Infant, Toddler, Preschool Speech/Language Intervention Related to Cleft Palate

SPEECH THERAPY RELATED TO CLEFT PALATE

Infant, Toddler, Preschool Speech/Language Intervention Related to Cleft PalateTheresa M. Snelling, MA, CCC-SLPPediatric Speech-Language PathologistClinical CoordinatorRose Cleft Palate and Craniofacial CenterDenver, Colorado1REFERENCES:Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP, Trost-Cardamone JE. (2006). The Clinicians Guide to Treating Cleft Palate Speech. St. Louis, MO, Mosby. Kummer AW. (2008) Cleft Palate and Craniofacial Anomalies: Effects on Speech and Resonance (2nd ed.). Englewood Cliffs, NJ: Thomson Delmar Learning.Hardin-Jones, M., Chapman, K., and Scherer, N.J. (2006, June 13th). Early Intervention in Children with Cleft Palate. The ASHA Leader.American Cleft Palate-Craniofacial Association (2009). Parameters or the Evaluation and Treatment of Patients with Cleft Lip/Palate or Other Craniofacial Anomalies. Available from www.acpa-cpf.org.

LUKELUKE- Diagnosis - Unilateral Complete Cleft Lip and PalateServices Early Intervention; Individual Private speech therapy from 3- 4 ; Child Find Preschool 3-5 years.(NO SPEECH THERAPY CURRENTLY); GOOD PALATAL CLOSURE.Surgeries:INITIAL LIP REPAIR FOLLOWING NASO-ALVEOLAR MOLDING- 3 MONTHS; PALATE REPAIR 11 MONTHS; 3 SETS PE TUBES.

Paige- cleft of soft palate onlyPalate repair- 12 months /developed fistula; second repair pharyngeal flap and fistula repair /developed fistula; ongoing speech therapy, pervasive HYPERNASALITY and nasal emission. Advanced language skills!!Wore obturatorRecent re-repair 2012 = palate closure and NORMAL resonance!INFANT WITH CLEFT PALATE-early concernsFeedingSpeech sound developmentOpen palate- cant create negative pressure for suckingLiquid and food leak in to nasal cavityADAPTATIONSFeeding positioning (upright)Adapted bottle to control for lack of suckLimit feeding sessions to 20-30 minutes to limit calorie burnOpen palate cant create oral pressure for speech soundsSounds needing oral pressure result in nasal airflow or nasal resonanceSPEECH ADAPTATIONSNasal sound substitutions for oral consonants (m/b, n/d)Increased glottal sound playNasalized vowelsOral structures for SPEECH AND FEEDINGSOFT PALATE and HARD PALATE CREATE CLOSURE BETWEEN ORAL CAVITY AND NASAL CAVITY

CHARACTERISTICS OF CLEFT PALATE SPEECH(Primary)RESONANCE DISORDERSARTICULATION DISORDERS***This is what Ill cover during this first half of our presentations!

(Secondary)LANGUAGE DISORDERS OR DELAYVOICE DISORDERS (Laryngeal)

7RESONANCE DISORDERSWHAT DOES NASAL MEAN?HYPERNASAL-excessive nasal resonance during production of VOWELS- VOWELS!!!!!HYPONASALITY- a reduction in normal nasal resonance resulting from a partial or complete blockage of the nasal airway by any number of sources.HYPER-HYPONASALITY (MIXED NASALITY)-the simultaneous occurrence of hypernasality and hyponasality in the same speaker usually as a result of VPI in the presence of high nasal resistance that is not sufficient to block nasal resonance completely.8NASAL EMISSION (articulation)Nasal emission- nasal air escape associated with consonants requiring high oral pressure. May or may not be audible- often seen in conjunction with hypernasality on vowels.

NASAL SUBSTITUTIONS (Articulation may overlap with hypernasal resonance and be secondary to VPI or unrepaired cleft palate!)/m/ and /n/ substitutions for consonants For example: m/p, b, w, r; n/ t, d, l, sh; ng/n, k, gNOTE:AVOID THE TERM- NASAL S/He sounds nasal does not differentiate hypo and hypernasality.ARTICULATIONPLACE, MANNER, AND VOICINGMost errors related to cleft palate have to do with PLACEMENT errors while manner is maintained!

ATTEND TO PLACEMENT!!!Usually BACKED!

Glottal stops, nasal snortsPLOSIVES /b, p, t, d, k, g/AFFRICATES /tS, dZ/

Pharyngeal Fricatives, Nasal FricativesFricatives- s, z, sh, v, th, fAffricates- ch/tS/, j/dZ/

Most common articulation errors related to palatal clefts- GLOTTAL STOPSPHARYNGEAL FRICATIVESNASAL FRICATIVESNASAL PHONEME SUBSTITIONSCOMPENSATORY MISARTICULATIONSCompensatory misarticulations related to cleft palate are usually errors in PLACEMENT OF PRODUCTION. They are learned articulatory postures or placements that typically persist even after successful surgery or appliance management of the pharyngeal port and therefore co-exist with an adequate closure mechanism.

They tend to be BACKED ARTICULATIONS relative to the target place of production.VELOPHARYNGEAL INSUFFICIENCYVelopharyngeal Insufficiency (VPI) is a resonance disorder associated with a natural pressure valve in the back of the mouth that does not maintain air pressures that are needed in typical speech production. The disorder may be structural or functional or results in inadequate separation of the oral and nasal cavities.

***JEFF WILL COVER THIS MORE IN PART II

INSTRUMENTAL ASSESSMENT OF VPIIn therapy settingMIRROR TEST**(great with little ones!!!)STRAW ASSESSMENT**(older children =biofeedback)

In team/clinic: (JEFF will cover)VIDEOFLOUROSCOPYNASOENDOSCOPY/VIDEOENDOSCOPYNASOMETRY

THERAPY TECHNIQUESALL AGESGoals: TO CORRECT THE PLACEMENT ERRORS (often will improve/correct hypernasal resonance.)Improve hypernasal resonance (if its structural secondary surgical management is needed- but therapy should be tried first especially in the presence of articulation errors.)Therapy techniquescontinuedTarget high pressure- oral vs. nasal.

LABEL air flow- windy sound, lip popper for direct feedback even with little ones (15-18 months old.)

TARGET strong and varied vowels and glides /w, l, r, j, h/ if not present or weak-Children will often produce glides even in the presence of VPI.BACKING reductionTARGET BACKING ERRORS- move sounds anterior!!!vowels (anterior round vowels /u/ /oe/) glides /w, r/not /j/ substitutionmid-dorsal IS NOT the goal but may be the process of moving sounds forward (from /k/ placement, to mid-dorsal placement, to tip alveolar)use lips to encourage ANTERIOR airflow- rounded lips help move air forward.

BACKING reductionTRY OVERPLACEMENT of articulators to decrease backing***/t/- produced as a /k/I often start with tongue between lips rather than on alveolar ridge- then pull it back in mouth once they can produce plosive with tongue tip! (Sarah) Family was given /t/ to work on- Child produced glottal stop + vowel and in all word attempts- this was given as homework BEFORE child could produce a /t/!

Approach- targeted /p/moved to overplacement for /t/.

KEY POINTS:Determine PLACE of articulation error and target with emphasis on manner, voicing and PLACE classifications.

Start with PLACEMENT- even pending surgery. IF YOU EMPHASIZE MANNER (plosive, fricative) with VPI- likely to teach/encourage compensatory articulation patterns.

VIDEOSE- th, t, d- GOAL eliminate BackingStella 2 yearsSpeech Therapy in the presence of Velopharyngeal Insufficiency (VPI)IN presence of Velopharyngeal InsufficiencyIF you teach STRIDENCY for s or sh in the presence of VPI or unrepaired palate, child will create stridency in back of throat = PHARYNGEAL FRICATIVE! (TARGET ONLY ORAL, ANTERIOR AIRFLOW!!!!

IF you teach PLOSIVES in presence of VPI- child may use GLOTTAL STOP. Target light contact, anterior airflow, overplacement,.strategies.DONT TEACH OR REINFORCE COMPENSATORY ARTICULATION ERRORS!!KEY POINTS:Rule out obvious structural issues such as a palatal fistula that does not allow for a build up of oral pressure even in the presence of a functional soft palate; may need obturator to cover fistula in the hard palate.

OBTURATORS ARE POSSIBLE FROM ABOUT 3 YEARS OLD (REMOVEABLE); NON-REMOVEABLE ATTACHED TO BRACKETS ON TEETH AT ABOUT 3 YEARS OLDKEY POINTS:Encourage strong productions-Use Your Big Strong Mouth. Patients frequently will try to control nasal escape related to VPI by decreasing oral strength, pressure, and volume. This does NOT contribute to optimizing VP closure. Although increasing pressure and volume may increase audible nasal emission, it may be a stepping stone allowing for contrast, and/or improved outcome even following secondary surgery (fistula repair or pharyngeal flap.)

KEY POINTS:Use visual and tactile feedback pop cotton, feel airstreams on your hand, see the tongue hump in the back, see air on a mirror or with SeeScape, etc

LUCY p-final

BIRTH TO 3 INTERVENTIONPlease read on own!!TEACH PARENTS/GRANDPARENTS/CARETAKERS...INDIRECT LANGUATE STIMULATION TECHNIQUES!!!Self TalkParallel Talk (play by play!)Naming/ModelingExpansionMotor, paired with sounds/speechCAN, AND SHOULD, PAIR WITH CLEFT PALATE GOALS AND OBJECTIVES!

PROBLEMChild doesnt imitate wordsIMITATION DEVELOPMENT.Eye contact/SmileMotor imitation (pat-a-cake, peek-a-boo, SO BIG!)Vocal imitation (reciprocal vocalization of vowels, grunting, giggling.)INFLECTION!! Easier to imitate- thus UH OH!!! OH *#@!*MOTOR paired with sounds (BYE BYE, UH OH) (BABY sign!)SOUND IMITATION easier developmentally than words!!! TARGET SOUNDS if they are not yet imitating sound play!WORDS, word combinations, phrases, sentencesESTABLISH IMITATION LEVELBUILD FROM STRENGTH!!!

PROBLEMChild doesnt imitate wordsESTABLISH WHAT THE CHILD IMITATES(motor movements, joint attention, feeding the baby)BUILD ON THAT LEVEL!! Dont make WORDS the target when child doesnt imitate motor actions in play- START WITH IMITATION!!IMITATION, IMITATION, IMITATION- IN PLAY!!Childs play, follow their lead, introduce new play schemes by playing them yourself, limit questions and commands.PROBLEMChild doesnt imitate wordsWhen Motor Imitation occurs in play- add sounds, noises, facial expressionsStirring food SH, SH, SH, SHKnock on doll house door knock, knock at same time as motor.SH, SH, SH baby is sleeping when putting doll to bed.UH OH!! Hand to your face-EVERYTIMEwhen they imitate putting hands to face- it increases chance theyll pair it with approximation of UH OH!PROBLEMChild doesnt imitate wordsWHAT ABOUT INFLECTION?WhateverBO BO! No! (yelling at dog was model)I LOVE YOU! (3 syllables approximated)

Inflection is why kids say uh oh! Early!

START IMITATION WHERE THEY ARE SUCCESSFUL- THATS THE STRATEGY!!!SUMMARY of Indirect LanguageStimulationReduce questionsespecially yes/no responses.(choice questions increase the chance of a verbal response)Dont use commands in play- model the activity!INSTEAD:Follow childs leadModel play skillsUse self talk, parallel talk, modeling, expansion.Use exaggerated inflection (UH OH! Oh NO!)Encourage turn-taking.2 year olds will sit in a chair and take turns- it can still be play.CLEFT PALATE SPEECH APPLICATIONSINFANTS:Make sure parents know that sounds infant pre-palate repair CAN make are M, N, NG, vowels, gurglesTalk and imitate childs sound playdont push sounds they CANT make (plosives, fricatives, affricates.)******Good sounds to target during play in EARLY INTERVENTION- vowels (increase variety), /w, r/, /l/,/m, n/.

USE INDIRECT LANGUAGE TECHNIQUES BUT HAVE SPECIFIC SOUND AND RESONANCE GOALS!

EATING/CHEWING SOUNDS to get lip smacks!Stacking blocks- Put block to face- make BIG OPEN VOWEL SOUNDSyou put block onthen give block to child your turndont tell them to say it at firstFIRST get the game of turn-taking (motor) then add soundthen modify soundPOP IT! BIG MOUTH!Animal sounds, car sounds,CHOOSE HIGH PRESSURE PHONEMES IF PALATE IS REPAIRED!!!!

BOOKSCHOSE BOOKS AND TARGET WORDS TO FACILITATE HIGH PRESSURE SOUND DEVELOPMENTWheres Spot? BOOK = NO PUPPY! Childs response to tell mommy dogNO PUPPY! DID YOU FEEL THE AIR POP? PUPPY!!Pop air on their hand- let them pop it on your handThis is a great combined language and articulation goal= 2 word combinations AND high pressure (plosive) sound production!!STRIDENCYDolls: sh! for sleeping- targeting fricatives!

FOOD/KITCHEN play- HOT! Big open air on /h/ to work towards stridency in sh

SNAKES- Snake sounds!! ssss

Shwoosh- paired with other sounds.

Paper/markers- make long lines or circles to represent continuant feature of /s/, sh, /f/pair sound with the motor.

HIGH PRESSURE PHONEMESColoring paper/markers- P, B- lip poppers- pair sound with any motor activity. Tap marker on paper for /p/ or /t/

Train setch, ch, ch Target pop component of the ch (the /t/).

/k/ = back scraper; /t tongue tapper; /p/ popper- and feel the air on your hand!!

WHAT IF PALATE IS UNREPAIRED OR CHILD HAS VPI?Target BIG OPEN vowels!!!Target anterior lip movement on vowels (oh, oo, ow)Target Glides- yes even /l/!! Many 2 years olds CAN make an /l/, and if theyre stimulable it will usually not result in a compensatory articulation error.Target Glides- I work on both /w/ and /r/ when they are backed or omitted altogether in words- ROUND ANTERIOR LIPS move the glide forward through the mouth- THIS IS HOW YOU IMPROVE ORAL MOTOR LIP AND TONGUE AND CHEEK STRENGTH!! IN WORDS AND SPEECH! NOT blowing exercise!WHAT IF PALATE IS UNREPAIRED OR CHILD HAS VPI?DONT teach glottal stops, pharyngeal fricatives or nasal fricatives on accident!

If palate is open or too short, but not yet ready for surgery be very aware of your targets!! To get good lip use, target /m/ words and tread lightly with a STRONG /b/- will get a paired glottal stop! (Chu Chu)WHAT IF PALATE IS UNREPAIRED OR CHILD HAS VPI?TARGET Glides and BIG vowels to increase intelligibility! More accuracy on vowels with improve intelligibility even in the presence of VPI!

VOICELESS plosives /p,t, k/are easier to approximate if VPI is present and less likely to be paired with a glottal stop than VOICED cognate /b,d, g/. Target voiceless, with light contactPRIOR TO PALATE REPAIR:Target IMITATION!! Not necessarily specific sounds, but the GAME OF IMITATION! This goal lays the ground work for speech therapy post palate repair.Target more than just receptive language skills- expanding play skills and motor imitation.Reciprocal vocalizations- develop between 6-9 months- play with vowels and inflection and facial expressions.AFTER palatal repair:Teach the contrast of oral vs. nasal by using terms like-that was in your mouth!

Uh Oh, that was in your nose! (my nose too!)

Target- big, open vowelsand high pressure consonants (plosives, fricatives and affricates)

IN THE CONTEXT OF PLAY!!!

GOALS AND OBJECTIVES:HAVE specific targetsrelated to resonance, articulatory placement, and compensatory articulation patterns:High pressure phonemes (even with 18 month olds).Stridency (sh, s) in sound play or words.Glides (w) using lip rounding.Develop big open vowels to reduce Hypernasality.If connected speech is mumbled with poor intelligibility- target use your big, strong mouth.GOALS AND OBJECTIVES:PROGRESS reports should include information about:Resonance.Articulatory placement patterns.Strategies that worked to address goals.Compensatory articulation errors.

GOAL: will use plosives /p, t, k/ in single words BE SURE to document error pattern as glottal stop, or nasal substitution or omission of consonants with vowels only sound used

REPORTS!INCLUDE DETAILS RELATED TO CLEFT PALATE IN YOUR REPORTS ITS CRITICAL TO THE DECISIONS THE CLEFT PALATE TEAM HAS TO MAKE OVER TIME!

TO DETERMINE IF SECONDARY SURGICAL MANAGEMENT IS NECESSARY- ITS IMPORTANT TO KNOW WHAT HAS BEEN TARGETED IN THERAPY!!

HAVE GOALS!More than just language stimulation with young children (birth to 3) have specific goals for articulation and resonance development related to cleft palate.Speech therapy is still appropriately play based but that does not mean you avoid articulation and resonance goals

*BIG OPEN MOUTH*STRONG,VARIETY OF VOWEL *SOUNDS, PAIRED WITH MOTOR IMITATION, TO INCREASE VARIETY OF VOWELS AND CONSONANTS PRODUCED. REMEMBERBLOWING AND SUCKING EXERCISES DO NOT IMPROVE CLOSURE FOR SPEECH (they might improve blowing and suckingbut the goal?????)

No clinical, scientific research to support the benefit to cleft palate speech error patterns for isolated blowing and sucking exercises!

SPEECH/SOUND correlation needed for speech improvementBlowing, suckingwhen to use itIf they have poor lip closure and you pop cotton balls to get lip pressureQUICKLY work into speech/sound context- Thats a lip popper!! My lips popped- PAH! Pooh, etc.

BLOWING to get oral air because all air is in nose- QUICKLY work to a sound WHOA! (/hw/) or HAH /h/ FOR EXAMPLE To work towards sh BLOW AIR OUT MOUTH, CLOSE TEETH, BLOW AIR AGAIN through teeth and will approximate sh!