Speech Therapy for students with Clefting - PowerPoint Presentation

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 bonesSlide4
Slide5
Slide6
Slide7
Slide8

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.