Speech Therapy for students with Clefting Loretta Dunkmann, MS, CFY-SLP

Anatomy and Physiology Clefting is not about what happens; it is about what does not happen.

Alveolar ridge—forms sulcus between hard palate and lip Hard palate formed by medial projections of the palatine process of the maxillary bone—suture at midline Palatine process is anterior ¾ of hard palate Posterior ¼ paired palatine bones

Types of Clefting:

Assessment

Obtain Adequate Sample Background Information Important that surgeries are included…they play a role in resonance Oral Mechanism Exam A thorough exam may explain resonance issues Standardized Assessment For Qualification Reasons Peripheral Speech Assessment Connected Speech Sample Hypernasality may only be noticed during connected speech Specialized sampling contexts (sensitive to cleft type speech errors) Handout attached

Oral Mechanism Exam Note all the things you usually note Tonsils? •Lip scars? •Palate scars? •High arched palate? •Palatal Lift? Malocclusion?

Analyze Speech Sample Rate Overall intelligibility Document phonetic inventory Document speech resonance Document nasal air emission Classify errors

Perceptual Assessment - Hypernasality Too much nasal resonance Causes: Persisting VPI Fistula Intermittent suggests: Sporadic closure of VP port Assimilation nasality (affected by nearby nasal consonants) Continuous suggests: Physically based VP problem Refer to Quick Check

Hyponasality/Cul de sac Resonance Hyponasality: too little resonance Could suggest: Large adenoids Obstructive pharyngeal flap Intranasal airway obstruction Recent Cold Allergies Cul-de-sac Resonance: “blind pouch” sound is trapped by the anterior nasal cavity constriction Deviated septum

Airflow Direction – Nasal Emission - results from the abnormal coupling of oral and nasal cavities. Airflow that normally is directed and emitted orally is allowed to escape into the nasal cavity and is emitted nasally. - nasal turbulence – audible nasal emission “audible snorting” “posterior nasal frication” “nasal rustle” Causes: Obligatory: VPI and/or fistula Learned: phoneme-specific nasal emission: affects production of certain high-pressure consonants while the remainder of the HPCs are produced correctly Most vulnerable: sibilant fricatives and affricates /s, z/ “sh” “zh” “ch” “j” Persisting postoperative nasal emission

Therapy

Collaboration Get the parents to sign a release allowing you to communicate with their medical team. “I would like for school clinicians to feel that they are a part of the medical team, and for them to be in regular contact with the team SLP. They are the clinician closest to the child, who knows the child best and is in the child's day to day world. The team SLP is not. The team cannot provide optimal care without collaboration from the school or community SLP.” Share your evaluation report and IEP with the medical team.

For any neurologically normal child born with a cleft, the expectation is for NORMAL SPEECH

Errors Obligatory errors: Learned Errors Errors that are caused by structural or neurogenic problems Such as Fistulas VP insufficiency These errors require physical management Learned Errors Habituated errors that are the result of early mislearning. They exist and persist in the context of adequate VP closure and required speech remediation. AKA: Maladaptive errors Compensatory misarticulations

Purposes of Early Speech-Language Stimulation Program (Phillips, ) To develop the child’s confidence in ability to achieve intelligible verbal communication To ally parental anxiety concerning the child’s development of verbal communication To encourage development of communication skills to the maximum of the child’s potential --Structural ability to produce consonants influences early lexicon (Willadsen, 2013). To minimize or prevent development of compensatory articulation and voice patterns To determine velopharyngeal competence as early as possible

Encourage parents to respond to child with prolonged vowel sounds or front sounds as oppose to back noises. No growling No car noises

Depending on extent of the cleft, child may selectively avoid the hard palate as a key articulator, preferring to produce sounds that do not require linguapalatal contacts. Coupling of the nasal and oral cavities will impound intraoral air pressure resulting in distorted productions, avoiding productions of /b/ and /d/ during babbling Chronic middle ear infections accompanying conductive hearing loss All these factors can influence the sounds that the baby chooses to produce…therefore resulting in the compensatory techniques we work on correcting.

School Based Therapy Errors we can work with Maladaptive compensatory productions Backed oral productions Pharyngeal stops, fricatives, affricates Glottal stops Nasal air emission Obligatory errors we cannot correct: Nasal emission and hypernasality caused by VPI Nasal air loss caused by fistulas Adaptive oral misarticulations resulting from structural abnormalities or severe malocclusions

School Based Therapy When To Start: Frequency & Duration Get these answers: Understand child’s hearing status Functional status of VP mechanism Oral structural hazards to speech progress Plans for ongoing team care Daily Basis…that would be awesome…but not realistic Twice weekly 30 minutes sessions Preferably 1:1 Supplement with daily speech homework/home practice program

School Based Therapy Teaching Correct Oral Airflow Blowing bubbles Whistles Blowing against cotton balls Blowing through a straw Nose pinching **Note: these are not to be used as oral motor exercises, this is strictly to teach the student correct air flow movement.

School Based Therapy Therapy Approach Resource Eliciting Sounds Traditional Articulation Therapy Isolation Syllables CV, VC, CVC, VCV Words Initial – medial – final Phrases Sentences Reading Tasks Lynn Marty-Grames recommends 100% accuracy at each level before progressing. Eliciting Sounds Techniques and Strategies for Clinicians – 2nd Edition Wayne A. Secord (2007)

School Based Therapy Target Sound Selection Target errors that have the greatest impact on speech understandability and acceptability This could mean going out of developmental sequence Stimulability Visibility Place of production Anterior sounds first Manner Fricatives will typically be easier than stops

Children with clefts make a variety of articulation error types •Not all errors are compensatory errors •There are four speech sound categories in cleft palate speech, we will talk about these shortly.

If the child with a cleft needs braces, you can work on articulation, especially [s], until after orthodontics is completed. Most often, the error is the result of what the tongue is doing, not the position of the teeth. •Diagnostic therapy should always be attempted. Certain orthodontic appliances may complicate speech therapy, depending on what you are working on.

VPI

If the child has velopharyngeal dysfunction, you can’t work on articulation until after surgery. VPD alters airflow, not articulatory function. While some children develop maladaptive patterns, not all do.

What could articulation therapy do? It may show us that velopharyngeal management is not needed. It may prepare the child for valid imaging studies. •It will make the child’s speech more intelligible. It’s possible to have completely normal articulation and still be hypernasal. •In some cases, articulation therapy must take place before velopharyngeal imaging. Refer to a cleft team speech pathologist with a velopharyngeal imaging lab instead!

Delaying articulation therapy delays speech normalization. •The better the articulation, the better the intelligibility after VP management If the velopharynx is dysfunctional, it will be dysfunctional across the phoneme spectrum If only a certain few sounds come out the nose, and the others don’t…. •It probably is an articulation problem……your problem! Mild forms of VPI may only manifest in the complexity of conversation •Sometimes, the velopharynx can push closed for short utterances, but can’t sustain over time.