10/23/15 1 Information on Clefting http:kidswithcleftsutah.blogspot.com 10/23/15 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) 10/23/15 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. 10/23/15
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Information on Clefting - College of Health · Cleft Palate Team Approach Pediatric ... Later Speech and Language: NCP ! ... Repaired cleft lip - Length, symmetry
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10/23/15
1
Information on Clefting
http:kidswithcleftsutah.blogspot.com
10/23/15
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)
10/23/15
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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10/23/15
2
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
Relationship Between Early Speech and Later Speech and Language: CP
(Chapman et al. 2003) 10/23/15
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11
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
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 Characteristics: Postsurgery
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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Speech Characteristics: Postsurgery
4. Compensatory productions - Place of articulation is moved posteriorly - Not sure why some children produce them - Attempts or meet pressure requirements for
! 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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Assessment Postsurgery
! 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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Assessment of Children with CP: OME
! What to look for: Repaired cleft palate - Hard Palate
# Palatal vault # Fistula
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Assessment of Children with CP: OME
! 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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Assessment of Children with CP: OME
! 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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Assessment of Children with CP: OME
! 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
! 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
(Chapman, Hardin-Jones, & Scherer, 2013)
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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
(Chapman, Hardin-Jones, & Scherer, 2013)
10/23/15
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
(Chapman, Hardin-Jones, & Scherer, 2013)
10/23/15
4 Profiles of Development
Speech-language
appropriate/
VP mechanism normal
Speech-language
appropriate/
VP mechanism questionable
Speech-language delayed/
VP mechanism normal
Speech-language delayed/
VP mechanism questionable
(Chapman, Hardin-Jones, & Scherer, 2013) 10/23/15
Profile 1
! Monitor every 3 - 6 months
Speech-language
appropriate/
VP mechanism normal
(Chapman, Hardin-Jones, & Scherer, 2013)
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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)
!
Speech-language delayed/
VP mechanism normal
!
Speech-language delayed/
VP mechanism questionable
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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
(Chapman, Hardin-Jones, & Scherer, 2013) 10/23/15
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
− Combination of the two www.latrobe,edu.au/hsc/projects/preschoolspeechlanguage/articphonol.html
(Williams, McLeod, McCauley, 2010) 10/23/15
Intervention Strategies
! “Why traditional articulation therapy is preferred.” (Peterson-Falzone et al., 2006)
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Intervention Strategies
! 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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Intervention Strategies
! 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
! 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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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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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
(Peterson-Falzone et al, 2006)
10/23/15
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
(Peterson-Falzone et al, 2006)
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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!)
(Chapman, Hardin-Jones, & Scherer, 2013) 10/23/15
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NSOMT
1947/1948
1951
1968
1973
1974
2004
2005
2008
(Chapman, Hardin-Jones, & Scherer, 2013)
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NSOMT
! Used in children with cleft palate - Why are they used? - Who uses them? - Do they work?
(Chapman, Hardin-Jones, & Scherer, 2013)
10/23/15
NSOMT
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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
! 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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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!InsRtute!for!EBP!
Pamplona & colleagues (1996; 1999;2000;
2004;2005)
Scherer (1999)
Scherer et al. (2008)
Hall & Tomblin, (1975)
Thompson et al. (2015)
10/23/15
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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