|Timberly Buskill, 2, smiles for the camera after a training session with her mom.
Over the years, much has been written about the communication problems associated with cleft palate and the strategies that can be employed to remediate these problems. Traditionally, however, this information has focused on the articulation and resonance problems associated with velopharyngeal insufficiency in the preschool and school-age child. Although the first study of the presurgery and prelinguistic speech characteristics of babies with cleft palate was carried out in the 1960s (Olson, 1965), it was not until more than 20 years later that research focusing on this early stage of development began to appear in the literature (see O'Gara and Logemann, 1988; Grunwell & Russell, 1987, 1988).
From this work, we know that babies with cleft palate show deficits in the size and composition of their early sound inventories, may reach the canonical babbling stage later than their noncleft peers (Chapman, Hardin-Jones, Schulte, & Halter, 2001), and may exhibit less variety in the canonical forms produced (Scherer, Williams, & Proctor-Williams, under review). Further, these early deficits affect later speech accuracy and vocabulary size. Interestingly, it appears that even before the palate is closed, some babies are attempting to produce stop consonants, and these are the same babies that have better speech and language outcomes later on (Chapman, Hardin-Jones, & Halter, 2003).
The research reviewed above, along with reports of better speech outcomes with earlier palatal surgery (e.g., Hardin-Jones & Jones, 2005), have led some researchers to argue that closing the palate by 12 months and prior to the onset of the first words is not soon enough (e.g., Kemp-Fincham, Kuehn, & Trost-Cardamone, 1990). Rather, surgery should be conducted prior to the onset of canonical babbling (e.g., Hardin-Jones, Chapman, & Schulte, 2003).
While there are considerations other than optimal speech outcome (i.e., size of cleft) that continue to influence how early palatal surgery is performed, speech-language pathologists can do much to lessen the impact of clefting on the developing communication skills of infants and toddlers with cleft palate through early intervention (Blakeley & Brockman, 1995; Scherer, 2003; Scherer, & Brothers, 2002; Scherer & McGahey, 2004). The purpose of this article is to provide suggestions for intervention for babies with cleft palate prior to palatal closure and post palatal repair. We will describe specific goals as well as techniques that can be employed with this population of infants and young children.
Goals of Early Intervention
The goals of early intervention for the child with cleft palate are to increase: consonant inventory, especially pressure consonants; vocabulary; and oral airflow.
Increasing consonant inventories
Prior to surgical repair of the palatal cleft, consonant sounds that are least affected by the cleft (e.g., nasals, glides) are typically stimulated first. As with any other baby, intervention is typically carried out by parents through the introduction of simple babbling games. If the baby is producing stop consonants, these consonants can be reinforced as well but parents should be advised to ignore the nasal emission that accompanies them.
It's important, too, to avoid reinforcing laryngeal growls and glottal stops in these babies. This can be a tough assignment for parents who view growling as a cute behavior. Although the presence of these laryngeal productions is normal during prelinguistic development, the frequency of these productions is generally low and they tend to decrease over time for noncleft babies as the babbling repertoire expands and their expressive lexicon emerges.
For some babies with cleft palate, however, particularly those with an impoverished repertoire of consonant sounds, these laryngeal productions occur more frequently than expected and may not always resolve spontaneously. When these behaviors occur, it is best to simply ignore them and respond to the baby by modeling a more appropriate, desired vocalization.
Following palatal surgery, it is not uncommon to see a decrease in both the frequency and variety of a child's vocalizations for up to six weeks. After that time, the child should begin adding new consonants (particularly stops) to the inventory and expanding the expressive vocabulary. If not, these are appropriate goals for early intervention (see below).
Lack of growth in the child's phonetic inventory and/or the persistence of nasal substitutions or glottal stops are red flags that signal the need for careful monitoring and/or early intervention. Although the persistence of these atypical substitutions may be an early indicator of velopharyngeal dysfunction (VPD) for some children, it is important to recognize that they can persist as learned behaviors following palatal surgery for some children who have an adequate mechanism.
Clinical treatment for a toddler with a restricted consonant repertoire should never be deferred because of suspected VPD. An adequate assessment of the velopharyngeal mechanism cannot be performed immediately following surgery for these toddlers, nor can it be performed for older children who are making no attempt to produce pressure consonants. It is important to establish pressure consonants with these children so that the child's velopharyngeal (VP) mechanism can be evaluated as early as possible.
Some of the most challenging children with cleft palate seen by SLPs are children who demonstrate pervasive glottal/nasal substitutions and few if any pressure consonants. The persistence of these atypical substitutions and the lack of oral consonants generally exacerbate the perception of nasalization and lead many clinicians to infer that VPD exists.
Even if VPD does exist, the true severity of nasalization cannot be assessed until these atypical substitutions have been eliminated and pressure consonants are being produced. In addition, an imaging study cannot provide valid information about the functional potential of the VP mechanism at this time because the child is not producing consonants that require VP closure.
Many children with cleft palate who persist in using nasal and glottal substitutions following surgery have limited consonant inventories and vocabulary use. SLPs can serve these children best by increasing the variety of oral consonants in their repertoire before these atypical nasal and glottal substitutions become integrated into their developing phonological systems. In cases where glottal substitutions are pervasive, it may not be enough to simply increase the child's inventory of consonants. The glottal substitutions may have to be actively eliminated once the child can comply with more formal intervention techniques.
A common strategy used to eliminate glottal stops pairs voiceless consonants with whispered vowels to keep the glottis open and prevent a glottal stop from occurring (Peterson-Falzone, Trost-Cardamone, Karnell, & Hardin-Jones, 2006). The child is instructed to overaspirate the consonant-again to prevent the glottal stop from occurring. As the child demonstrates success with this whispered production, voicing is gradually reintroduced for the vowel.
Increasing consonant inventory and vocabulary simultaneously
For young children, it is often most efficacious to combine goals for expanding consonant inventory with vocabulary goals. Some considerations in choosing the words to teach children with small vocabularies are taken from words used first by typically developing children. Words must be both functional and fulfill a broad range of communicative purposes. Approximately one-half of early vocabularies are names for familiar people, toys, clothes, food, and social routines while the remaining half include words used to talk about the relations among objects, such as attributes (e.g., big, hot, dirty), possession (e.g., mine), action (e.g., throw, eat), and location of objects (e.g., up, on, in) (Nelson, 1973).
An additional consideration is the phonological shape and phonetic composition of the words to be taught. The words should use simple syllable structure (e.g., CV, CVC, and CVCV) and contain consonants in the child's consonant inventory. Most often these consonants include nasals, glides, and glottal fricatives. As the child's vocabulary expands, words with new sounds not in their consonant inventory can be added. For many children with clefts, words containing the stop consonant class of sounds are selected and words with fricatives are added later.
The relationship between sound inventory and vocabulary growth in early development is intertwined; vocabulary expansion provides opportunities to practice new sounds and increased sound inventories permit greater diversity of vocabulary. Intervention methods may focus on sound production directly or indirectly through vocabulary intervention. For young children with clefts, naturalistic methods of vocabulary intervention have been shown to be efficacious in facilitating increased consonant inventories and reducing glottal stop production (Scherer, 1999; Scherer & Kaiser, in press).
Focused stimulation and Enhanced Milieu Training (EMT) models have been implemented by clinicians and parents to facilitate both vocabulary and consonant inventory growth. These models both rely on use of modeling and child-centered strategies but EMT also includes prompts to support language production. These methods are particularly important for children in the earliest stages of speech and language acquisition when drill and practice methods are less effective. Further, these naturalistic methods have documented success when implemented by parents to augment traditional therapy and in rural settings where there are few SLPs. Additional methods that address sound inventory expansion directly include traditional articulation and phonological approaches (see Bernthal & Bankson, 2004).
Increasing awareness of oral airflow
In addition to increasing the child's expressive vocabulary and consonant inventory, the SLP may also need to increase some children's awareness of oral airflow. Simple blowing toys that offer low resistance can be used to demonstrate oral airflow, but they should be used sparingly and considered one of many strategies used to teach sound production. Be sure to always follow-up a blowing activity with a sound production activity. Although using a blow toy to demonstrate oral airflow is an appropriate task in therapy, the use of such toys to "exercise" or strengthen the palate musculature is not.
Why Not Oral Motor Exercises?
From the 1940s into the 1960s, a number of clinicians believed that nonspeech activities could be used to strengthen the VP mechanism and increase voluntary control for speech. Recommended activities during those years included blowing, sucking, whistling, and swallowing. These types of tasks were later discredited during the 1960s and 1970s because research failed to substantiate an improvement in velopharyngeal function (see Tomes, Kuehn, & Peterson-Falzone for an extensive review).
Although SLPs have known for years that these tasks offer little resistance to the velopharyngeal mechanism and thus cannot be used to strengthen the musculature, some clinicians continue to advocate for and recommend these activities to parents. This is an unfortunate waste of time and money. The typical child with cleft lip and palate does not have oral motor problems. These children have sound production problems that are best addressed using conventional articulation/phonological strategies or vocabulary approaches such as those described above that have been shown to improve speech production skills.
Intervention techniques for infants and toddlers with cleft palate include a variety of approaches depending on the age and linguistic level, and the profile of communicative strengths and weaknesses of the child. The techniques combine early language intervention methods with speech production strategies to facilitate place of articulation and oral airflow. Perhaps if we can dispel the assumption that "clefting does not affect speech until the onset of the first words" and begin intervening early and continue to advocate for early surgery, we will see less of an impact of clefting on communication skills of children with cleft palate.