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

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

3. 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

8. Types of Clefting:

9. Assessment

10. 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

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

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

13. 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

14. 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

15. 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

16. Therapy

17. 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.

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

19. 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

20. 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

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

22. 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.

23. 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

24. 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

25. 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.

26. 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)

27. 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

28. 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.

29. 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.

30. VPI

31. 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.

32. 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!

33. 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.