• 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.

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).

• Compensatory Articulation Errors Related To Cleft Palate. For reasons not completely understood, some children with repaired 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 with the back of the tongue rather than in the mouth with the front of the tongue (called a "pharyngeal fricative" substitution) or even snorting air through the nose for /s/ (sometimes called a "nasal fricative"). Compensatory errors such as glottal stops and/or pharyngeal fricatives can make a child's speech quite unintelligible if used frequently.

    

     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]. 

• 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., VPI due to a structural problem). Surgery, not speech therapy, is needed to correct this condition.

    

     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.

• 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, air must flow over the tongue and strike the front teeth. This causes the air to become turbulent (a hissing-like sound).  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"). Zajac et al. (2012) has also reported that collapsed upper dental arches are associated with backing of sounds such as /t/ and /d/. Depending upon the type and severity of malocclusion, speech therapy might help some children with sibilant distortions or backing errors. The child, however, will need to consciously monitor his/her speech in order to eliminate the error. 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 and/or backing errors. This may or may not occur. Obviously, the benefits of speech therapy should be greater following orthodontic treatment.

       

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, 3^rd 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.