Speech Therapy Help When a Child Has a Repaired Cleft Palate?
by David J. Zajac, Ph.D., CCC-SLP
Who Provides Therapy? Individuals who provide speech
therapy are called Speech-Language Pathologists (SLPs). SLPs usually have at
least master's level graduate training (they must have a master's degree to be
certified by the American Speech-Language-Hearing Association, ASHA). Similar
to medical doctors, SLPs usually specialize in certain areas and with certain
age groups -- for example, childhood speech and language disorders, adult
language disorders, voice disorders, cleft palate or craniofacial disorders. A
parent of a child with a repaired cleft palate should seek the services of a
SLP who works extensively with children. (Although experience with cleft palate
is a plus, it is not required in all cases). The SLP that you select should not
only be knowledgeable about childhood speech disorders, but also possess good
interpersonal skills and be able to relate well to children. Don't be afraid to
trust your instincts. (And don't be afraid to change therapists if one doesn't
seem right for your child).
Therapy for What? This might seem like a silly question, but it is perhaps the most important one to ask. In the traditional sense, speech therapy is meant to help children who have disorders of speech and/or language. In my local newspaper (Cary, NC), an advertisement for a SLP states that services are provided for problems such as "lisping" and "baby talk." While children with repaired cleft palate may "lisp" and/or use "baby talk," they may do so for different reasons than children without cleft palate. The key is for the SLP to know which problems can be successfully treated and which ones cannot be successfully treated.
At times, a young child with repaired cleft palate may use primarily nasal substitutions. That is, the phonemes /m/ and /n/ are used pervasively for all oral pressure consonants. Speech therapy should always be initiated in these cases before recommending additional surgery, or even objective assessment. As noted by Peterson-Falzone et al. (2001), “Only when the child is attempting to produce pressure consonants can velopharyngeal function be adequately assessed” (p. 239).
The presence of compensatory articulations in a young child with repaired cleft palate is usually but not always a sign that palatal surgery was ineffective. The use of glottal stops, for example, is an effective way to circumvent the inability to impound oral air pressure due to velopharyngeal inadequacy (VPI). VPI is the inability of the soft palate to make contact with the upper throat wall to close off the nose during speech. This usually occurs in a child with repaired cleft palate because the soft palate is too short and/or does not move well enough. Additional surgery will most likely be required if the soft palate moves well but is too short. Speech therapy, however, will be needed to correct compensatory articulations. Many SLPs will tell parents that they cannot do anything to help the child until additional surgery is completed. Unfortunately, this is a myth. Ideally, speech therapy should begin before additional surgery in order to establish correct oral placement for sounds. Many parents – and some SLPs – may think this is counter-intuitive. If VPI caused the compensatory errors, then how can they be corrected before additional surgery? If a child is old enough, speech therapy can be effective to teach the child to use the lips versus the vocal folds to make sounds such as /p/. This may not be easy depending upon the child but it can be done! The SLP may need to occlude the child’s nose during therapy to prevent nasal air escape and allow the child to focus on correct placements for articulation.
Retained compensatory errors. If speech therapy is not started prior to additional surgery, then it is likely that the child will persist in using compensatory articulations following surgery. Assuming that palatal surgery was successful, speech therapy is needed to correct retained errors. [Below are some resources that SLPs might find helpful when attempting to remediate compensatory errors].
Having said the above, under some circumstances, a SLP might attempt speech therapy to reduce symptoms of hypernasality, weak pressure consonants, and/or nasal air emission on a trial basis. Typically, a child may benefit if the symptoms are mild and/or inconsistent. For example, a child may sound especially nasal late in the day when tired. There are several speech therapy techniques that are designed to mask or cover-up symptoms of hypernasality and/or audible nasal air emission. These techniques include a) talking louder and/or opening the mouth more while talking to reduce hypernasality, and b) making light and quick contacts of the lips and tongue while talking to reduce nasal air escape. A basic problem with these techniques is that the child is required to consciously monitor how he/she is talking. Typically, children -- especially young children -- are not willing to monitor speech for extended periods of time.
Trial speech therapy may also be tried in cases where additional palatal surgery has already been done but obligatory symptoms of hypernasality, weak pressure consonants, and/or audible nasal air emission persist. In these cases, nostril occlusion may be employed to facilitate tactile and auditory awareness of oral air pressure build up and release. If the child cannot maintain oral air pressure without nostril occlusion in a reasonable period of time, then therapy should be discontinued.
Finally, because the soft palate consists of muscles, many SLPs will attempt muscle strengthening exercises. Typically, these exercises consist of non-speech tasks such as blowing, sucking through a straw, or eliciting a gag reflex. The thinking behind these approaches is that increased muscle strength obtained during these exercises will carryover to speech. Although this idea seems intuitive, there is little scientific evidence to show that non-speech muscle strengthening exercises actually reduce hypernasality and/or nasal air emission. Parents should be leery of non-speech oral motor exercises recommended for hypernasality.
The following books provide both general information and specific techniques that might be used to treat compensatory articulations, hypernasality and/or nasal air emission, and dental-related sound distortions:
Golding-Kushner, K. Therapy Techniques for Cleft Palate Speech & Related Disorders. San Diego, CA: Singular, 2001.
Kummer, A. Cleft Palate & Craniofacial Anomalies: Effects on Speech and Resonance (Chapter 21). San Diego, CA: Singular, 2001.
Peterson-Falzone, S., Hardin-Jones, M., and Karnell, M. Cleft Palate Speech, 3rd Edition. St. Louis, MO: Mosby, 2001.
Peterson-Falzone, S., Trost-Cardamone, J., Karnell, M., and Hardin-Jones, M. The Clinician’s Guide to Treating Cleft Palate Speech. St. Louis, MO: Mosby, 2006.
Return to Dr. Zajac's Homepage
Last Updated: 2/16/13