Play-Based Speech Intervention for the Infant, Toddler, and Preschooler with Cleft Palate

Theresa M. Snelling, MA, CCC-SLP

Pediatric Speech-Language Pathologist

Rose Cleft Palate and Craniofacial Center

REFERENCES:

Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP, Trost-Cardamone JE. (2006). The Clinician’s 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

TEAM CONSULTATIONS- Birth to Adulthood

LIP repair- birth to 3 months

PALATE repair- 9-15 months

GENETIC counseling – Birth to Adulthood

Follow-up varies with diagnosis

PEDIATRICIAN/Primary Care- Birth to Adult

(Establish a Medical Home)

SPEECH/LANGUAGE/RESONANCE- 6 mos. to Adulthood (or until normal speech and resonance established.) From Birth- for feeding support

ENT CARE:

Ears/Hearing- Birth to Adulthood

Nose/Nasal Airway- Childhood to Adulthood

PLASTIC SURGERY- Birth to Adulthood

ORTHODONTIA- 7 years to adulthood (often 2 rounds of pre-surgical orthodontia and/or post oromaxillofacial surgery)

PEDIATRIC DENTRISTY- Birth to Adulthood

(establish a dental home)

CLEFT LIP/PALATE TIMELINE cont.

ORAL SURGERY- 6 years to adulthood

8 years to adulthood with some craniofacial conditions/syndromes.

Bone graft (8-12 yrs.) Orthognathic surgery (13 to adult)

SOCIAL WORK/PSYCHOLOGY- Birth to Adulthood

Developmental Assessment- Birth through School-age

health care setting or school.)

OCCUPATIONAL THERAPY- Feeding

Birth through establishment of feeding success.

WHAT DOES “NASAL” MEAN?

HYPERNASAL-excessive nasal resonance during production of vowels.

NASAL SUBSTITUTION-incomplete VP closure causes oral consonants in the correct place of articulation to be produced as nasal consonants…

m/b, n/d, ng/g

NASAL EMISSION- nasal air escape associated with production of consonants requiring high oral pressure. May be audible or not (check with a mirror.)

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.

Vowels resonate in nose… Say “EEEEE” and pinch nose, air stops or sound changes…

“baby” may sound more like “Mayme”

YOU HAVE TO BE ABLE TO DIFFERENTIATE!

Quick screen…

Use a small mirror under nose…

Use a straw or listening tube per Anne Kummer’s book (in references).

On “mmmm” does air flow equally through both nostrils?

On “baby, baby, baby…” there should be no nasal airflow on mirror (unless they stop and breathe… then try with one word.)

AVOID THE TERM- “NASAL” …”They sound nasal…” does not

differentiate hypo and hypernasality.

CHARACTERISTICS OF CLEFT PALATE SPEECH

(Primary)

ARTICULATION DISORDERS

RESONANCE DISORDERS

(Secondary)

LANGUAGE DISORDERS OR DELAY

VOICE DISORDERS (Laryngeal)

ARTICULATION DISORDERS:

PLACE, MANNER, AND VOICING…

Most errors related to cleft palate have to do with PLACEMENT errors while manner is maintained!

ATTEND TO PLACEMENT!!!

Usually BACKED!

Glottal stops, nasal snorts

PLOSIVES /b, p, t, d, k, g/

AFFRICATES /tS, dZ/

Pharyngeal Fricatives, Nasal Fricatives

Fricatives- s, z, sh, v, th, f

Affricates- ch/tS/, j/dZ/

Most common articulation errors related to palatal clefts-

GLOTTAL STOPS PHARYNGEAL FRICATIVES NASAL FRICATIVES NASAL PHONEME SUBSTITIONS

RESONANCE ERRORS:

Hypernasality-Excessive nasal resonance during vowel productions.

Hyponasality- Reduced nasal airflow on nasal phonemes.

NASAL 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.

VOICE DISORDERS

Hyperfunctional voice disorders, secondary to compensatory patterns of articulation and resonance. May develop vocal nodules, hoarseness, reduced vocal intensity, and persistent vocal strain.

IF YOU SEE THIS, IT IS IMPORTANT TO DETERMINE IF VELOPHARYNGEAL INSUFFICIENCY (VPI) IS CONTRIBUTING- HAVE TO DEAL WITH VPI TO REDUCE VOCAL STRAIN.

LANGUAGE DISORDERS

Significant occurrence of OTITIS MEDIA (ear infections and/or middle ear fluid) in individuals with cleft palate due to anatomical differences, may increase time with hearing loss, and contribute to a language disorder or delay.

Other developmental issues, reduced vocal output, hospitalizations, parental reaction/attitude, and associated with some syndromes.

COMPENSATORY MISARTICULATIONS related to cleft palate are usually errors in PLACEMENT OF PRODUCTION. They are learned sound placements that typically persist even after successful surgery or obturation of the palate and therefore co-exist with adequate Velopharyngeal closure.

They tend to be BACKED ARTICULATIONS relative to the target place of production.

VELOPHARYNGEAL 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.

INSTRUMENTAL ASSESSMENT OF VPI

In team/clinic:

VIDEOFLOUROSCOPY

NASOENDOSCOPY/VIDEOENDOSCOPY

NASOMETRY

In therapy setting

MIRROR TEST**

STRAW ASSESSMENT**

THERAPY TECHNIQUES…

Goals:

TO CORRECT THE PLACEMENT ERRORS (often will improve/correct hypernasal resonance.)

Improve hypernasal resonance (if it’s structural secondary surgical management is needed- but therapy should be tried first especially in the presence of articulation errors.)

Target 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 reduction…

TARGET BACKING- move sounds anterior!!!

vowels (anterior round vowels (/u/ /oe/)

glides /w, r/…not /j/ substitution

mid-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 reduction…

TRY 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!

(Example of reinforcing error) 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/!

(Example of overplacement) Approach= targeted /p/…moved to overplacement for /t/….

Speech Therapy- what about blowing exercises?

REMEMBER…

BLOWING AND SUCKING EXERCISES DO NOT IMPROVE CLOSURE FOR SPEECH (they might improve blowing and sucking…but 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 improvement…

Blowing, sucking…when to use it…

If they have poor lip closure… and you “pop” cotton balls to get lip pressure…QUICKLY work into speech/sound context- “That’s 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’!

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.

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.

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.)

Chose targets based on stimulability, visual cues (especially with young children), and contribution to keeping sounds ANTERIOR!

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…

Listen for and eliminate co-articulated errors!! Especially glottal stops paired with stop consonants (/b/ correct in placement with some plosive quality, but combined with a glottal stop.)

Use contrast! You will not be teaching the error… (think Minimal Pairs).

/t/ vs. /k/ needs contrast with the above strategies; Minimal Pairs contrasts work well for carryover.

“Push air in Nose…Push/blow air out mouth”… back and forth.

With MIXED NASALITY (hypernasality seen in conjunction with denasality and/or nasal obstruction) IT IS MOST EFFECTIVE TO CONTROL THE HYPONASALITY FIRST WITH MEDICAL SUPPORT- o allow for therapy progress related to hypernasality!

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.

BIRTH TO 3 INTERVENTION….TEACH PARENTS/GRANDPARENTS/CARETAKERS...

INDIRECT LANGUAGE STIMULATION TECHNIQUES!!!

Self Talk Parallel Talk (play by play!) Naming/Modeling Expansion Motor, paired with sounds/speech

CAN, AND SHOULD, PAIR INDIRECT LANGUAGE STRATEGIES, WITH CLEFT PALATE GOALS AND OBJECTIVES!

KEY STRATEGIES…

REDUCE (Eliminate!)…YES/NO QUESTIONS!

REDUCE (Eliminate!)… COMMANDS in Play!!

HOMEWORK…. 5 minutes of PLAY with infant, toddler, preschooler… NO QUESTIONS, NO COMMANDS….

Let caretaker/parent know…“The reason you ask questions and give commands is because you have not gotten a verbal response to these strategies in the past. IT IS NOT THE REASON YOUR CHILD IS NOT TALKING, but if we go back to indirect, natural language stimulation, we can move forward. With patience… it really works…” This helps reduce/eliminate parent guilt- don’t want to suggest that because they haven’t been using the strategies that they caused the delay/disorder!

POINT OUT WHAT THEY ALREADY IMITATE WELL- MOTOR, MUSIC, DANCING…build from there!!

Whose PLAY is this? Yours or the child’s?

CHILD DIRECTED MEANS WE DON’T TELL THEM how TO PLAY!!!!

WHAT DO ADULTS NEED TO DO??

PLAY, PLAY, PLAY…with the toys yourself!

GOAL- Expand the child’s play skills to include more exploration of toys and manipulatives in their environment…

***The Therapist or ADULT models this to meet the goal!!!

WATCH AND OBSERVE….

WATCH OTHER CHILDREN WITH THE CHILD…THEY DON’T ASK QUESTIONS OR GIVE COMMANDS (UNLESS THEY HAVE LEARNED FROM ADULTS IN THE ENVIRONMENT) AND THE CHILD WILL PLAY WITH THE SIBLING OR PEER….

IF PARENT SAYS “S/HE DOESN’T LIKE TO PLAY WITH ME…” PARENT IS PROBABLY DIRECTING THE PLAY AND DEMANDING SPEECH!!

(EXAMPLE- 2 brothers playing with blocks….)

BE INDIRECT… IT WORKS!!!!!

PROBLEM…Child doesn’t imitate words…

IMITATION DEVELOPMENT….

Eye contact/Smile

Motor 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, sentences…

ESTABLISH IMITATION LEVEL FROM ABOVE…BUILD FROM STRENGTH!!!

PROBLEM…Child doesn’t imitate sounds…

ESTABLISH WHAT THE CHILD IMITATES…(motor movements, joint attention, feeding the baby…)

BUILD ON THAT LEVEL!! Don’t make WORDS the target when child doesn’t imitate motor actions in play- START WITH IMITATION!!

IMITATION, IMITATION, IMITATION- IN PLAY!!

Child’s play, follow their lead, introduce new play schemes by playing them yourself, limit questions and commands….

PROBLEM…Child doesn’t imitate words…

When Motor Imitation occurs in play- add sounds, noises, facial expressions…

Stirring food “SH, SH, SH, SH…”

Knock 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-EVERYTIME…when they imitate putting hands to face- it increases chance they’ll pair it with approximation of “UH OH!”

WHAT ABOUT INFLECTION…?

“Whatever”; “BO BO! NO!” ( Yelling at dog); I LOVE YOU (3 syllables approximated)

START IMITATION WHERE THEY ARE SUCCESSFUL- THAT’S THE STRATEGY!!!

ROLE OF TURN-TAKING…

CONVERSATION and SPEECH…involves turn-taking.

OBSERVE adult partner with child- who’s taking all the turns?

BUILD on motor turn taking…USE words like “MY TURN”….”YOUR TURN” when playing with toys…if they’ll take a motor turn…you increase the chance they’ll take a verbal turn when you pair the motor activity with a sound….

EXAMPLES:

COLORING with markers on a big sheet of paper…

I take a marker, make circles or dots… “MY turn!”

I hand marker to child “your turn”… I repeat this a few times…

T HEN I ADD SOUND TO MY TURN, if child is imitating the motor…

I DO NOT TELL THEM TO SAY IT! THIS MAKES A DIFFERENCE!!!!

SUMMARY of Indirect LanguageStimulation…

Reduce questions…especially yes/no responses.

(‘choice’ questions increase the chance of a verbal response)

Don’t use commands in play- model the activity!

INSTEAD:

Follow child’s lead

Model play skills

Use self talk, parallel talk, modeling, expansion.

Use exaggerated inflection (UH OH! Oh NO!)

Encourage turn-taking….2-3 year olds will sit in a chair and take turns.

CLEFT PALATE SPEECH APPLICATIONS…

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 SOUNDS…you put block on…then give block to child “your turn”…don’t tell them to say it at first…FIRST get the game of turn-taking (motor) then add sound…then modify sound…”POP IT!” “BIG MOUTH!”

BOOKS…

CHOSE BOOKS AND TARGET WORDS TO FACILITATE HIGH PRESSURE SOUND DEVELOPMENT…

“Where’s Spot?” BOOK = “NO PUPPY!” Child’s response to tell mommy dog…”NO PUPPY!”

“DID YOU FEEL THE AIR POP? PUPPY!!”

Pop air on their hand- let them pop it on your hand…

This is a great combined language and articulation goal= 2 word combinations AND high pressure (plosive) sound production!!

STRIDENCY…

Dolls: “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 PHONEMES…

Coloring paper/markers- P, B- “lip poppers”- pair sound with any motor activity. “Tap” marker on paper for /p/ or /t/…

Train set…”ch, ch, ch… Target “pop” component of the “ch” (the /t/).

/k/ , /t/ , /p/ - 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 they’re 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!

WHAT IF PALATE IS UNREPAIRED OR CHILD HAS VPI?

DON’T 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!

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 contact

PRIOR 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 vowels…and high pressure consonants (plosives, fricatives and affricates)…

IN THE CONTEXT OF PLAY!!!

GOALS AND OBJECTIVES:

HAVE specific targets…related 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.

INCLUDE DETAILS RELATED TO CLEFT PALATE IN YOUR REPORTS… IT’S CRITICAL TO THE DECISIONS THE CLEFT PALATE TEAM HAS TO MAKE OVER TIME!

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