Cleft Palate Speech

Assessment and Intervention

Sara Howard, Anette Lohmander, Sara Howard, Anette Lohmander

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9780470743300
• eBook ISBN: 9781119970644
• Edition: 1
• Topic: Medicine
• Subtopic: Audiology & Speech Pathology

The focus of this book is on speech production and speech processing associated with cleft palate, covering phonetic (perceptual and instrumental), phonological and psycholinguistic perspectives, and including coverage of implications for literacy and education, as well as cross-linguistic differences. It draws together a group of international experts in the fields of cleft lip and palate and speech science to provide an up-to-date and in-depth account of the nature of speech production, and the processes and current evidence base of assessment and intervention for speech associated with cleft palate. The consequences of speech disorders associated with cleft on intelligibility and communicative participation are also covered. This book will provide a solid theoretical foundation and a valuable clinical resource for students of speech-language pathology, for practising speech-language pathologists, and for others interested in speech production in cleft palate, including researchers and members of multi-disciplinary cleft teams who wish to know more about the nature of speech difficulties associated with a cleft palate.

Part One: Speech Production and Development

Sara Howard¹ and Anette Lohmander²

¹ University of Sheffield, Department of Human Communication Sciences, Sheffield, S10 2TA, UK

² Karolinska Institutet, Department of Clinical Science, Intervention and Technique, Division of Speech and Language Pathology, SE 141 86, Stockholm, Sweden

In this book we examine the nature and impact of speech difficulties associated with cleft. As with all developmental speech impairments, cleft speech problems have experienced a significant broadening of perspective over the last century. Following a long period when all children’s speech difficulties were seen as articulatory in origin, and as being wholly interpretable through a medical model (Macbeth, 1967), there has been a gradual but welcome transformation to the current position, where much more emphasis is placed on other potential areas of difficulty (including phonology, language, literacy and interpersonal communication and interaction, as well as psychological and psychosocial implications). Developmental speech impairment is thus now situated within a social context. This fits comfortably with developments over the last decade or so, which have sought to classify and consider speech, language and communication impairments using the ICF (the International Classification of Function, Disability and Health; WHO (World Health Organization), 2001). In this book we use the ICF throughout as a point of reference.

Even a glance at the structure and headings used by the ICF indicates how useful it can be for extending our understanding of the possible impact of a communication impairment associated with cleft palate. There are two main parts (‘Functioning and Disability’ and ‘Contextual Factor’) with subcomponents which include, for the former, Body Structures, Body Functions, and Activity and Participation, and for the latter, Environmental Factors and Personal Factors. Such is the value of this framework that in the United Kingdom the Royal College of Speech and Language Therapists, in its manual on commissioning and planning services for cleft palate and velopharyngeal impairment (VPI), provides a detailed description of the impact of a cleft which relates specifically to the ICF classification (RCSLT (Royal College of Speech and Language Therapists), 2009). The ICF provides what McLeod (2006) describes as as ‘biopsychosocial view of health’ and, thus, of communication impairment.

It is noteworthy, of course, that unlike many types of developmental speech impairment, cleft speech problems do, indeed, have a physical basis, and thus the ICF subcomponent Body Structures is relevant in a way which is not the case for most children with speech difficulties. Thus, we need to understand what the anatomical and functional constraints on speech production are likely to be, as well as being aware of how physical structure and function are likely to be affected, over the lifespan, and over the course of speech and language development, by surgical intervention. Chapters in the following section consider each of these issues and also reflect on current evidence for different methods of assessment and intervention. The ways in which speech development for a child with a cleft palate are likely to be similar to and different from speech development in children without a cleft is clearly a hugely important area, which is also addressed in this section.

To make clinical, diagnostic decisions and to plan effective intervention, we need to be able to distinguish between speech difficulties directly attributable to the cleft and its consequences (including the likelihood of hearing impairment), and the coexistence of more general phonological delay or disorder. Such diagnosis can only take place if we have detailed information about the typical course(s) of speech and language development for children with a cleft. The ICF component ‘Body Functions’ is relevant here, including, as it does, intellectual and cognitive function, and temperament and personality, as well as specific aspects of speech production, including articulation, voice, fluency and also hearing (McLeod and Bleile, 2004).

In seeking a wider, more holistic perspective on the impact of a speech impairment, the ICF can also help us to understand the effects of a cleft on a child’s ability to participate more broadly in social interaction, across different contexts, including vital areas such as education, family and social life. The ICF components remind us that a communication impairment is not just the property of an individual, but is constantly negotiated between different individuals, in different contexts: a child’s intelligibility, for example, will differ depending on when, why, where and with whom they are talking. As the title of McCormack et al.’s article (2010) eloquently puts it ‘My speech problem, your listening problem and my frustration …’. Later chapters in this book deal in detail with intelligibility and with the child’s ability to participate in society through effective use of communicate.

The second of the main parts of the ICF, Contextual Factors, encourages us to consider the impact of a cleft palate and cleft speech difficulties in terms of the systems, policies, services and attitudes existing in a particular society, country or culture that will exert an influence on the support a child is likely to receive. Taking this perspective, one can quickly see how the impact of a cleft could be very different in the developed versus developing (minority versus majority) world, where infrastructure and attitudes may differ significantly. One of the chapters in the following section addresses this important issue. Personal factors, such as age, gender, race, character and general psychological resilience and well-being, will also need to be taken into account when considering the impact of a cleft. Some children with severe speech disorders will nevertheless prove remarkably resilient in the face of their difficulties, whereas others may need specific help to adapt to even mild speech problems (Nash, 2006).

The ICF, then, provides us with a framework which can extend our thinking about the impact of a speech impairment associated with cleft palate and encourage us to take a more holistic view of individuals thus affected (Ma, Threats and Worrall, 2008). The material we cover in this book endeavours to do just that.

References

Ma, E.P.-M., Threats, T. and Worrall, L. (2008) An introduction to the International Classification of Functioning, Disability and Health (ICF) for speech-language pathology: its past, present and future. International Journal of Speech-Language Pathology, 10, 2–8.

Macbeth, E. (1967) Speech therapy as a paramedical subject. British Journal of Disorders of Communication, 2, 69–72.

McCormack, J., McLeod, S., McAllister, L. and Harrison, L. (2010) My speech problem, your listening problem, and my frustration: the experience of living with childhood speech impairment. Language, Speech, and Hearing Services in Schools, 41, 379–392.

McLeod, S. (2006) An holistic view of a child with unintelligible speech: insights from the ICF and ICF-CY. Advances in Speech-Language Pathology, 8, 293–315.

McLeod, S. and Bleile, K. (2004) The ICF: a framework for setting goals for children with speech impairment. Child Language, Teaching and Therapy, 20, 199–219.

Nash, P. (2006) The assessment and management of psychosocial aspects of reading and language impairments, Dyslexia, Speech and Language: A Practitioner’s Handbook, 2nd edn (eds M. Snowling and J. Stackhouse), John Wiley & Sons Ltd, pp. 278–301. Chapter 13.

RCSLT (Royal College of Speech and Language Therapists) (2009) RCSLT Resource Manual for Commissioning and Planning Services for SLCS: Cleft Lip/Palate and Velopharyngeal Impairment, RCSLT, London.

WHO (World Health Organization) (2001) ICF: International Classification of Functioning, Disability and Health, WHO, Geneva, Switzerland.

1

Physical Structure and Function and Speech Production Associated with Cleft Palate

Martin Atkinson¹ and Sara Howard²

¹ University of Sheffield, School of Clinical Dentistry, Sheffield, S10 2TA, UK

² University of Sheffield, Department of Human Communication Sciences, Sheffield, S10 2TA, UK

1.1 Introduction

Speakers with a cleft lip and/or palate contend with unusual structure and function of the vocal organs from birth and physical abnormalities may persist after surgical intervention. (Surgery itself, for many individuals with a cleft, consists of a series of interventions over an extended period, so both structural and functional changes to the speech apparatus may be a feature of the entire period of speech development). These differences and changes may have a profound effect on speech production and speech development, and cleft lip and palate is one area where a significant proportion of the speech difficulties encountered (although not necessarily all) can be traced back in some way to an anatomical or physiological cause. This chapter explores some of the links between atypical vocal organ structure and function in cleft lip and palate, and those many and varied features encountered in speech production associated with cleft palate. Of course, some of these issues are also dealt with in other chapters in this book (Chapters 3, 5, 8, 10, 11 and 12), so the reader is directed, where appropriate, to seek further information from these chapters; this chapter, therefore, focuses on those issues not discussed elsewhere in the book. More detailed accounts of the physical structures and functions associated with speech production can be found in Atkinson and White (1992) and Atkinson and McHanwell (2002).

1.2 The Hard and Soft Palates and the Velopharynx

1.2.1 Anatomy of the Hard and Soft Plate

The palate comprises the rigid bony hard palate anteriorly and the mobile muscular soft plate (velum) posteriorly. The shape of the hard plate is variable but is usually a concave dome. However it may take on a V-shape with the apex superiorly, which narrows the hard palate. This configuration of the hard palate often accompanies a class II malocclusion (Section1.5.1); as the upper dental arch is narrowed the posterior teeth cannot align along a curved dental arch but follow the V-shape, pushing the anterior teeth forward. The bony plate is formed from components of two pairs of bones; the palatine plates of the maxilla form the anterior two thirds and the horizontal plates of the palatine bones form the remainder. The bones are joined at sutures. A midline suture marks the line of fusion of the two halves of the palate during palatogenesis and terminates anteriorly at the incisive foramen, another landmark relating to the development of the palate. The sutures are, of course, covered in life by the mucosa lining the mouth. However, the site of the incisive foramen is marked by a small incisive papilla visible just behind the central incisor teeth.

The soft palate extends from the posterior border of the hard palate. Four pairs of muscles form the soft palate (Figure 1.1). The tensor veli palatini tenses the velum by exerting a lateral force; these muscles are tendinous within the soft palate and the other muscles are attached to the tendons. The levator veli palatini raises the soft palate. Note that the tensor and levator palatini attach to the Eustachian tube and open it when the velum is raised or tensed, so that fluid drains from the middle ear cavity and air pressure is equalised on the either side of the e...

Table of contents

• Cover
• Title page
• Copyright page
• List of Contributors
• Preface
• Part One: Speech Production and Development
• Part Two: Speech Assessment and Intervention
• Index