Published: June 20, 2007
Updated: June 20, 2007
The speech/language pathologist is the specialist on the cleft palate team who evaluates speech, language, and soft palate functioning. As the child grows older, speech and language are evaluated according to developmental status. After surgery has taken place, the child's speech will be evaluated as well. If needed, recommendations for treatment, including speech therapy or additional surgery, will be made.
As your child begins to make intelligible sounds the "first words" will be noted, and the number of words and phrasing will be evaluated. Another thing listened for as speech develops is articulation. We will note the movement of the structures of the mouth to make speech sounds. The lower jaw, teeth, tongue, lips, hard palate, and soft palate (velum) all participate to make speech sounds. When soft palate movement is inadequate and speech inappropriately escapes into the nose, hyper-nasality and nasal air emission result. We will also carefully observe your child's speech adaptations to the structural changes made by the plastic surgeon and orthodontist.
Our goal is age-normal speech by the time your child enters kindergarten. This is usually a reasonable goal, unless there are some complications in addition to cleft palate that are affecting speech. Early identification and treatment of speech disorders is important if this goal is to be realized. This requires consistent cleft palate team follow-up of your child.
In order to understand the issues concerning speech and hearing in your child with a cleft, it is important to understand some basics about language.
Language is the system of rules by which understanding and expression of meaning takes place. You might say that we learn language through a sort of "building blocks" approach: First children make general sounds, then they try to make sounds which approximate speech sounds, then they actually make speech sounds. After we put some of these sounds together to form a few words, we have the foundation to start learning sentences, which will ultimately provide the foundation for learning written language. In children with clefts, the development of verbal language can be hindered because of mechanical and anatomical differences in the vocal apparatus. If the children do not learn to make the same sounds as other children, it means they are starting with a different set of building blocks! Our job is to make sure that your child with a cleft is able to build the same linguistic skills as other children. You, your family, and other caretakers will also play important roles as models in helping this process along; because it is your voices to which your youngster will be closely listening as he or she learns to speak.
Children who do not receive adequate amounts of repetitive modeling may have difficulty developing language skills such as vocabulary, concepts, and grammar. Their speech may develop slowly, or they may not learn certain skills simply because they are not exposed to them. There are a few things that you can do to improve your abilities as a speech model for your child: Use short sentences when speaking to your child. Avoid over-doing "baby talk" because it does not provide the normal model speech and language examples that the child needs.
Speech is learned in the first few years of life. Normal speech depends not only on modeling, but also on good hearing, adequate mental functioning, and normal vocal anatomy. Of all of these factors, the one you will personally have the most control over will be modeling. Your cleft palate team will help to make normal speech mechanically possible, but they cannot do much about modeling. That is up to you and your family; and you should take special pride in that area as your child develops.
Practice for normal speech begins during the first year of life and continues over the next several years. Normal speech develops in a somewhat orderly fashion from sounds that are easiest to make (vowels) to sounds that require more coordination (s, r, th, st, and str).
Children will learn "object" words first and it is a good idea to name and talk about the objects in your child's environment. This includes the names of people, toys food, eating utensils, and furniture. Take advantage of trips to the store or to relatives to name and talk about new objects. Between the first and second year, "action" and "description" words begin taking on importance. When your child begins to show interest in books, a good starting place is to talk about the pictures. Take turns naming the objects and talking about what is happening in the pictures.
Normal speech consists of approximately 46 sounds. Three of these sounds emanate from the nose (nasal sounds), and approximately forty-three sounds emanate from the mouth (oral sounds). The nasal sounds are M,N, and NG. The remaining consonants and vowels are the oral sounds. Most of the consonants require pressure to be built up in the mouth. This pressure is then released (such as in the sounds P, T, or K) or it is constricted (such as in the sounds S, F, or TH.
Hyper-nasality is the resonance that we hear when voice is allowed into the nose for those sounds that should not have nasal resonance.
Hypo-nasality is the resonance that we hear when voice is not allowed into the nose for the three nasal sounds.
Glottal stops, pharyngeal fricatives, and posterior nasal fricatives are unusual sounds that are peculiar to children with cleft palate who still have speech escaping into the nose. These unusual articulation errors result when children try to stop sound from getting into the nose. These sounds are not otherwise heard in English, thus their unusual quality.
A combination of hyper-nasality and these unusual articulation errors are sometimes referred to as cleft palate speech.
The oral sounds emanate from the mouth by closure of the velopharyngeal valve (that is, the soft palate and the pharyngeal muscles). Figures A and B demonstrate the relationship of the oral and nasal cavities and normal velopharyngeal opening and closing.
The hard palate is the bony roof of the front of the mouth. It separates the nasal and oral cavities. The soft palate (or velum) is the muscular part of the roof of the mouth in the back of the throat. The soft palate is like a muscular door, the pharyngeal wall is the door jamb, and the nasopharynx is the doorway. In a condition known as of velopharyngeal competence (when these mechanisms are working properly), the velum opens the doorway for the nasal speech sounds and closes the doorway for the oral speech sounds. We refer to a condition as of velopharyngeal incompetence when the soft palate does not successfully close off the nose for the oral sounds. The hyper-nasality and the nasal air escape often associated with clefts are usually the result of velopharyngeal incompetence.
Speech problems are usually divided into two categories, hyper-nasality, and articulation problems. Either of these can make speech noticeably different from those of other children the same age and can make speech difficult to understand. Some of these speech problems may be caused by a structural defect that may require surgery, prosthodontics, or orthodontic treatment. For example, some problems may be related to a small opening remaining in the hard palate that allows speech to escape into the nasal cavity.
This may be covered by a dental appliance or closing the opening may require additional surgery. Some speech problems may be the result of poorly learned or incorrectly learned speech habits. These will require speech therapy. Speech therapy may be provided by the speech therapist on the cleft palate team, at a clinic in your home community, or in school. Evaluation by the speech pathologist will determine the cause of any speech problems. In almost all cases, these problems can be managed through the combined efforts of the plastic surgeon, the orthodontist. and the speech pathologist.
Before a cleft palate is repaired, there is an opening between the oral and nasal cavities. Speech enters the nose through this opening. Although nasal sounds (m, n, and ng) sound normal, the oral speech sounds are distorted by too much nasal resonance (hyper-nasality) and the inability to build up pressure in the mouth. The child should be encouraged to use words that have nasal sounds such as "mamma." Unfortunately, the child will be unable to say "dada," since this word has oral pressure sounds. The cleft of the palate will have to be closed in order for your child to have normal speech. The closure of the cleft will depend on the size of the cleft, the health of the child, and the level of speech development.
After the cleft is closed, you will be instructed about how to encourage your child to make sounds that will help the muscles in the soft palate begin to function. Most children have normal soft palate function after the cleft is closed. A small percentage will not and will need a second surgery. The speech pathologist will evaluate your child's speech and soft palate function to make this determination.
Correcting this soft palate deficit, when required, often involves the combined skills of the plastic surgeon, orthodontist, and speech pathologist. The structure and function of the soft palate are evaluated by visual examination, videofluoroscopy (motion x-ray pictures), special fiber-optic scopes, and computerized instruments. These studies determine which procedures are used to correct the deficit.
Figure A (arrow) illustrates an abnormal velopharyngeal opening because of a short soft palate causing hyper-nasality and speech distortions. After careful evaluation it was determined that adding a ridge of muscle at the proper height on the posterior pharyngeal wall would allow the soft palate to make closure. Figure B (asterisks) shows how this surgical procedure resolved the hyper-nasality and speech distortions.
The outlook for good speech and language is bright. The combined efforts of caring specialists and cooperative families can help the child achieve normal speech and language -- the goal of cleft palate team treatment.