Study Notes: Tutorial Treatment of Speech Sound Errors in Cleft Palate

Authors: Katelyn J. Kotlarek and Breanna I. Krueger
aUniversity of Wyoming, Laramie
Article History:
- Received: April 19, 2022
- Revised: July 19, 2022
- Accepted: September 27, 2022
Editor-in-Chief: Amanda J. Owen Van Horne
Editor: Katie Squires
DOI: https://doi.org/10.1044/2022_LSHSS-22-00071
Contact: kkotlare@uwyo.edu
Disclosure: No financial or nonfinancial interests were declared at publication time.

To provide a comprehensive tutorial for speech-language pathology assistants (SLPAs) on treatment techniques for children with cleft palate.
Cleft palate is a significant birth defect affecting around 7,000 newborns annually in the U.S.

Speech therapy is common among preschoolers with repaired cleft palate; 68% receive therapy.
Preschool and school-based speech-language pathologists (SLPs) express desire for professional development in cleft palate treatment.
The article details speech errors found in children with cleft palate, elicitation strategies for articulations, evidence-based treatment approaches, and indicators (“red flags”) necessitating SLP consultation.

SLPAs will learn elicitation techniques and implement evidence-based treatments to enhance speech accuracy in children with cleft palate.

Familiarity with speech therapy specifics regarding cleft palate is crucial for school-based clinicians.

Cleft lip/palate is the second most frequent birth defect in the U.S.
Typically repaired in newborns between the ages of 6-12 months.
Children often produce fewer consonants and avoid specific sounds, typically having a consonant inventory limited to nasal, glide, and glottal sounds before repair of the palate.

Post-surgery, children should gradually improve their consonant inventory and lexical skills because of the expected velopharyngeal closure.
Development of speech varies, with some children eventually needing therapy due to speech intelligibility issues despite repair success.
Children may reach developmentally appropriate speech by age 5, but only 60% do so per recent studies.

Obligatory Errors: These are anatomical errors where the correct production is impossible; e.g., a cleft or velopharyngeal scar preventing closure.
Learned Errors: Errors that occur because of compensatory behaviors following patterns of speech that develop due to prior anatomical issues; these are treatable through therapy.

Velopharyngeal insufficiency (VPI) can result from both anatomical issues requiring surgery and learned misarticulations requiring speech therapy.
Approximate prevalence: 37% of children post-repair experience VPI, leading to challenges in speech clarity.

Velopharyngeal Port: Space behind the soft palate, closed during speech production.
Velopharyngeal Closure: Critical for normal speech and swallowing; requires complete separation of oral and nasal cavities.
Hypernasality: Excessive nasal resonance during speech due to VPI.
Weak Pressure Consonants: Sounds produced with insufficient air pressure, often remedied only through surgical interventions.
Nasal Air Emission (NAE): Air leakage through the nose during speech, requiring differential diagnosis regarding cause.
Compensatory Articulations: Substitutions that represent adjustments made in response to structural deficits, like using a glottal stop instead of an oral stop.
Obligatory Speech Errors: Direct consequences of structural differences, non-stimulable for correction.
Learned Speech Errors: Errors that are correctable through instruction or practice.

Assessment:
- Differential diagnosis between obligatory and learned speech errors is vital for the treatment plan.
- Stimulability testing aids in this assessment, discerning whether an error is correctable.
Long-term Treatment Goals:
- Aim for intelligible, socially acceptable speech that aligns with age-appropriate norms by age 5.
- Acknowledge the role of both physical management of obligatory errors (surgery) and teaching strategies for learned errors.
Treatment Techniques:
- Articulatory Approaches: Use articulation-focused methods—targeting placement for sounds and employing shaping strategies.
- Phonological Approaches: Address making perceptual contrasts between similar sounds and correcting entire patterns of errors.
- Combine motor-based and phonological approaches based on individual patient needs.

Target anterior consonants since they are more visible.
Use nasal occlusion to assist children with airflow issues.
Renaming incorrect sounds with descriptors that differentiate them from correct productions.
Emphasize auditory and visual discrimination for children to recognize correct sound placement.
Provide correct placement feedback directly in therapy sessions, building complexity over time.

Lack of progress for multiple sessions prompts reevaluation of techniques or targets.
Introduction of new error patterns should be monitored and potentially modified in therapeutic strategies.
Signs indicating anatomical breakdown like emergence of new insufficiency or emergence of NAE (nasal air emission).

The use of nonspeech oral motor exercises (NSOMEs) is discredited as ineffective and may delay progress. Implementing strategies which lack robustness can be unethical as it impacts overall patient care.

The tutorial provides practical techniques and principles for SLPAs to improve the treatment of cleft palate-related speech sound errors effectively.
Emphasis on the importance of interdisciplinary collaboration and maintaining effective communication with supervising SLPs.

Include comprehensive references with details for each cited study and relevant literature for further reading.