Theresa M. Snelling, MA, CCC-SLP
Pediatric Speech-Language Pathologist
Clinical Coordinator
Rose Cleft Palate and Craniofacial Center
Denver, Colorado
REFERENCES:
 Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP, Trost-Cardamone
JE. (2006). The Clinician’s Guide to Treating Cleft Palate Speech. St.
Louis, MO, Mosby.
 Kummer AW. (2008) Cleft Palate and Craniofacial Anomalies: Effects
on Speech and Resonance (2nd ed.). Englewood Cliffs, NJ: Thomson
Delmar Learning.
 Hardin-Jones, M., Chapman, K., and Scherer, N.J. (2006, June 13th).
Early Intervention in Children with Cleft Palate. The ASHA Leader.
 American Cleft Palate-Craniofacial Association (2009). Parameters or
the Evaluation and Treatment of Patients with Cleft Lip/Palate or Other
Craniofacial Anomalies. Available from www.acpa-cpf.org.
LUKE
 LUKE-
Diagnosis - Unilateral Complete Cleft Lip and Palate
Services – Early Intervention; Individual Private speech
therapy from 3- 4 ½; Child Find Preschool 3-5 years.(NO
SPEECH THERAPY CURRENTLY); GOOD PALATAL
CLOSURE.
Surgeries:
INITIAL LIP REPAIR FOLLOWING NASO-ALVEOLAR
MOLDING- 3 MONTHS; PALATE REPAIR – 11
MONTHS; 3 SETS PE TUBES.
Paige- cleft of soft palate only
 Palate repair- 12 months
/developed fistula; second repair
–pharyngeal flap and fistula
repair /developed fistula;
ongoing speech therapy,
pervasive HYPERNASALITY and
nasal emission. Advanced
language skills!!
 Wore obturator
 Recent re-repair 2012 = palate
closure and NORMAL
resonance!
INFANT WITH CLEFT PALATEearly concerns…
Feeding
Speech sound development
 Open palate- can’t create
 Open palate can’t create oral
negative pressure for sucking
 Liquid and food leak in to
nasal cavity
ADAPTATIONS…
Feeding positioning (upright)
Adapted bottle to control for
lack of suck
Limit feeding sessions to 20-30
minutes to limit calorie burn
pressure for speech sounds
 Sounds needing oral pressure
result in nasal airflow or nasal
resonance
SPEECH ADAPTATIONS…
Nasal sound substitutions for
oral consonants (m/b, n/d)
Increased glottal sound play
Nasalized vowels
Oral structures
for SPEECH AND
FEEDING
SOFT PALATE
and HARD
PALATE CREATE
CLOSURE
BETWEEN ORAL
CAVITY AND
NASAL CAVITY
(Primary)
RESONANCE DISORDERS
ARTICULATION DISORDERS
***This is what I’ll cover during this first half of our
presentations!
(Secondary)
LANGUAGE DISORDERS OR DELAY
VOICE DISORDERS (Laryngeal)
 HYPERNASAL-excessive nasal resonance during
production of VOWELS- VOWELS!!!!!
 HYPONASALITY- a reduction in normal nasal resonance
resulting from a partial or complete blockage of the nasal
airway by any number of sources.
 HYPER-HYPONASALITY (MIXED NASALITY)-the
simultaneous occurrence of hypernasality and hyponasality
in the same speaker usually as a result of VPI in the
presence of high nasal resistance that is not sufficient to
block nasal resonance completely.
NASAL EMISSION (articulation)
Nasal emission- nasal air escape associated with
consonants requiring high oral pressure. May or may
not be audible- often seen in conjunction with
hypernasality on vowels.
NASAL SUBSTITUTIONS (Articulation – may overlap
with hypernasal resonance and be secondary to VPI or
unrepaired cleft palate!)
/m/ and /n/ substitutions for consonants
For example: m/p, b, w, r; n/ t, d, l, sh; ng/n, k, g
AVOID THE TERM- “NASAL”
…”S/He sounds nasal…” does not
differentiate hypo and
hypernasality.
ARTICULATION
 PLACE, MANNER, AND VOICING…
Most errors related to cleft palate have to do with
PLACEMENT errors while manner is maintained!
ATTEND TO PLACEMENT!!!
Usually BACKED!
Glottal stops, nasal snorts
PLOSIVES /b, p, t, d, k, g/
AFFRICATES /tS, dZ/
Pharyngeal Fricatives, Nasal Fricatives
Fricatives- s, z, sh, v, th, f
Affricates- ch/tS/, j/dZ/
Most common articulation errors related to palatal
clefts-
GLOTTAL STOPS
PHARYNGEAL FRICATIVES
NASAL FRICATIVES
NASAL PHONEME SUBSTITIONS
COMPENSATORY MISARTICULATIONS
Compensatory misarticulations related to cleft palate are
usually errors in PLACEMENT OF PRODUCTION.
They are learned articulatory postures or placements
that typically persist even after successful surgery or
appliance management of the pharyngeal port and
therefore co-exist with an adequate closure
mechanism.
They tend to be BACKED ARTICULATIONS relative to
the target place of production.
VELOPHARYNGEAL INSUFFICIENCY
Velopharyngeal Insufficiency (VPI) is a resonance
disorder associated with a natural “pressure valve” in
the back of the mouth that does not maintain air
pressures that are needed in typical speech
production. The disorder may be structural or
functional or results in inadequate separation of the
oral and nasal cavities.
***JEFF WILL COVER THIS MORE IN PART II
In therapy setting
 MIRROR TEST**(great with little ones!!!)
 STRAW ASSESSMENT**(older children =biofeedback)
In team/clinic: (JEFF will cover)
 VIDEOFLOUROSCOPY
 NASOENDOSCOPY/VIDEOENDOSCOPY
 NASOMETRY
…
ALL AGES
Goals:
 TO CORRECT THE PLACEMENT ERRORS (often
will improve/correct hypernasal resonance.)
 Improve hypernasal resonance (if it’s structural
secondary surgical management is needed- but
therapy should be tried first especially in the
presence of articulation errors.)
Therapy
techniques…continued…
 Target high pressure- oral vs. nasal.
 LABEL air flow- “windy sound”, “lip popper” for direct
feedback… even with little ones (15-18 months old.)
 TARGET strong and varied vowels and glides /w, l, r, j,
h/ if not present or weak-Children will often produce
glides even in the presence of VPI.
BACKING reduction…
TARGET BACKING ERRORS- move sounds anterior!!!
 vowels (anterior round vowels /u/ /oe/)
 glides /w, r/…not /j/ substitution
 mid-dorsal IS NOT the goal… but may be the “process”
of moving sounds forward (from /k/ placement, to
mid-dorsal placement, to tip alveolar…)
 use ‘lips’ to encourage ANTERIOR airflow- rounded
lips help move air forward.
BACKING reduction…
 TRY OVERPLACEMENT of articulators to decrease backing…
***/t/- produced as a /k/…I often start with tongue between lips
rather than on alveolar ridge- then pull it back in mouth once
they can produce plosive with tongue tip!
(Sarah) Family was given /t/ to work on- Child produced “glottal
stop + vowel” and in all word attempts- this was given as
homework BEFORE child could produce a /t/!
Approach- targeted /p/…moved to overplacement for /t/….
KEY POINTS:
 Determine PLACE of articulation error and target with
emphasis on manner, voicing and PLACE
classifications.
 Start with PLACEMENT- even pending surgery. IF
YOU EMPHASIZE MANNER (plosive, fricative)
with VPI- likely to teach/encourage compensatory
articulation patterns.
VIDEOS
E- th, t, d- GOAL “eliminate Backing”
Stella 2 ½ years
Speech Therapy in the presence of
Velopharyngeal Insufficiency (VPI)
IN presence of Velopharyngeal
Insufficiency…
IF you teach STRIDENCY for “s” or “sh” in the presence
of VPI or unrepaired palate, child will create stridency in
back of throat = PHARYNGEAL FRICATIVE! (TARGET
ONLY ORAL, ANTERIOR AIRFLOW!!!!
IF you teach “PLOSIVES” in presence of VPI- child may
use GLOTTAL STOP…. Target light contact, anterior
airflow, overplacement,….strategies.
DON’T TEACH OR REINFORCE COMPENSATORY
ARTICULATION ERRORS!!
KEY POINTS:
 Rule out obvious structural issues such as a palatal
fistula that does not allow for a build up of oral
pressure even in the presence of a functional soft
palate; may need obturator to cover fistula in the hard
palate.
OBTURATORS ARE POSSIBLE FROM ABOUT 3 ½
YEARS OLD (REMOVEABLE); NON-REMOVEABLE
ATTACHED TO BRACKETS ON TEETH AT ABOUT 3
YEARS OLD
KEY POINTS:
 Encourage strong productions-”Use Your Big Strong
Mouth.” Patients frequently will try to control nasal
escape related to VPI by decreasing oral strength, pressure,
and volume. This does NOT contribute to optimizing VP
closure. Although increasing pressure and volume may
increase audible nasal emission, it may be a stepping stone
allowing for contrast, and/or improved outcome even
following secondary surgery (fistula repair or pharyngeal
flap.)
KEY POINTS:
 Use visual and tactile feedback… pop cotton, feel
airstreams on your hand, see the tongue hump in the
back, see air on a mirror or with SeeScape, etc…
LUCY p-final
Please read on own!!
TEACH PARENTS/GRANDPARENTS/CARETAKERS...
 Self Talk
 Parallel Talk (play by play!)
 Naming/Modeling
 Expansion
 Motor, paired with sounds/speech
CAN, AND SHOULD, PAIR WITH CLEFT
PALATE GOALS AND OBJECTIVES!
PROBLEM…Child doesn’t imitate
words…
IMITATION DEVELOPMENT….
 Eye contact/Smile
 Motor imitation (pat-a-cake, peek-a-boo, SO BIG!)
 Vocal imitation (reciprocal vocalization of vowels, grunting,
giggling….)
 INFLECTION!! Easier to imitate- thus “UH OH!!!” “OH *#@!*”
 MOTOR paired with sounds (BYE BYE, UH OH) (BABY sign!)
 SOUND IMITATION – easier developmentally than words!!!
TARGET SOUNDS if they are not yet imitating sound play!
 WORDS, word combinations, phrases, sentences…
 ESTABLISH IMITATION LEVEL…BUILD FROM STRENGTH!!!
PROBLEM…Child doesn’t imitate
words…
 ESTABLISH WHAT THE CHILD IMITATES…(motor
movements, joint attention, feeding the baby…)
 BUILD ON THAT LEVEL!! Don’t make WORDS the
target when child doesn’t imitate motor actions in
play- START WITH IMITATION!!
 IMITATION, IMITATION, IMITATION- IN PLAY!!
Child’s play, follow their lead, introduce new play
schemes by playing them yourself, limit questions and
commands….
PROBLEM…Child doesn’t imitate
words…
When Motor Imitation occurs in play- add sounds,
noises, facial expressions…
 Stirring food “SH, SH, SH, SH…”
 Knock on doll house door “knock, knock” at same
time as motor.
 “SH, SH, SH… baby is sleeping” when putting doll to
bed.
 UH OH!! Hand to your face-EVERYTIME…when they
imitate putting hands to face- it increases chance
they’ll pair it with approximation of “UH OH!”
PROBLEM…Child doesn’t imitate
words…
WHAT ABOUT INFLECTION…?
 “Whatever”
 “BO BO! No!” (yelling at dog was model)
 “I LOVE YOU!” (3 syllables approximated)
Inflection is why kids say “uh oh”! Early!
START IMITATION WHERE THEY ARE
SUCCESSFUL- THAT’S THE STRATEGY!!!
SUMMARY of Indirect Language
Stimulation…
 Reduce questions…especially yes/no responses.
(‘choice’ questions increase the chance of a verbal response)
 Don’t use commands in play- model the activity!
INSTEAD:
 Follow child’s lead
 Model play skills
 Use self talk, parallel talk, modeling, expansion.
 Use exaggerated inflection (UH OH! Oh NO!)
 Encourage turn-taking….2 year olds will sit in a chair and
take turns- it can still be “play”.
INFANTS:
Make sure parents know that sounds infant pre-palate
repair CAN make are “M, N, NG, vowels, gurgles”
Talk and imitate child’s sound play…don’t push sounds
they CAN’T make (plosives, fricatives, affricates.)
******Good sounds to target during play in
EARLY INTERVENTIONvowels (increase variety), /w, r/, /l/,/m, n/.
USE INDIRECT LANGUAGE TECHNIQUES BUT…
HAVE SPECIFIC SOUND AND RESONANCE GOALS!
 EATING/CHEWING SOUNDS – to get lip smacks!
 Stacking blocks- Put block to face- make BIG OPEN
VOWEL SOUNDS…you put block on…then give block
to child “your turn”…don’t tell them to say it at
first…FIRST get the game of turn-taking (motor) then
add sound…then modify sound…”POP IT!” “BIG
MOUTH!”
 Animal sounds, car sounds,…
CHOOSE HIGH PRESSURE PHONEMES IF PALATE
IS REPAIRED!!!!
BOOKS…
CHOSE BOOKS AND TARGET WORDS TO
FACILITATE HIGH PRESSURE SOUND
DEVELOPMENT…
“Where’s Spot?” BOOK = “NO PUPPY!” Child’s response
to tell mommy dog…”NO PUPPY!”
“DID YOU FEEL THE AIR POP? PUPPY!!”
Pop air on their hand- let them pop it on your
hand…
This is a great combined language and articulation goal=
2 word combinations AND high pressure (plosive)
sound production!!
STRIDENCY…
 Dolls: “sh!” for sleeping- targeting fricatives!
 FOOD/KITCHEN play- “HOT!” Big open air on /h/ to work
towards stridency in “sh”…
 SNAKES- Snake sounds!! “ssss”
 “Shwoosh”- paired with other sounds.
 Paper/markers- make long lines or circles to represent
continuant feature of /s/, ‘sh’, /f/…pair sound with the motor.
HIGH PRESSURE PHONEMES…
 Coloring paper/markers- P, B- “lip poppers”- pair
sound with any motor activity. “Tap” marker on paper
for /p/ or /t/…
 Train set…”ch, ch, ch… Target “pop” component of the
“ch” (the /t/).
 /k/ = back scraper; /t tongue tapper; /p/ “popper”- and
“feel” the air on your hand!!
WHAT IF PALATE IS UNREPAIRED
OR CHILD HAS VPI?
 Target BIG OPEN vowels!!!
 Target anterior lip movement on vowels (“oh”, “oo”,
“ow”…)
 Target Glides- yes even /l/!! Many 2 years olds CAN
make an /l/, and if they’re stimulable it will usually
not result in a compensatory articulation error.
 Target Glides- I work on both /w/ and /r/ when they
are backed or omitted altogether in words- ROUND
ANTERIOR LIPS move the glide forward through the
mouth- THIS IS HOW YOU IMPROVE ORAL
MOTOR LIP AND TONGUE AND CHEEK
STRENGTH!! IN WORDS AND SPEECH! NOT
blowing exercise!
WHAT IF PALATE IS UNREPAIRED
OR CHILD HAS VPI?
 DON’T teach glottal stops, pharyngeal fricatives or
nasal fricatives… on accident!
If palate is open or too short, but not yet ready for
surgery… be very aware of your targets!! To get good lip
use, target /m/ words and tread lightly with a STRONG
/b/- will get a paired glottal stop! (Chu Chu)
WHAT IF PALATE IS UNREPAIRED
OR CHILD HAS VPI?
TARGET Glides and BIG vowels to increase
intelligibility! More accuracy on vowels with improve
intelligibility even in the presence of VPI!
VOICELESS plosives /p,t, k/are easier to approximate if
VPI is present and less likely to be paired with a glottal
stop than VOICED cognate /b,d, g/. Target voiceless,
with light contact
PRIOR TO PALATE REPAIR:
 Target IMITATION!! Not necessarily specific sounds,
but the GAME OF IMITATION! This goal lays the
ground work for speech therapy post palate repair.
 Target more than just receptive language skillsexpanding play skills and motor imitation.
 Reciprocal vocalizations- develop between 6-9
months- play with vowels and inflection and facial
expressions.
AFTER palatal repair:
Teach the contrast of oral vs. nasal by using terms like “that was in your mouth!”
 “Uh Oh, that was in your nose!” (my nose too!)
 Target- big, open vowels…and high pressure
consonants (plosives, fricatives and affricates)…
IN THE CONTEXT OF PLAY!!!
GOALS AND OBJECTIVES:
HAVE specific targets…related to resonance, articulatory
placement, and compensatory articulation patterns:
 High pressure phonemes (even with 18 month olds).
 Stridency (sh, s) in sound play or words.
 Glides (w) using lip rounding.
 Develop big open vowels to reduce Hypernasality.
 If connected speech is mumbled with poor
intelligibility- target “use your big, strong mouth”.
GOALS AND OBJECTIVES:
PROGRESS reports should include information about:
 Resonance.
 Articulatory placement patterns.
 Strategies that worked to address goals.
 Compensatory articulation errors.
GOAL: “…will use plosives /p, t, k/ in single words…”
BE SURE to document error pattern as glottal stop, or
nasal substitution or omission of consonants with
vowels only sound used…
REPORTS!
 INCLUDE DETAILS RELATED TO CLEFT PALATE IN
YOUR REPORTS… IT’S CRITICAL TO THE
DECISIONS THE CLEFT PALATE TEAM HAS TO
MAKE OVER TIME!
 TO DETERMINE IF SECONDARY SURGICAL
MANAGEMENT IS NECESSARY- IT’S IMPORTANT
TO KNOW WHAT HAS BEEN TARGETED IN
THERAPY!!
HAVE GOALS!
 More than just language stimulation with young children
(birth to 3)… have “specific” goals for articulation and
resonance development related to cleft palate.
 Speech therapy is still appropriately ‘play based’ but that
does not mean you avoid articulation and resonance goals…
*BIG OPEN MOUTH
*STRONG,VARIETY OF VOWEL
*SOUNDS, PAIRED WITH MOTOR IMITATION, TO
INCREASE VARIETY OF VOWELS AND CONSONANTS
PRODUCED.
REMEMBER…
 BLOWING AND SUCKING EXERCISES DO NOT
IMPROVE CLOSURE FOR SPEECH (they might
improve blowing and sucking…but the goal?????)
 No clinical, scientific research to support the benefit to
cleft palate speech error patterns for isolated
blowing and sucking exercises!
SPEECH/SOUND correlation needed for speech
improvement…
Blowing, sucking…when to use it…

If they have poor lip closure… and you “pop” cotton
balls to get lip pressure…QUICKLY work into
speech/sound context- “That’s a lip popper!! My lips
popped- “PAH!” “Pooh”, etc.

BLOWING to get oral air because all air is in noseQUICKLY work to a sound… “WHOA!” (/hw/) or
“HAH” /h/
FOR EXAMPLE… To work towards ‘sh’… BLOW AIR
OUT MOUTH, CLOSE TEETH, BLOW AIR AGAIN
through teeth and will approximate ‘sh’!