Can 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 (
- Developmental
Articulation and/or Phonology Problems. SLPs know that approximately 6
to 10% of all children (boys somewhat more frequently than girls) will
exhibit difficulty in learning the sounds of English and will require
speech therapy. (This therapy is usually provided through the school).
Most of these children will have no obvious structural problems with the
ears, mouth, or throat, yet they will omit, distort, or substitute certain
speech sounds. The reason for such errors might be related to subtle
problems with hearing and/or motor control of the speech articulators.
Regardless of cause, the majority of these children will learn to correct
their speech errors through therapy and go on to lead normal lives.
Children who are born with cleft lip and/or palate are not immune from
these types of speech problems. If a child with a repaired cleft palate
has these types of speech problems, then traditional types of speech
therapy should be successful -- assuming that palatal surgery was
successful.
- Compensatory
Articulation Errors Related To Cleft Palate. For reasons not
completely understood -- speech and hearing sciences are not only complex
but also relatively young -- some children with cleft palate will develop
"compensatory" articulations. Typically, this means that the
child will produce sounds farther back in the mouth (or throat) than is
normal. For example, instead of using the lips to block air and produce a
/p/ sound, the child might use the vocal cords as a substitute (called a
"glottal stop" substitution). Other compensatory errors might
involve making the /s/ sound in the throat rather than in the mouth
(called a "pharyngeal fricative" substitution) or even snorting
air through the nose for the /s/ (sometimes called a "posterior nasal
fricative"). Compensatory errors such as glottal stops and/or
pharyngeal fricatives can make a child's speech quite unintelligible if
used frequently.
Retained compensatory errors. If a child with cleft palate develops compensatory errors
prior to palate repair, it is likely that these errors will continue following
surgery. Assuming that palatal surgery
was successful, speech therapy can correct these retained errors. [Below are
some resources that SLPs might find helpful when attempting to remediate these
errors]. Often, to get a head start on
compensatory errors, SLPs will recommend that speech therapy begin prior to
surgery, especially for older children who are undergoing secondary surgery to
correct persistent velopharyngeal inadequacy. In these cases, it is important
for both the parents and SLP to recognize that the goal of speech therapy is to
correct faulty placement of articulation and not to correct obligatory symptoms
such as hypernasality (see below). When
working with a child who has compensatory articulations prior to surgery, it is
critical that the SLP occlude the child’s nostrils to prevent nasal air
escape and allow the child to focus on correct tongue placement for
articulation.
- Obligatory Hypernasality,
Weak Pressure Consonants, and/or Audible Nasal Air Emission Related To
Cleft Palate. Often, following initial palate surgery (and
sometimes following secondary palatal surgery), children will sound
"nasal" and/or audible puffs of air will escape from the nose
while talking. Even if the child does not have articulation errors, the
degree of hypernasality and/or nasal emission may cause speech to be
difficult to understand and/or present social problems. Often,
well-meaning physicians will prescribe speech therapy for these symptoms.
Parents and SLPs, however, need to be informed that speech therapy -- even
by the most experienced pediatric craniofacial SLP -- will probably not
correct these problems. These symptoms are the result of inadequate
physical separation of the mouth and nose by the soft palate (i.e., a
structural problem). Surgery, not speech therapy, is needed to correct
this condition.
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. 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 stimulating a gag reflex. The thinking behind these
approaches is that increased muscle strength obtained during these exercises
will carryover to speech. Although this idea has face validity, there is
little scientific evidence to show that non-speech muscle strengthening
exercises actually reduce hypernasality and/or nasal air emission. (I should
note that some newer techniques are being developed that attempt to improve
palatal function during speech production. These techniques might hold promise
in the future).
In a few special cases, a SLP
might try speech therapy on a trial basis for obligatory symptoms such as weak
pressure consonants and nasal air emission following surgery if symptoms
persist. In these cases, nostril occlusion should 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, there are several speech
therapy techniques that are designed not to physically improve palatal function
but simply to mask or cover-up symptoms of hypernasality and/or audible nasal
air emission. These techniques include talking louder, opening the mouth more
while talking, and reducing contact pressure of the articulators while talking.
A basic problem with all of 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.
- Sound Distortions Due
to Dental Malocclusion. Typically, many children with repaired clefts
that involve the gum ridge (alveolar ridge) will distort the sounds
"s z ch j (as in “judge”) sh
zh." These sounds are called "sibilants." To
produce these sounds, turbulent air must flow over the tongue and strike
the front teeth. If teeth are missing or misaligned (malocclusion), then
the air flow may escape before striking the front teeth. Many children
with repaired cleft palate have restricted (or collapsed) upper dental
arches. This condition may cause a cross-bite (upper teeth not meeting
lower teeth) that allows lateral escape of air and sound distortion
(called a "lateral lisp"). Depending upon the type and severity
of malocclusion, speech therapy might help some children with sibilant
distortions. The child, however, will need to consciously monitor his/her
speech in order to eliminate the distortion. As indicated above, most
young children tend not to do this. Following orthodontic treatment of the
underlying dental malocclusion, one might expect that children would
spontaneously self-correct sibilant distortions. This may or may not
occur. Obviously, the benefits of speech therapy should be greater
following orthodontic treatment.
Click here
to see current research project related to dental malocclusion
The following books provide both general information and specific techniques
that might be used to treat retained compensatory articulations, hypernasality
and/or nasal air emission, and dental-related sound distortions:
Golding-Kushner, K. Therapy Techniques for Cleft Palate Speech &
Related Disorders.
Kummer, A. Cleft Palate & Craniofacial Anomalies: Effects on
Speech and Resonance (Chapter 21).
Peterson-Falzone, S.,
Trost-Cardamone, J., Karnell, M., and Hardin-Jones, M. The
Clinician’s Guide to Treating Cleft Palate Speech.