Information on Clefting Myths Myths

10/23/15
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)
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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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1
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Common Facts about Clefting
! 
! 
Most common birth defect (CDC, 2006)
Who has a cleft?
" 
" 
Native American/India
Utah
1:250
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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Pediatric
Psychologist
Prosthodontist
Speech-Language
Pathologist
Geneticist
ENT
Pediatrician
Cleft Palate
Team Approach
Social worker
Orthodontist
Speech Surgeon
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A Little About Anatomy
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2
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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
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(Peterson-Falzone, Hardin-Jones, & Karnell, 2010)
3
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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
1s
tag
e
8-9
yrs
ts
6m
2s
ts
m
12
tag
e
6
mts
4 yrs
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The Debate Continues:
Facial
Growth
Speech
Development
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4
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Timing: One Stage Repair
1980’s
!!!18$24!
!!months!!
!Wardill!(1937)!!
“younger!than!
1!year”.!!
Holdsworth!
(1945)!6!–!9!
months.!
2000’s
6$12!
months!
≈12!!
months!
1990’s
(Peterson-Falzone et al., 2010; Katzel et al., 2009)
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Timing: One Stage Repair
(Katzel et al., 2009) US data
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Timing: Delayed Hard Palate Repair
Rohrich et al.
(2000)
suggested SPR
at 3-6 mts and
HPR at 15-18
mts
1980’s
!
!!!!!!5.5!years!
!!
2000’s
7$11!
years!
!
3$4!years!!
1990’s
(Lohmander et al., 2012)
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5
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What is the Evidence?
Systematic
Reviews of
RCT
!TOPPS!
(ongoing)!
!
Willadsen!
(2011)!
!
One RCT
AmericleL!
(ongoing)!
Well controlled study No Randomization
Holland!
et!al.!
(2007)!
Adapted from Joanna
Briggs Institute for EBP
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
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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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6
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Secondary Surgery: Sphincter
pharyngoplasty
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Impact of Clefting on
Communication: Presurgery
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Impact of Clefting on Communication:
Presurgery
• 
Inability to
impound
intraoral air
pressure
“Avoids”
alveolar
sounds
Cou.
• 
• 
No surface
against which to
place the tongue
.
Less practice
with with these
sounds
.
Delayed
speech,
Reduced
intelligibility,
CAs
“Avoids”
pressure
consonants
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7
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Impact of Clefting on Communication:
Presurgery
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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Characteristics - Presurgery
! 
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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Characteristics - Presurgery
! 
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
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(Chapman
et al. 2003)
10
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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)
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Speech Characteristics: Postsurgery
! 
Variability in speech development postsurgery
- 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
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(Hardin-Jones
& Jones, 2005)
11
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Impact of Clefting on Speech:
“Cleft” Speech Characteristics
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Cleft Palate
Speech
Learned
Obligatory
Oral
Deviations
VPD
Hypernasality
Nasal Emission
Phoneme
Specific Nasal
Emission
Dental
Deviations
Fistula
Oral
Distortions
Nasal Emission
Compensatory
Articulations
(CAs)
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Obligatory
Oral
Deviations
VPD
Hypernasality
Nasal Emission
Dental
Deviations
Fistula
Oral
Distortions
Nasal Emission
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12
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Learned
Phoneme
specific nasal
emission
Compensatory
articulations
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Velopharyngeal Dysfunction
Velopharyngeal Inadequacy (VPI)
Velopharyngeal Dysfunction (VPD)
VP
Insufficiency
VP
Incompetence
VP
Mislearning
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(Trost-Cardamone,
1989)
Speech Characteristics: Postsurgery
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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13
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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
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4. 
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
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 coarticulation
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)
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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
(Trost, 1981; Peterson-Falzone et al., 2006)
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15
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Compensatory articulations:
Mid-dorsum Palatal Stop [c] & [ ]
! 
! 
! 
Mid-dorsum part of
tongue contacts midpalate
Place of articulation
similar to /j/
Can be related to a
fistula
(Trost, 1981; Peterson-Falzone et al., 2006)
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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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16
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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)
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Conversational Profiles (Fey, 1986)
+ Assertive + Responsive
- Assertive + Responsive
+ Assertive - Responsive
- Assertive - Responsive
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Assessment Presurgery
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17
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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)
10/23/15
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!!
Observed!!!!!!!!!!!!!!!!!!!!!!!!!!Not!Observed!
Inten9onal&
Communica9on&
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!!!!!!!!!!!!!!!!
10/23/15
(Scherer, Chapman, & Hardin-Jones, 2005)
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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18
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Assessment Postsurgery
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Assessment Postsurgery
! 
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!
10/23/15
(Scherer, Chapman, & Hardin-Jones, 2005)
19
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Assessment Postsurgery
! 
! 
! 
! 
! 
! 
! 
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
10/23/15
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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20
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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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21
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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
10/23/15
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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22
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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
# 
# 
10/23/15
American English Sentence Sample
(Judith Trost-Cardamone, 2012)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Mom ‘n Amy are home
Puppy will pull a rope
Buy baby a bib
A fly fell off a leaf
I love every view
Thirty-two teeth
The other feather
Anna knew no one
Your turtle ate a hat
Do it today for Dad
Laura will yell
Sissy saw Sally race
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
puppy
pop
bee
baby
bib
fire
waffle
leaf
V
Over
five
three
XX
wreath
there
father
XX
tea
letter
eat
deer
ladder
red
see
sissy
house
zoo
scissor
eyes
shoe
washer
wish
chew
catch
watch
judge
veggie
edge
key
cookie
rake
go
goggle
leg
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23
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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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Assessment Postsurgery
Resonance
!  Hypernasality
Severity rating scales:
Normal, Mild, Moderate, Severe
! Hyponasality
Hyponasality:
__Absent__Present
Hypernasality
1____________________7
Normal
Severe
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24
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Assessment Postsurgery
! 
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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25
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Results of Your Assessment
Speechlanguage
appropriate/
Speechlanguage
appropriate/
VP mechanism
normal
VP mechanism
questionable
Speechlanguage
delayed/
Speechlanguage
delayed/
VP mechanism
normal
VP mechanism
questionable
10/23/15
(Chapman, Hardin-Jones, & Scherer, 2013)
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
10/23/15
(Chapman, Hardin-Jones,
& Scherer, 2013)
26
10/23/15
Common Misconceptions
Nasal
substitutions
are indicators
of VPI
Or related to
phonological
learning
(Chapman, Hardin-Jones,
& Scherer, 2013)
10/23/15
Common Misconceptions
Glottal stops
present due to
VPI
Or due to
phonological
learning
10/23/15
(Chapman, Hardin-Jones,
& Scherer, 2013)
Implications
Difficult to
evaluate
mechanism with
NS and GSs
Therapy to
eliminate these
before evaluation
of VP function
(Chapman, Hardin-Jones, & Scherer, 2013)
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27
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Decisions?
When to refer to Cleft PalateCraniofacial Team?
!  When to refer for intervention?
! 
10/23/15
Things to Consider
1. Child’s age/
maturity
2. Speech
skills
Severe speech problem?
Nasal substitutions?
Glottal stops?
3. Palatal
fistula
10/23/15
Some Debate
Intervention is a
waste of time
Run the risk of
recommending
surgery for a child
who does not really
need it!
Eliminate all
nonobligatory
speech errors prior
to surgery
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28
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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
− 
− 
10/23/15
What Improves with Surgery?
Should Improve
Hypernasality
Weak pressure
consonants
!  Nasal emission/
turbulence*
! 
! 
Does Not Improve
Compensatory
articulations
!  Delayed speech
!  Nasal substitutions
!  Oral distortion of
fricatives/affricates
! 
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Intervention
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29
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!!!Prelinguistic/Presurgery Treatment
! 
When is intervention appropriate?
10/23/15
Principles of Intervention
Naturalistic approach
!  Family centered
!  Culturally/linguistically appropriate
!  Guided by the toddler’s communication skills,
not condition of clefting
!  Evidence based
! 
(Chapman, Hardin-Jones, & Scherer, 2013)
10/23/15
Prelinguistic Treatment
Goal 1
!  Parent education
−  Review
of developmental milestones
of cleft on speech/language development
and hearing
−  Impact
! 
Parents as intervention agents
− 
− 
Parent “training”
Monitor what parents are doing
(Chapman, Hardin-Jones,
& Scherer, 2013)
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30
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Prelinguistic Treatment
Goal 2
!  Increase frequency and diversity of
vocalizations
−  Imitate
−  Model
baby’s vocalization
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
10/23/15
(Chapman, Hardin-Jones,
& Scherer, 2013)
Prelinguistic Treatment
Goal 3
!  Increase communicative opportunities
−  Environmental
arrangement
temptations
−  Communicative
−  Be
responsive
(Chapman, Hardin-Jones, & Scherer, 2013)
10/23/15
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
(Chapman, Hardin-Jones, & Scherer, 2013)
10/23/15
31
10/23/15
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
10/23/15
Intervention Postsurgery
10/23/15
32
10/23/15
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
Speechlanguage
appropriate/
Speechlanguage
delayed/
VP mechanism
normal
VP mechanism
normal
Speechlanguage
delayed/
Speechlanguage
appropriate/
VP mechanism
questionable
VP mechanism
questionable
(Chapman,10/23/15
Hardin-Jones, & Scherer, 2013)
Profile 1
! 
Monitor every 3 - 6 months
Speechlanguage
appropriate/
VP mechanism
normal
(Chapman, Hardin-Jones, & Scherer, 2013)
10/23/15
33
10/23/15
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)
!
!
Speechlanguage
delayed/
Speechlanguage
delayed/
VP mechanism
VP mechanism
normal
10/23/15 questionable
Comparison of Goals
Profile 2
! 
! 
Expand vocabulary
Expand consonant
inventory
nasals/glides
fricatives
−  front sounds
− 
! 
Profile 3
! 
! 
stops
Eliminate CAs
(if present)
Expand vocabulary
Expand consonant
inventory
−  focus
on pressure
consonants
Eliminate CAs
Ignore NE &
hypernasality
!  Awareness of oral air
flow
! 
! 
(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)
10/23/15
34
10/23/15
Enhanced Milieu Training with
Phonological Emphasis
Environmental
Arrangement
Milieu
Teaching
Procedures
Responsive
Interaction
Selecting
words
Selecting
sounds
10/23/15
(Scherer & Kaiser, 2010)
Choosing Targets for Early Words
First 50
words
“In” sounds
and “out”
sounds
Words that
serve many
functions
How to
select
words/
sounds?
10/23/15
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
10/23/15
35
10/23/15
Expand Consonant Inventory: Choosing
Sounds
Consonant inventory
ʔ
h
m
w
n
j
10/23/15
Expand Consonant Inventory: Choosing
Sounds
Consonant inventory
ʔ
h
m
10/23/15
Eliminating Glottal Stops
! 
Use /h/ to “break up” glottal pattern
Produce whispered /h/ + vowel
/h/ while producing /p/ or /t/
−  Overaspirate until production correct
−  Gradually introduce voicing
– 
−  Prolong
(Peterson-Falzone et al, 2006)
10/23/15
36
10/23/15
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)
10/23/15
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
Speechlanguage
appropriate/
VP mechanism
questionable
(Chapman, Hardin-Jones, & Scherer, 2013)
10/23/15
Intervention Preschoolers
10/23/15
37
10/23/15
Intervention Strategies
! 
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
10/23/15
(Williams, McLeod,
McCauley, 2010)
Intervention Strategies
! 
“Why traditional articulation therapy is
preferred.” (Peterson-Falzone et al., 2006)
10/23/15
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)
10/23/15
38
10/23/15
Intervention Strategies
! 
After determining sound(s) to work on
−  Teach
correct placement for the sound
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
−  May
10/23/15
(Peterson-Falzone, Trost-Cardamone, Karnell, & Hardin-Jones, 2006)
Intervention Strategies
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
10/23/15
39
10/23/15
M
Multiple Oppositions
n
b
p
k
s
(Williams, 2003)
10/23/15
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
10/23/15
(Peterson-Falzone
et al, 2006)
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)
10/23/15
40
10/23/15
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)
10/23/15
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
41
10/23/15
NSOMT
1947/1948
1968
1951
1974
1973
2005
2004
2008
(Chapman, Hardin-Jones, & Scherer, 2013)
10/23/15
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
10/23/15
42
10/23/15
What is the Evidence?
Systematic
Reviews of
RCT
One RCT
Adapted!from!Joanna!Briggs!
InsRtute!for!EBP!
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/
10/23/15
Descriptive Studies/Studies with Poor Methodology
Early Intervention Studies
! 
Vocabulary!training!administered!by!a!
clinician!(Scherer,!1999)!and!mothers!(Scherer!
et!al.,!2008)!improved!lexical!and!speech!
development!
10/23/15
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)
! 
10/23/15
43
10/23/15
What is the Evidence?
Systematic
Reviews of
RCT
Scherer
(1999)
Pamplona & colleagues
(1996; 1999;2000;
2004;2005)
One RCT
Adapted!from!Joanna!Briggs!
InsRtute!for!EBP!
Well controlled study -No
Randomization
Scherer et
al. (2008)
Hall & Tomblin,
(1975)
Well designed cohort/intervention
comparison (more than one center)
Thompson et
al. (2015)
Multiple time series/Single Case Design
Expert Opinion/Case Reports/Clinical Series/
10/23/15
Descriptive Studies/Studies with Poor Methodology
44
K. Chapman, PhD
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