Loretta Dunkmann MS CFYSLP Clefting is not about what happens it is about what does not happen Anatomy and Physiology Alveolar ridgeforms sulcus between hard palate and lip Hard palate formed by medial projections of the palatine process of the maxillary bonesuture at midline ID: 681238
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Slide1
Speech Therapy for students with Clefting
Loretta Dunkmann, MS, CFY-SLPSlide2
Clefting is not about what happens; it is about what does not happen.
Anatomy and Physiology Slide3
Alveolar
ridge—forms sulcus between hard palate and lip
Hard palate formed by medial projections of the palatine process of the maxillary bone—suture at midline
Palatine process is anterior ¾ of hard palate
Posterior ¼ paired palatine bonesSlide4Slide5Slide6Slide7Slide8
Types of Clefting: Slide9
AssessmentSlide10
Obtain Adequate Sample
Background Information
Important that surgeries are included…they play a role in resonance
Oral Mechanism Exam
A thorough exam may explain resonance issues
Standardized Assessment
For Qualification Reasons
Peripheral Speech Assessment
Connected Speech Sample
Hypernasality may only be noticed during connected speech
Specialized sampling contexts (sensitive to cleft type speech errors)
Handout attached Slide11
Oral Mechanism Exam
Note all the things you usually
note
Tonsils?
•Lip scars?
•Palate scars?
•High arched palate?
•Palatal Lift?
Malocclusion
? Slide12
Analyze Speech Sample
Rate Overall intelligibility
Document phonetic inventory
Document speech resonance
Document nasal air emission
Classify errors Slide13
Perceptual Assessment - Hypernasality
Too much nasal resonance
Causes:
Persisting VPI
Fistula
Intermittent suggests:
Sporadic closure of VP port
Assimilation nasality (affected by nearby nasal consonants)
Continuous suggests:
Physically based VP problem
Refer to Quick Check Slide14
Hyponasality/Cul
de sac Resonance
Hyponasality
: too little resonance
Could suggest:
Large adenoids
Obstructive pharyngeal flap
Intranasal airway obstruction
Recent Cold
Allergies
Cul-de-sac Resonance: “blind pouch” sound is trapped by the anterior nasal cavity constriction
Deviated septum Slide15
Airflow Direction – Nasal Emission
-
results from the abnormal coupling of oral and nasal cavities.
Airflow that normally is directed and emitted orally is allowed to escape into the nasal cavity and is emitted nasally.
- nasal
turbulence – audible nasal emission
“audible snorting”
“posterior nasal frication”
“nasal rustle”
Causes:
Obligatory: VPI and/or fistula
Learned: phoneme-specific nasal emission: affects production of certain high-pressure consonants while the remainder of the HPCs are produced correctly
Most vulnerable: sibilant fricatives and affricates /s, z/ “
sh
” “
zh
” “
ch
” “j”
Persisting postoperative nasal emissionSlide16
Therapy
Slide17
Collaboration
Get the parents to sign a release allowing you to communicate with their medical team.
“I
would like for school clinicians to feel that they are a part of the medical team, and for them to be in regular contact with the team SLP. They are the clinician closest to the child, who knows the child best and is in the child's day to day world. The team SLP is not. The team cannot provide optimal care without collaboration from the school or community SLP
.”
Share your evaluation report and IEP with the medical team.Slide18
For any neurologically normal child born with a cleft, the expectation is for
NORMAL SPEECHSlide19
Errors
Obligatory errors:
Errors that are caused by structural or neurogenic problems
Such as
Fistulas
VP insufficiency
These errors require physical management
Learned Errors
Habituated errors that are the result of early
mislearning
. They exist and persist in the context of adequate VP closure and required speech remediation.
AKA:
Maladaptive errors
Compensatory
misarticulations
Slide20
Purposes of Early Speech-Language Stimulation Program (Phillips, )
To develop the child’s confidence in ability to achieve intelligible verbal communication
To ally parental anxiety concerning the child’s development of verbal communication
To encourage development of communication skills to the maximum of the child’s potential
--Structural ability to produce consonants influences
early lexicon (
Willadsen
, 2013).
To minimize or prevent development of compensatory articulation and voice patterns
To determine velopharyngeal competence as early as
possibleSlide21
Encourage parents to respond to child with prolonged vowel sounds or front sounds as oppose to back noises.
No growling
No car noisesSlide22
Depending on extent of the cleft, child may selectively avoid the hard palate as a key articulator, preferring to produce sounds that do not require
linguapalatal
contacts.
Coupling of the nasal and oral cavities will impound intraoral air pressure resulting in distorted productions, avoiding productions of /b/ and /d/ during babbling
Chronic middle ear infections accompanying conductive hearing loss
All these factors can influence the sounds that the baby chooses to produce…therefore resulting in the compensatory techniques we work on correcting. Slide23
School Based Therapy
Errors we can work with
Maladaptive compensatory productions
Backed oral
productions
Pharyngeal stops, fricatives, affricates
Glottal stops
Nasal air emission
Obligatory errors we cannot correct:
Nasal emission and
hypernasality
caused by VPI
Nasal air loss caused by fistulas
Adaptive oral
misarticulations
resulting from structural abnormalities or severe malocclusions Slide24
School Based Therapy
When To Start:
Get these answers:
Understand child’s hearing status
Functional status of VP mechanism
Oral structural hazards to speech progress
Plans for ongoing team care
Frequency & Duration
Daily Basis…that would be awesome…but not realistic
Twice weekly
30 minutes sessions
Preferably 1:1
Supplement with daily speech homework/home practice programSlide25
School Based Therapy
Teaching Correct Oral Airflow
Blowing bubbles
Whistles
Blowing against cotton balls
Blowing through a straw
Nose pinching
**Note: these are not to be used as oral motor exercises, this is strictly to teach the student correct air flow movement. Slide26
School Based Therapy
Therapy Approach
Traditional Articulation Therapy
Isolation
Syllables
CV, VC, CVC, VCV
Words
Initial – medial – final
Phrases
Sentences
Reading Tasks
Lynn Marty-
Grames
recommends 100% accuracy at each level before progressing.
Resource
Eliciting Sounds
Techniques and Strategies for Clinicians – 2
nd
Edition
Wayne A. Secord (2007)Slide27
School Based Therapy
Target Sound Selection
Target errors that have the greatest impact on speech understandability and acceptability
This could mean going out of developmental sequence
Stimulability
Visibility
Place of production
Anterior sounds first
Manner
Fricatives will typically be easier than stopsSlide28
Children with clefts make a variety of articulation error types
•Not all errors are compensatory errors
•There are four speech sound categories in cleft palate speech, we will talk about these shortly.Slide29
If the child with a cleft needs braces, you
can
work on articulation, especially [s], until after orthodontics is completed
.
Most often, the error is the result of what the
tongue
is doing, not the position of the teeth.
•Diagnostic therapy should always be attempted
.
Certain orthodontic appliances may complicate speech therapy, depending on what you are working on. Slide30
VPISlide31
If the child has velopharyngeal dysfunction, you can’t work on articulation until after surgery
.
VPD alters airflow, not articulatory function.
While some children develop maladaptive patterns, not all do. Slide32
What could articulation therapy do?
It may show us that velopharyngeal management is not needed
.
It may prepare the child for valid imaging studies.
•It will make the child’s speech more intelligible.
It’s possible to have completely normal articulation and still be
hypernasal
.
•In some cases, articulation therapy must take place before velopharyngeal imaging
.
Refer to a cleft team speech pathologist with a velopharyngeal imaging lab instead! Slide33
Delaying articulation therapy delays speech normalization.
•The better the articulation, the better the intelligibility after VP
management
If the
velopharynx
is dysfunctional, it will be dysfunctional across the phoneme spectrum
If only a certain few sounds come out the nose, and the others don’t….
•It probably is an articulation problem……your problem!
Mild forms of VPI may only manifest in the complexity of conversation
•Sometimes, the
velopharynx
can push closed for short utterances, but can’t sustain over time.