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This article details speech characteristics in children with cleft palate.

Contents 1 Cleft palate 2 Terminology 2.1 Manner 2.2 Place 3 Speech Characteristics before surgical repair of the palate 4 Repair of the palate and post surgical speech outcomes 4.1 When is the best time to get surgery for my child? 4.2 What immediate affects will the surgery have on my child’s speech? 4.3 Will my child show normal speech development after palatal repair? 5 Treatment Considerations 6 References

There is no doubt that cleft palate cases are complex. Children with cleft lip and palate face not only an insufficient mechanism, but also chronic interference of middle ear infections. Looking at these two factors alone, children affected by clefting should be considered at risk for speech and language delay. In addition to these issues, other considerations must be taken into account when considering future speech and language outcomes. Some of these factors include: cleft type, severity of the cleft, age of palatoplasty, palatoplasty technique, the possible need for secondary surgical management, therapy vs. no therapy, appropriate stimulation by family, and cognitive function. Even after all the factors are explored it doesn’t necessarily mean the result will be normal speech production (O’Gara, Logemann, Rademaker, 1994). Children with cleft palate do begin to show improvements in speech sound development as a result of surgical intervention. However, acquisition of age-appropriate speech is not achieved immediately or quickly for many of these children (Chapman, Hardin-Jones, Halter, 2003). In order to develop a better idea of what speech outcomes can and should be expected after palatal surgery it is also important to investigate speech development of these children before surgery has taken place.

• Palatoplasty - surgery on the palate

• Phonetic inventory - sounds child can produce

• Consonant inventories - letters child can produce

• Phonemes - sounds letters produce (examples: the sound b as in boy)

• Phonological process – a learned rule used across a class of sounds (example: producing stops for fricatives)

• Backing- producing front sounds in the back of the mouth

• Nasal assimilation – producing oral sounds as nasals

• Velopharyngeal function – the ability of the velum and pharynx to close off your nasal passage for the production of oral sounds and other functions

• Manner

• Place

Manner is the way a sound is produced.

• Nasals - n, m, ng

• Glides - l, r

• Liquids - y, w

• Oral sounds - any sound produced when air flow is through the mouth

• Oral Stops - sounds produced that airflow cannot be sustained, p, b, t, d, k, g

• Oral fricatives - sounds produced that airflow can be sustained f, v, th, s, z, sh, h

• Glottal fricatives - h

Place refers to the place in the mouth where a sound is produced (examples: alveolar, palatal, velar, labial, etc.)

• Alveolar sounds - t, d, l, n, s, z

• Palatal sounds - sh, y, ch

• Velar sounds - k, g, ng

• Glottal place - sounds produced with the glottis

• Labials - p, b, m

Studies of phonetic development of babies during the first year of life have showed a greater number of nasals, glides, and glottal fricatives and fewer oral stops in early phonetic inventories. A preference has also been shown for the glottal and labial place of articulation. The avoidance of alveolar and palatal' sounds could be in part due to reduced palatal surface available for lingual contact. This can especially be noted in babies with wide palatal clefts. The decreased ability to produce oral stops is particularly of concern as oral stops are some of the first sounds to emerge in a baby’s inventory. The limitations in manner and place listed above can lead to severely decreased consonant inventories. Whether surgical repair of the palate is performed or not, if velopharyngeal function cannot be achieved chances are high that the child will continue to experience speech difficulties. At the least, children with unrepaired cleft palate will show restrictions in the variety and frequency of consonants produced during babbling (Chapman, Hardin-Jones, Schulte, Halter, 2001). Not only may children with unrepaired cleft palate show speech production deficits early on, they may also receive less feedback from parents for communicative attempts due to fewer instances of babbling for parents to respond to. This in turn can also impact lexical development. Understanding the relationship between early vocal behavior and later speech and language skills can prove important for understanding how early deficits influence later speech and language development. As a result, this knowledge can be used to guide early treatment decisions and programs for children with cleft palate (Chapman, et al., 2003).

There are many methods surgeons use in order to effectively repair a palatal cleft. Regardless of the method chosen, as there are many, the most important consideration is what will provide the best outcomes for each individual child. It is important to remember that each cleft palate case is highly variable and each child’s individual characteristics need to be considered.

Children with palatal repair prior to onset of speech show significantly better speech results than those repaired between 12 and 27 months of age. Earlier palatal repair may lead to more normal speech development and less compensatory articulation patterns compared to later palatal repair (>12 month at time of surgery) (Dorf & Curtin,1982). Earlier surgical repair may also help to further develop what would normally be difficult speech sounds for children with unrepaired cleft palate. In fact children repaired by 18 months of age show: decrease in glottal place, glottal stops, and glottal fricatives with a steady increase in palatal, alveolar and velar places, and oral fricatives (O’Gara & Logemann, 1988). However some research suggests that age of palatal repair is not a significant factor in determining speech development (O’Gara, 1994). In order to achieve the best speech potential and normal development for the child considering the child’s phonemic development rather than chronological age alone for timing of the initial palatal repair may prove most helpful.

Early post-surgery children show a significant decrease in phonetic inventories. However, as early as 6-8 weeks after surgery, improvements can be seen in consonant acquisition with a significant increase in the number of different consonant produced. The majority of the children show increases in production of front sounds (labials/velars), a decrease in the production of posterior sounds, and a beginning of production of oral stops. Although palatoplasty affects speech output for a short time, recovery to presurgery levels and toward more normal development occurred rather quickly. In spite of a quick recovery delay of speech may still be present (Grunwell & Russell, 1987 & 1988).

After surgery cleft children have more errors overall, but are similar to non-cleft peers in phonological process use with the exception of backing and nasal assimilation. Cleft children are comparable in number and types of phonemes present in their consonant inventories, but the accuracy of production of manner categories differs. Cleft children are less accurate with nasals and liquids (Chapman & Hardin, 1992).

The production of oral stops doubles from the time before surgery to the time after surgery. Overall children with cleft palate make gains after surgery in production of canonical syllables and size of consonant inventory; however deficits in production of stops and alveolar place features may still be present. Specifically children with cleft palate tend to show smaller consonant inventories and produce fewer oral stops in their utterances. This reinforces the idea that early deficits impact later speech development. Twelve months may not be early enough to achieve the best speech outcome (Jones, Chapman, Hardin-Jones, 2003). True stop production is related to later vocabulary development and true consonant inventory is related to all measures of speech production. There is much variability in individual children regarding speech proficiency. Some may show great improvement after surgery while others don’t. It is important to evaluate each child separately to determine prognosis and outcomes of speech development after palatal surgery (Chapman et al., 2003).

Speech-language pathologists assessing and treating persons with cleft palate have an important job to do in speech development, remediation, and providing the interdisciplinary team with information that leads to appropriate and timely decisions in regards to physical management (Kuehn & Moller, 2000).

Some important considerations to keep in mind when working with children with cleft palate include:

1. When evaluating be sure to include whether or not the sound inventories contain stops and other true consonants
2. These sounds should be targeted early in treatment as the ability to produce them early on can affect later speech development
3. Therapy goals should focus not only on acquisition of new words, but also the acquisition of new sounds. These recommendations should help to improve the child’s speech development and also facilitate production of intelligible words (Chapman et al., 2003).

• Chapman, K.L.; Hardin, M.A. (1992). Phonetic and phonologic skills of two-year-olds with cleft palate. Cleft Palate Craniofacial Journal, 29(5), 435-443.
• Chapman, K.L.; Hardin-Jones, M.; Schulte, J.; Halter, K.A. (2001). Vocal development of 9-month-old babies with cleft palate. Journal of Speech, Language, and Hearing Research, 44, 1268-1283.
• Chapman, K.L.; Hardin-Jones, M.; Halter, K.A. (2003). The relationship between early speech and later speech and language performance for children with cleft lip and palate. Clinical Linguistics and Phonetics, 17(3), 173-197.
• Dorf, D.S.; Curtin, J.W. (1982). Early cleft palate repair and speech outcome. Plastic and Reconstructive Surgery, 70(1), 74-81.
• Grunwell, P.; Russel, J. (1987). Vocalizations before and after cleft palate surgery: a pilot study. British Journal of Disorders of Communication, 22, 1-17.
• Grunwell, P.; Russel, J. (1988). Phonological development in children with cleft lip and palate. Clinical Linguistics and Phonetics, 2, 75-95.
• Jones, C.E.; Chapman, K.L.; Hardin-Jones, M.A. (2003). Speech development of children with cleft palate before and after palatal surgery. Cleft Palate Craniofacial Journal, 40(1), 19-31.
• Kuehn, D. P.; Moller, K.T. (2000). Speech and language issues in the cleft palate population: the state of the art. Cleft Palate Craniofacial Journal, 37(4), 348:1 – 348:35.
• O’Gara, M.M; Logemann, J.A. (1988). Phonetic analysis of the speech development of babies with cleft palate. Cleft Palate Craniofacial Journal, 25, 122-134.
• O’Gara, M.M.; Logemann, J.A.; Rademaker, A.W. (1994). Phonetic features by babies with unilateral cleft lip and palate. Cleft Palate Craniofacial Journal, 31(6), 446-451.