Opening the Toolbox for Cleft Palate–Related Speech Disorders Two cleft palate experts, Angela Dixon and Kristen DeLuca, discussed treatment principles and case studies in a recent ASHA online chat. The Leader listened in. Overheard
Overheard  |   September 01, 2016
Opening the Toolbox for Cleft Palate–Related Speech Disorders
Author Notes
  • Kristen Deluca, MS, CCC-SLP, works in the craniofacial program at Joe DiMaggio Children’s Hospital in Hollywood, Florida. She is an affiliate of ASHA Special Interest Group 5, Craniofacial and Velopharyngeal Disorders.
    Kristen Deluca, MS, CCC-SLP, works in the craniofacial program at Joe DiMaggio Children’s Hospital in Hollywood, Florida. She is an affiliate of ASHA Special Interest Group 5, Craniofacial and Velopharyngeal Disorders.×
  • Angela Dixon, MA, CCC-SLP, works on the cleft-palate team at Riley Hospital for Children in Indianapolis. She is an affiliate of SIG 5.
    Angela Dixon, MA, CCC-SLP, works on the cleft-palate team at Riley Hospital for Children in Indianapolis. She is an affiliate of SIG 5.×
Article Information
Speech, Voice & Prosodic Disorders / Special Populations / Genetic & Congenital Disorders / ASHA News & Member Stories / Overheard
Overheard   |   September 01, 2016
Opening the Toolbox for Cleft Palate–Related Speech Disorders
The ASHA Leader, September 2016, Vol. 21, online only. doi:10.1044/
The ASHA Leader, September 2016, Vol. 21, online only. doi:10.1044/
Participant: How do you teach a child to produce a pressure consonant when they only have nasal phonemes in their phonetic inventory?
Angela Dixon: Often you can shape from the nasal phoneme to an oral phoneme. For example, I’ll have the child produce an /n/ and nasal occlusion will often stimulate the /d/. Or you can go from an /m/ to a /b/ as well.
Kristen DeLuca: I like to use a child’s strength to teach their weaknesses. You can also use an /ing/ with nasal occlusion to obtain velar production. As soon as they are able to produce an oral phoneme with nasal occlusion, attempt to wean from nasal occlusion. If they don’t have adequate velopharyngeal (VP) function however, they will often rely on the occlusion until the anatomy is corrected.
Dixon: Good point, Kristen! You would want to make sure that adequate VP function had been determined as well.
Participant: How do I move from child producing air-pressure consonants with occlusion to without?
DeLuca: In my therapy, I will often “pretend” to occlude the nares. This gives the child a tactile cue, but I’m not occluding the nares.
Dixon: I agree! The tactile cue can still be very helpful and you can fade it out gradually. You can also use other types of cues to encourage oral production—I will use a tissue in front of the mouth and watch for it to move with a /p/ sound. Try to feel the air from the mouth, or listen to the air through a straw.
Participant: What is a realistic therapy goal for a child with hypernasality and nasal emission?
DeLuca: Generally, hypernasality and nasal emission are suggestive of a structural deficit. I would refer to a craniofacial team or SLP experienced with this population to determine if, in fact, these characteristics are due to velopharyngeal insufficiency. These are considered obligatory errors and will not correct through speech therapy alone.
Dixon: I completely agree and would reiterate that the referral should be made to a craniofacial team to help make that judgment of VP function.
Participant: What should a school or early intervention therapist do when they suspect a child may have a structural problem underlying their speech difficulty?
DeLuca: Try your best to educate the family and refer to a craniofacial team or SLP. I always recommend sending them to a craniofacial team versus an independent ENT. It’s important that this child is evaluated by a trained SLP who truly understands the speech mechanism. If the child presents with CMAs [compensatory misarticulations] or disordered articulation, it’s appropriate for you to treat the articulation errors to change the function of his speech.
Dixon: If you don’t know of any teams in your area, you can find a directory on the Cleft Palate Foundation website or by calling 1-800-24-CLEFT. In general, pervasive hypernasality and nasal air emission suggest a structural problem, but it can be tricky to differentiate, so the team referral would be important.
Participant: I recently discontinued a 10-year-old student from my school caseload who continued to present with hypernasality post-surgery, but who demonstrated correct “articulatory placement” (i.e., except for velopharyngeal insufficiency, from what I could tell in an OME [oral-motor exercise]) for all phonemes. Before doing so, I urged his parents to take him back to the local cleft clinic team and to have him scoped to view his velar movement and confirm my observations. They did so and confirmed my observations. Might the cleft clinic team decide to wait until the student is older before doing follow-up surgeries? What are some of the pros and cons to waiting until the child is older (other than the extended period of habitualized low-velar movement)?
Dixon: My team might wait if the child was to undergo any medical/surgical procedures in the near future that might impact the plan of care. The biggest con I can think of in children would be the potential to develop compensatory misarticulation errors; however, by age 10, I would hope that wouldn’t be the case.
DeLuca: What were the team’s recommendations?
Participant: They had no articulation or resonance recommendations. They did have some behavior suggestions to help him gain confidence, which I can informally work with the teacher to support.
DeLuca: I would encourage you to reach out to the team SLP to discuss his case! It’s important to collaborate together to best plan his care. I love when the treating therapists reach out to me. It’s extremely helpful.
Dixon: Do you know if there was any reason as to why the team didn’t recommend surgical intervention if a VPI [velopharanyngeal insufficiency] diagnosis was confirmed?
Participant: I believe it is the parents who are resisting further surgery at this time. The team’s decision was also pending the results of the nasendoscopy, and although I heard informally from my contact at the clinic, I might learn some new information when school resumes in the fall.
Dixon: I think it is important to respect the parents’ (and the child’s as he/she gets older) opinion. These kids go through multiple surgeries and medical procedures—it’s hard to really put yourself in their shoes! However, I do feel like it’s my responsibility to make sure the parents and child have as much information as possible when making their decisions. I want to be clear about what may or may not change in the child’s speech and also want to encourage them to think long term.
Participant: A child on my caseload had an adenoidectomy six months ago and is still hypernasal. What do I do now?
DeLuca: I just had this same scenario last week. Literature suggests that a small percentage of children following adenoidectomy will develop VPI. Spontaneous recovery has been shown to happen up to one year post-surgical intervention. Every team has different protocols. Some teams will intervene six months post. I would say the average is six to 12 months. In the case that I saw last week, the patient actually presented with an occult submucous cleft palate. He was three months post-surgical intervention; however, due to his occult submucous cleft palate that was not picked up prior to adenoidectomy, he will likely not spontaneously recover.
Dixon: At the risk of sounding redundant, you can still work on articulation, if appropriate! And, when in doubt, always refer to the team for instrumental assessment (depending on the child’s age).
Participant: What should you do in therapy with a toddler who has an unrepaired cleft palate?
DeLuca: First, I would suggest taking a phonetic inventory and assess language skills. Oftentimes these toddlers present with a restricted phonetic inventory and an expressive language delay. Nasal occlusion will be your best friend, as the child with an unrepaired cleft will be unable to build up intraoral air pressure. You want to “teach” oral airflow, and introduce new phonemes using maximal multisensory cues as previously discussed. You can also encourage use of low-pressure loaded phonemes to increase speech utterances as the child will be able to produce nasals, glides and liquids (m, n, w, h, l, etc.).
Dixon: I also think parent education is really important here. They need to understand what sounds the child can and cannot make due to the unrepaired cleft so they can encourage and reinforce the child’s productions but not accidentally provide negative reinforcement when the child produces nasalized sounds. For example, if the child’s attempt at “daddy” is the nasalized “nanny,” parents need to ignore the nasalized production and provide lots of positive reinforcements to help prevent the development of compensatory articulation errors. You can also help the parents generate a vocab/word list that is full of nasals and low-pressure oral phonemes.
Participant: I referred a child to a cleft palate team. What sort of information should I send with the family and what should I expect in return?
DeLuca: I love when the child and family come with an IEP, the SLP’s impressions, how the patient’s speech is impacting the child (i.e., educationally, emotionally). In return, our team will send the family a full team letter including all the medical findings, impressions and recommendations found during the team visit. Additionally, I always try my best to reach out to the referring SLP after I evaluate the patient to provide specific therapy techniques if appropriate. Each team runs differently; however, all team SLPs are super motivated to help SLPs in the community!
Dixon: I love working with community SLPs but will be honest that sometimes it can be difficult due to time constraints, etc. I would add that I love receiving specific questions you might have so I can try to answer them directly. To be honest, my team is so large we don’t send summary reports home to everyone; however, I try to have the family sign a release of information at their visit that includes my email/phone contact information when I know there are questions. I often rely on the school SLP to reach out to me from that point, unless I have significant concerns with the child. That being said, I also love collaborating and am happy to do so. I wish there were more time in the day! But, you should never hesitate to ask for the information you need to help with therapy planning.
Participant: What do you do in therapy with a child who only has nasal emission some of the time?
DeLuca: First, I would assess the pattern of nasal emission. If nasal emission is only on some phonemes, but not on all, this may be a learned behavior that can be targeted in speech therapy. This learned pattern can be called “phoneme-specific nasal air emission” and is often seen on fricatives—often /s/ and /z/. To assess the pattern, it’s helpful to use sound-specific sentences, such as “puppy pull a rope,” “do it for Daddy,” “Suzy sees scissors,” etc.
Dixon: If there is no pattern to the nasal emission and you are only hearing it intermittently or sporadically, it may be due to touch VP closure or a small VP gap. Again, I would want imaging to confirm VP function—we may leave it alone if it is not impacting understandability or acceptability, or we may decide to do some sort of medical intervention, whether that is surgery or pharyngeal wall augmentation.
Participant: Glottal stops are very difficult to treat. What tips do you have for correcting or eliminating glottal stop substitutions?
DeLuca: Using a “whisper” technique can be helpful, as whispering prevents vocal cord adduction, therefore eliminating or lessening the glottal stop. Additionally, targeting voiceless phonemes before voiced phonemes is helpful, along with targeting the target sound in final position (VC). The other thing to consider is the level of mastery prior to moving up the hierarchy. I will not move to a CV, VC, etc., until the target phoneme is 100 percent established in the child’s repertoire. Once consistent, then segmentation will help (V---C, C----V). Then consider adding /h/ between C/V to prevent glottal adduction at the onset of the vowel. Tailoring words is also key. Tailor words to the child’s phonetic inventory so as to not reinforce deviant productions.
Dixon: First, I start with probing what sounds the child is stimulable for. I almost always rename the sound. I call a /p/ a “popping” sound or a /t/ a “tapping” sound and use a lot of visual and tactile cues to try to generate them in isolation. I agree completely with Kristen that voiceless sounds are often easiest—but I would always encourage you to probe a variety of sounds and then go with what the child is stimulable for. For example, I have a 4-year-old right now who was most stimulable for /sh/ (which I would normally consider a later-developing sound) and he was able to produce /b/ before /p/. Repetition is important! I aim for at least 100 correct productions in my therapy sessions.
Participant: I currently have a 4-year-old bilingual child (Spanish as the primary language) with a repaired cleft palate on my caseload. In treatment, which sounds do I target first? And in which language: Spanish or English?
Dixon: I still work with the general theory that you work with what the child is most stimulable for and then shape other sounds as necessary.
DeLuca: I live in South Florida and unfortunately don’t speak Spanish! As a general rule of thumb, I would approach this patient just the same regarding therapy techniques and establishing a phonetic inventory using the child’s strengths.
Participant: What if you think that the child should target sounds in the primary language but the parents disagree because they want the child to learn English?
DeLuca: There are a few of our cleft/craniofacial colleagues who are more experienced in working with bilingual children. Feel free to reach out to me and I will pass on your information.
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September 2016
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