces CAs cannot evaluate VP

function - Rule governed—becomes part of child’s

phonological system

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Compensatory Articulations: Glottal Stop [�]

!  Substitution for stops, less frequently fricatives and affricates

!  Can occur as a co-articulation

!  Most common �compensatory� error

(Trost, 1981; Peterson-Falzone et al., 2006)

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Compensatory Articulations: Pharyngeal Fricative/Stop/Affricate

!  Linguapharyngeal articulation - Pharyngeal fricative:

� �

- Pharyngeal stop:

- Pharyngeal affricate:

(Trost, 1981; Peterson-Falzone et al., 2006) 10/23/15

Compensatory Articulations: Nasal Fricative

!  Produced as air passes through the nasal cavity at the same time that closure occurs at the bilabial, alveolar or velar place of production

!  Co-artic with any pressure consonant


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Compensatory articulations: Mid-dorsum Palatal Stop [c] & [�]

!  Mid-dorsum part of tongue contacts mid-palate

!  Place of articulation similar to /j/

!  Can be related to a fistula


Backing

!  Child moves the place of articulation farther back within the oral cavity - Alveolar stop $ velar stop - Alveolar fricative $ velar fricative

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Impact of Clefting on Language: Postsurgery

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Language Characteristics: Postsurgery

Delayed onset and acquisition of words (Broen et al., 1998; Hardin-Jones & Chapman, in press; Scherer et al., 1999)

Score lower (but within normal limits) on tests of language (see Chapman, 2009; Chapman, et al., 2015; Klinto et al., 2014)

Lower scores for MLU-M, but not grammatical accuracy (Chapman, et al.,2015)

Passive Communication style (Chapman et al.,1998; Frederickson et al., 2006)

Relationship between speech delays and reading delays (Chapman, 2011) 10/23/15

Conversational Profiles (Fey, 1986)

+ Assertive + Responsive

- Assertive + Responsive

+ Assertive - Responsive

- Assertive - Responsive

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Assessment Presurgery

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Prelinguistic Assessment/Presurgery

! Case history ! Hearing assessment ! Sample of vocal behavior ! MacArthur-Bates Communicative

Development Inventories (CDI) ! Standardized receptive and expressive

language test (Chapman, Hardin-Jones, & Scherer, 2013)

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Name:&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&Cle)&Type:&&&&&&&&&&&&&&&&&&&&&&&&&&Age:&&&&&&&&&&&&&&&Date:&Date&of&lip&surgery:&&&&&&&&Date&of&palate&surgery:!!!!!!!!!!!!!!!!Communica9ve&

Area&&

Circle&All&Observed&

Vocaliza9ons& Highest&Stage!!!!!Reflexive!!Cooing!!Vocal!Play/MB!!Canonical!Babble!

w!!!j!!!h!!ʔ! m!!!!n!!!!ŋ!!!!p!!!!b!!!!t!!!!d!!!!k!!g!

!!V!!!!!CV!!!!!VC!!!!!CVCV!!!!!!!Other:!

CDI&(Percen9le)& ____!!Phrases!Understood!!!!!!____!Vocabulary!Comprehension!!____!!Vocabulary!ProducRon!!____!Total!Gestures!!

Inten9onal&Communica9on&

Observed!!!!!!!!!!!!!!!!!!!!!!!!!!Not!Observed!

Standardized&&Tests&

RecepRve!Language!Standard!Score!!!______________________!!!!!Expressive!Language!Standard!Score!!_____________________!

Hearing&& Tympanometry!!!!!!!!!Pass!!!!Fail!!!!!!!!!!!!!!!!!!!!!!Hearing!screening!!!!Pass!!!!Fail!PE!Tubes!!!!!!!!!!!!!!!!!!!!!Yes!!!!!!No!

Observa9ons& Palatal!Obturator!!!!!!Yes!!!!!!No!!Date(s)!of!PE!Tubes!!!!!!!!!!!!!!!!

(Scherer, Chapman, & Hardin-Jones, 2005) 10/23/15

Presurgery Redflags: Intervention Recommended

Delays in comprehension

Delays in expressive language

Not vocalizing

Not producing nasals, glides, glottals

No canonical babbling by 9 – 10 months

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Assessment Postsurgery

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!  Procedures vary depending on the age of the child - Single word stage - Early word combinations and beyond

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Name:&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&Cle)&Type:&&&&&&&&&&&&&&&&Age:&&&&&&&&&&&&&&&&&&Date:&Date&of&lip&surgery:&&&&&&&&&&&&&&&&&Date&of&palate&surgery:&&&&&&&&&&&&&&&&Interven9on:&Yes&&&&&No&&&&&&&&&&&(Parent&s9mula9on&&&&&&&&&Direct&services)&&&&&&Communica9ve&Area& Circle&All&Observed&

Vocaliza9ons& w!!!j!!!h!!!!ʔ! !m!!!!n!!!!ŋ!!!!p!!!!b!!!!t!!!!d!!!!k!!!!g!!!!f!!!!s!!!!ʃ!!Words& w!!!j!!!h!!!!ʔ! !m!!!!n!!!!ŋ!!!!p!!!!b!!!!t!!!!d!!!!k!!!!g!!!!f!!!!s!!!!ʃ!!!!!!!

!_____!!#!Stable!Consonants!(70%!correct)!

Audible&nasal&emission& Yes!!!!!!!!!!!!!!!!!!!!No!

Resonance& Normal!!!!!!!!!!!!!!!!!!!!!!Hypernasal:!!!!!!!!!!!!Mild!!!!!!!!Moderate!!!!!!!!!Severe!

Word&Shapes/Length& &&V!!!!!CVVC!!!!!CVCV!!!!!CVC!!!!!Other:!!!!!!!!!!!!!!1!!!!2!!!!3!!!!4!!!!4+!!!!Syllables!

Atypical&Subs9tu9ons& Glooal!Stops!!!!!!!!!Nasal!SubsRtuRons!!!!!!Other!

CDI&(Percen9le)& !_____!Vocabulary!ProducRon!!!!_____!Irregular!Words!!_____!Sentence!Complexity!!!!!!_____!Mean!of!3!Longest!Sentences!!

Language&Sample& ______!#!of!Different!Words!!!!!!!_____!#!of!Word!CombinaRons!!!!!_____!MLU!!!!!!!!ConversaRonal!Profile!!!!!!!!!!!!!!!!!!!AcRve!!!!!!Passive!!!!!!Other!!!!!!!!!

Standardized&Tests& RecepRve!Language!Standard!Score!!!_______!!!!GFTA$2!_______!Expressive!Language!Standard!Score!!_______!!!!!PEEPS!!______!

Hearing&& Tympanometry!!!!!!!!!Pass!!!!Fail!!!!!!!!!!!!!!!!!!!!!!Hearing!screening!!!!Pass!!!!!!Fail!PE!Tubes!!!!!!!!!!!!!!!!!!!!!Yes!!!!!!No!

Observa9ons& Fistula!!!!!Yes!!!!No!!Date(s)!of!PE!Tubes!

(Scherer, Chapman, & Hardin-Jones, 2005) 10/23/15

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!  Case history !  Oral mechanism exam !  Hearing evaluation !  Spontaneous speech/language sample !  Standardized test of speech sound

production !  Standard set of sentences !  Counting

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!  Case history !  Oral mechanism exam !  Hearing evaluation !  Perceptual speech evaluation !  Language and phonology

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Oral Mechanism Examination

!  Important to reconcile perceptual findings with evaluation of speech mechanism

!  Cannot make judgments of VP function from an OME !  What can you see? - Lips - Tongue - Teeth—occlusion - Hard and soft palate - Tonsils

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Assessment of Children with CP: Oral Mechanism Exam (OME)

! Face

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Assessment of Children with CP: OME

!  Repaired cleft lip - Length, symmetry - Open/closed at rest - Movement

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! What to look for: Repaired cleft palate - Hard Palate

#  Palatal vault #  Fistula

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! What to look for: Repaired cleft palate - Dentition/occlusion " Missing, extra, or teeth in the wrong place " Alveolar cleft " Occlusal relationship: Upper incisors to lower incisors

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! What to look for: Repaired cleft palate

- Soft Palate #  Length at rest #  Fistula #  Elevation on sustained /a/, �ha ha ha�

- Oral Cavity # Tonsils (size)

- Pharyngeal depth

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!  What to look for: Patient referred with VPD…no overt cleft - Everything mentioned previously

AND - Bifid uvula -  Bluish line in midline of hard palate and/or

transparent area -  Notch in back of hard palat

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Perceptual Assessment of Speech

! Cornerstone of assessment - Your EAR is the most important assessment

tool (“GOLD STANDARD”) −  Sample

#  Conversational speech #  Sentence repetition #  Counting 1-20; 60-70 #  Single word production #  Zoo passage

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American English Sentence Sample (Judith Trost-Cardamone, 2012) 1. Mom ‘n Amy are home 2. Puppy will pull a rope 3. Buy baby a bib 4. A fly fell off a leaf 5. I love every view 6. Thirty-two teeth 7. The other feather 8. Anna knew no one 9. Your turtle ate a hat 10. Do it today for Dad 11. Laura will yell 12. Sissy saw Sally race 13. She washed a dish

14. Zoey has roses 15. Watch a choo-choo

16. George saw Gigi

17. We are hanging on

18. A cookie or a cake

19. Give Aggie a hug

20. Hurry ahead Harry

21. I spy a starry sky

22. Ray will arrive early

23. We were away 24. We ran a long mile

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American-English Word Sample (Judith Trost-Cardamone, 2012) pool three puppy XX pop wreath bee there baby father bib XX fire tea waffle letter leaf eat V deer Over ladder five red

see judge sissy veggie house edge zoo key scissor cookie eyes rake shoe go washer goggle wish leg chew catch watch

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Low Tech Procedures (Kummer, 2011; Peterson-Falzone, 2006)

!  Mirror test (nasal emission) !  Feel side of the nose (hypernasality) !  Nares open – nares closed (hypernasality) !  Listening tube – (nasal emission)

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Analysis of Speech Findings

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! Hypernasality Severity rating scales:

Normal, Mild, Moderate, Severe

Hypernasality 1____________________7

Normal Severe

! Hyponasality

Hyponasality: __Absent__Present

Resonance

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!  Articulation/phonology -  Nasal emission "  Audible "  Visible "  Phoneme specific

-  Weak pressure -  Compensatory articulations

!  Acceptability !  Intelligibility !  Voice

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Speech Acceptability

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What Do We Need to Know from the Assessment?

!  What? - Which errors are due to learning which are related

to structural problems? - What is the next step?

#  Intervention #  Referral to a cleft palate team for instrumental

evaluation #  No concerns

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Results of Your Assessment

Speech-language

appropriate/

VP mechanism normal

Speech-language

appropriate/

VP mechanism questionable

Speech-language delayed/

VP mechanism normal




Important to Consider

! RE: Resonance/nasal emission - Cannot determine adequacy of the VP

mechanism immediately after surgery - Assessment is ongoing - Must separate articulation from resonance

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Important to Consider

1. Cannot blame everything on the cleft

2. Phonology impacted by clefting


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Common Misconceptions

Nasal substitutions

are indicators of VPI

Or related to phonological

learning


Common Misconceptions

Glottal stops present due to

VPI

Or due to phonological

learning


Implications

Difficult to evaluate

mechanism with NS and GSs

Therapy to eliminate these

before evaluation of VP function


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Decisions?

! When to refer to Cleft Palate-Craniofacial Team?

! When to refer for intervention?

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Things to Consider

1. Child’s age/maturity

2. Speech skills

Severe speech problem?

Nasal substitutions?

Glottal stops?

3. Palatal fistula

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Some Debate

Intervention is a waste of time

Eliminate all nonobligatory

speech errors prior to surgery

Run the risk of recommending

surgery for a child who does not really

need it! 10/23/15

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When VPI is suspected

!  Others things to consider when making a referral:

− Persistent glottal/pharyngeal articulations − Palatal fistula − Ability to cooperate − Sound inventory

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What Improves with Surgery?

!  Hypernasality !  Weak pressure

consonants !  Nasal emission/

turbulence*

!  Compensatory articulations

!  Delayed speech !  Nasal substitutions !  Oral distortion of

fricatives/affricates

Should Improve Does Not Improve

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Intervention

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!!!Prelinguistic/Presurgery Treatment

!  When is intervention appropriate?

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Principles of Intervention

!  Naturalistic approach !  Family centered !  Culturally/linguistically appropriate !  Guided by the toddler’s communication skills,

not condition of clefting !  Evidence based


Prelinguistic Treatment

Goal 1 !  Parent education − Review of developmental milestones −  Impact of cleft on speech/language development

and hearing

!  Parents as intervention agents −  Parent “training” −  Monitor what parents are doing


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Goal 2 !  Increase frequency and diversity of

vocalizations −  Imitate baby’s vocalization − Model new sound combinations

"  Sounds/syllables with nasals, glides, liquids, etc. (e.g., wawa, mama, nana, lala).

"  Some babies produce stops—okay to model " Assume baby is attempting to communicate



Goal 3 !  Increase communicative opportunities − Environmental arrangement − Communicative temptations − Be responsive

(Chapman, Hardin-Jones, & Scherer, 2013)

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Parent Training Protocols

!  Important part of parent education/training program -  Avoid reinforcing growls/glottal stops

#  Ignore and model sounds produced within oral cavity

- “hhhhhh” while opening and closing mouth - Occlude nares


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Presurgery Treatment

!  How to choose words presurgery -  Low pressure -  Front sounds -  Avoid words that begin with vowels

!  Stimulate sounds as you would with any baby !  Reinforce sound production


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First Words

Presurgery hi me more mine mommy moo no nana (banana) yeah

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Intervention Postsurgery

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Early Language Goals/Post Surgery

!  Don’t wait too long! −  Red flags " No evidence of oral stops 3 months post palatal

surgery "  Persistence of nasal/glottal substitutions "  Lack of growth in phonetic inventory "  Language delay


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4 Profiles of Development

Speech-language

appropriate/

VP mechanism normal

Speech-language

appropriate/



VP mechanism normal




Profile 1

!  Monitor every 3 - 6 months

Speech-language

appropriate/

VP mechanism normal


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Profile 2 & 3

!  Do you work on speech, language or both? -  At earliest ages cannot separate vocabulary from

phonology/speech production -  Older children

−  Are speech and language skills equally delayed? −  Is speech delayed more than language or...? −  Is speech “atypical”?

(Stoel-Gammon & Stone, 1991)

!


VP mechanism normal

!



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Comparison of Goals

!  Expand vocabulary !  Expand consonant

inventory − nasals/glides � stops �

fricatives − front sounds

!  Eliminate CAs (if present)

!  Expand vocabulary !  Expand consonant

inventory −  focus on pressure

consonants !  Eliminate CAs !  Ignore NE &

hypernasality !  Awareness of oral air

flow

Profile 2 Profile 3


Intervention Strategies

!  Language intervention techniques/strategies - Similar to what you would do with noncleft youngsters

with delayed language - Break the cycle - Focused stimulation - Enhanced Milieu Training with Phonological

Emphasis (Scherer & Kaiser, 2010)

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Enhanced Milieu Training with Phonological Emphasis

Environmental Arrangement

Milieu Teaching

Procedures

Selecting sounds

Selecting words

Responsive Interaction

(Scherer & Kaiser, 2010) 10/23/15

Choosing Targets for Early Words

How to select

words/sounds?

First 50 words

“In” sounds and “out”

sounds Words that serve many

functions

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First Words

Without Pressure Consonants hi me more mine mommy moo no nana (banana) yeah

With Pressure Consonants baby book bear ball bye-bye daddy doll cookie

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Expand Consonant Inventory: Choosing Sounds

Consonant inventory

ʔ

h m n

w j

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Expand Consonant Inventory: Choosing Sounds

Consonant inventory

ʔ

h m

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Eliminating Glottal Stops !  Use /h/ to “break up” glottal pattern

–  Produce whispered /h/ + vowel − Prolong /h/ while producing /p/ or /t/ − Overaspirate until production correct − Gradually introduce voicing

(Peterson-Falzone et al, 2006) 10/23/15

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Intervention Considerations

!  May want to avoid words with other nasals !  Choose a limited set of words !  Words should be functional !  Practice is important !  Begin at isolation !  Practice, practice, practice !  May be best to start with voiceless sounds if

glottal stops are present (Baylis & Chapman, 2014)

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Profile 4

!  Refer for objective assessment when hypernasality is present

!  Speech therapy cannot change hypernasality - Child has oral sounds/pressure consonants - Child can cooperate for exam

Speech-language

appropriate/

VP mechanism questionable (Chapman, Hardin-Jones, & Scherer, 2013)

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Intervention Preschoolers

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!  Speech sound intervention − Traditional articulation approaches − Phonological approaches

"  Core Vocabulary (Dodd & Bradford, 2000) "  Contrast approaches (Weiner, 1981; Gierut,

1989; Williams, 2000) "  Cycles approach (Hodson & Paden, 1983)

−  Combination of the two www.latrobe,edu.au/hsc/projects/preschoolspeechlanguage/articphonol.html

(Williams, McLeod, McCauley, 2010) 10/23/15


!  “Why traditional articulation therapy is preferred.” (Peterson-Falzone et al., 2006)

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!  Familiarize child with oral structures −  May use hand-drawn pictures to show place of

articulation for specific sounds

(Peterson-Falzone et al., 2006)

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! After determining sound(s) to work on − Teach correct placement for the sound − May need to “shape” the correct sound − Teach the orthographic symbol for the sound − Teach sound contrasts (start with place) − May need to re-name the sound − Discrimination of error and target − Don’t worry about hypernasality

(Peterson-Falzone, Trost-Cardamone, Karnell, & Hardin-Jones, 2006)

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!  Discrimination training !  Phonetic placement techniques !  Place map for sounds !  Target selection !  Stabilize the sound !  Contrast training !  Self-monitoring

(Peterson-Falzone et al., 2006) 10/23/15

Contrast Treatments

!  Minimal pairs—FCD—go vs. goat !  Maximal oppositions—vary along dimensions

of voice, place, manner -  [m] voiced, bilabial, sonorants vs. [k] voiceless, velar,

obstruents

!  Multiple oppositions—trains several sounds at the same time

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40

M

n

b

k

Multiple Oppositions

(Williams, 2003)

p

� s

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Eliminating Glottal Stops

•  Place map •  Auditory and visual discrimination •  Use /h/ to break up glottal pattern

–  Whispered h+vowel •  Sustain /h/ as lips close/open for voiceless labial/lingual stop •  Encourage overaspiration of voiceless stop until voiceless

plosive-vowel syllables are correctly produced •  Gradually introduce voicing for voiced stop •  May need to begin with fricatives, VC, VCV •  Self monitoring

(Peterson-Falzone et al, 2006) 10/23/15

Eliminating Pharyngeal Fricatives

!  Place map !  Discrimination !  ʃ then S - VC with high front & mid-central vowels - Then CV, CVC

!  Self monitoring

(Peterson-Falzone et al, 2006)

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41

Eliminating Pharyngeal Stops

!  Place map—moving forward !  Discrimination (pharyngeal muscle activity) !  VC—ik, ek, -> CV, monosyllabes, etc !  Maybe fricative first at same place !  Voicing not important !  Self monitoring


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Treating Backed Oral Productions

!  Consonants are backed but within oral cavity !  Identify and contrast place of production

(visually and auditorily) !  Use sounds already produced at same place to

elicit production


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Nonspeech Oral Motor Treatment

!  NO evidence to support the use of NSOMT for improving speech or VP function in children with cleft palate

(or in any children for that matter!)


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42

NSOMT

1947/1948

1951

1968

1973

1974

2004

2005

2008


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NSOMT

!  Used in children with cleft palate - Why are they used? - Who uses them? - Do they work?


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NSOMT

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43

What is the Evidence?

Systematic Reviews of

RCT

One RCT

Well controlled study -No Randomization




Adapted!from!Joanna!Briggs!InsRtute!for!EBP!

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Early Intervention Studies

! Vocabulary!training!administered!by!a!clinician!(Scherer,!1999)!and!mothers!(Scherer!et!al.,!2008)!improved!lexical!and!speech!development!

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Intervention Studies

!  Phoneme specific NE can be eliminated (Hall and Tomblin, 1975)

!  Articulation can improve even with VPI (Chisum et al., 1969; Van Demark, 1974; Van Demark and Hardin, 1986; Pamplona et al., 2005)

!  Short-term, intensive therapy better than shorter periods over a longer time (Albery and Enderby, 1984; Van Demark and Hardin, 1986; Pamplona et al., 2005)

!  Parent involvement resulted in better gains in intervention (Pamplona et al., 1996, 2000)

!  Phonology intervention more effective than articulation therapy (Pamplona et al., 1999)

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44

What is the Evidence?

Systematic Reviews of

RCT

One RCT

Well controlled study -No Randomization




Adapted!from!Joanna!Briggs!InsRtute!for!EBP!

Pamplona & colleagues (1996; 1999;2000;

2004;2005)

Scherer (1999)

Scherer et al. (2008)

Hall & Tomblin, (1975)

Thompson et al. (2015)

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K. Chapman, PhD

REFERENCES

1. Baylis, A. L., & Chapman K. L. (2014). Early intervention for infants and toddlers with cleft palate. [PowerPoint slides]. 2014 Conference on Velopharyngeal Dysfunction and Associated Speech Disorders. Lecture conducted from Nationwide Children’s, Columbus, OH.

2. Broen, P. A., Devers, M. C., Doyle, S. S., Prouty, J. M., & Moller, K. T. (1998). Acquisition of linguistic and cognitive skills by children with cleft palate. Journal of Speech, Language, and Hearing Research, 41, 676-687.

3. Camp, B.W., Burgess, D., Morgan, L.J., & Zerbe, G. (1987). A longitudinal study of infant vocalization in the first year. Journal of Pediatric Psychology, 12, 321-331.

4. Chapman, K. L. (1991). Early vocalizations of young children with cleft lip and palate. Cleft Palate-Craniofacial Journal, 28, 12-178.

5. Chapman, K. L. (2004). Is presurgery and early postsurgery performance related to speech and language outcomes at 3 years of age for children with cleft palate? Clinical Linguistics & Phonetics, 18, 235-257.

6. Chapman, K. L. (2009). Speech and language of children with cleft palate: Interactions and influences. In K. T. Moller & L. E. Glaze (Eds.), Cleft Palate: Interdisciplinary issues and treatment – For clinicians by clinicians. Austin: Pro-Ed Publications.

7. Chapman, K.L. (2011). The relationship between early reading skills and speech and language performance in young children with cleft lip and palate. Cleft Palate-Craniofacial Journal, 48, 301-311.

8. Chapman, K.L., Graham, K.T., Gooch, J., & Visconti, C. (1998). Conversational skills of preschool and school-age children with cleft lip and palate. Cleft Palate-Craniofacial Journal, 35, 503-516.

9. Chapman, K. L., & Hardin-Jones, M. A. (2011, April). Compensatory articulation usage in preschool children with cleft palate. Paper presented at the 68th Annual Meeting of the American Cleft Palate-Craniofacial Association, San Juan, PR.

10. Chapman, K. L., Hardin-Jones, M., & Halter, K. A. (2003). The relationship between early speech and later speech and language performance for children with cleft palate. Clinical Linguistics & Phonetics, 17, 173-197.

11. Chapman, K. L., Hardin-Jones, M., Moreau, K., & Fetrow, R. Language skills of preschoolers with cleft palate. Manuscript in preparation.

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22. Hardin-Jones, M. A., Chapman, K. L., Wright, J., Halter, K. A., Schulte, J., Dean, J. A., Havlik, R. J., & Goldstein, J. (2002). The impact of early palatal obturation on consonant development in babies with unrepaired cleft palate. Cleft Palate-Craniofacial Journal, 39, 157-163.

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30. Kuehn, D. P., Folkins, J. W., & Linville, R. N. (1988). An electromyographic study of the musculus uvulae. Cleft Palate Journal, 25(4), 348-355.

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37. Perry, J. L. (2011, May). Anatomy and physiology of the velopharyngeal mechanism. In Seminars in speech and language (Vol. 32, No. 02, pp. 083-092). © Thieme Medical Publishers.

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40. Scherer, N.J., & Kaiser, A. (2010). Enhanced Milieu Teaching with Phonological Emphasis for children with cleft lip and palate, In A.L. Williams, S. McLeod & R. McCauley (Eds.), Interventions for Speech Sound Disorders In Children, Baltimore, MD: Brookes.

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43. Scherer, N.J., Williams, L.A., & Proctor-Williams, K. (2008). Early and later vocalizations skills in children with and without cleft palate. International Journal of Pediatric Otorhinolarygology, 72, 827-840.

44. Scherer, N.J., Boyce, S., & Martin, G. (2013). Pre-linguistic children with cleft palate: Growth of gesture, vocalization, and word use. International Journal of Speech-Language Pathology.

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47. Trost, J. E. (1981). Articulatory additions to the classical description of the speech of persons with cleft palate. Cleft Palate Journal, 18(3), 193-203.

48. Trost-Cardamone JE. American English Sentence Sample: A controlled sample for assessing cleft palate speech outcome. Presented at the Meeting of the American Cleft Palate-Craniofacial Association; April 2012; San Jose, CA.

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