BACKGROUND
Amy Peterson, age 11, is a fifth grader at Hassan Elementary School. She was referred
for special education evaluation due to MN state law, which states that an evaluation
must be completed every three years for students already receiving special education
services. Results are used to determine whether a student continues to demonstrate a
disability and to plan for future special education services. On 3/11/09, a Case History
Questionnaire and Consent to Release Private Information form were mailed to Amy's
home address in order to obtain information about her medical history and current health
status. A follow up voice mail message was also left at the home telephone number.
These items were not returned at the time this report was written. As a result, information
in this report was obtained from Amy's cumulative school records, speech therapy data
from Hassan Elementary School, and current 5th grade teachers.
According to assessment reports from the Elk River School District in 2004 and
Minnetonka School District in 2006, Amy's mother, Jennifer reported that Amy was born
premature with a complete cleft of the hard and soft palates. Amy exhibited multiple
congenital defects and was diagnosed as having Pierre Robin Syndrome. This syndrome
is characterized by a cleft palate, very small lower jaw, and posterior tongue placement
that interfere with feeding and breathing. Amy had an artificial palate implanted to close
the oral and nasal cavities and she had a gastrointestinal tube placed to help with feeding
until the age of five. Amy also was reported to have other conditions associated with
Pierre Robin Syndrome including heart, hearing, and vision problems. For example,
Amy's cardiovascular system was described as "defective" with an aneurysm that "may
require more surgery". Amy was reported to have 'borderline' bilateral hearing loss and to
have corrective lenses for farsightedness and astigmatism because her corneas were
"misshaped". Cumulative school records indicated that Amy has received special
education service for a communication disorder since Kindergarten. She attended four
elementary schools including a school in Long Island NY; Lincoln Elementary in Elk
River, MN; Oak View Elementary in Minnetonka, MN; and Hassan Elementary in
Rogers, MN. Amy's initial Individual Education Plans (IEPs) focused on improving her
articulation skills for a variety of speech sounds. Later, as a second grader in 2004, mildto-moderate nasality was noted in Amy's speech and "a fistula at the left side, back of the
palate" was reported. A goal to address Amy's nasality problems was subsequently added
to her IEP.
Recent progress reports from Hassan Elementary indicate that Amy has been successful
in improving articulatory placement for specific speech sounds. However, there has not
been significant improvement in Amy's nasality and overall speech intelligibility. These
IEP goals have remained relatively the same. At the present time, fifth grade teachers
report moderate difficulty understanding Amy. Amy's lack of progress in the area of
nasal resonance was discussed with Ms. Peterson during the time of annual IEP renewal
in 2007. The team decided to continue services with goals to improve nasality and
intelligibility, and then to re-evaluate Amy’s progress in the fall of 2008. At this time,
school records indicate that Amy is achieving academically in the classroom and meeting
state test standards. Teachers did not report any concerns about academics. Amy’s has
not received any disciplinary referrals while at Hassan Elementary School . No other
concerns were reported at the time of assessment planning.
RESULTS
Sarah Peterson, speech language pathologist, evaluated Amy’s communication skills in
the area of voice. The test battery consisted of the following: Vocal Characteristics
Checklist and informal speaking tasks, See-Scape Nasal Air Emission Measurements,
Descriptive Features Assessment, and Oral Peripheral Examination. Also included were
speech therapy data from Amy’s special education file and information reported by her
fifth grade teachers.
The Vocal Characteristic Checklist is guide to identify problems that may contribute to a
voice disorder. It examines the vocal parameters of pitch, loudness, quality, and
resonance. A student’s vocal characteristics are assessed as he/she performs a variety of
speaking tasks. Amy’s speaking pitch was judged as relatively high, but within normal
limits for her smaller body frame. Pitch breaks and unusual pitch variability were not
noted. Amy’s loudness was judged as within normal limits. Her maximum phonation
time (MPT), the maximum amount of time a person can sustain sound plus air, was
longer than 10 seconds. Her s/z ratio, a measure to determine laryngeal and respiratory
problems, was 1.0 and both ‘s’ and ‘z’ sounds were sustained for longer than 10 seconds.
She demonstrated a normal loudness range while counting from 1 to 100, starting softly
and gradually getting louder. Amy’s attempts to maintain the increased loudness level
near 100 were accompanied by noticeable strain and effort in the head, neck, and
shoulder regions. Amy’s voice quality was judged as within normal limits as her voice
was not perceived as breathy, harsh, or hoarse sounding. Amy’s resonance was
characterized by aberrant nasality that was judged as mild to moderate in severity. Amy
was asked to read aloud from word lists and sentences of varying length that had many
non-nasal phonemes while the examiner alternately compressed and released her nares.
When Amy’s nares were released, perceived nasality increased as the length of Amy’s
utterances increased. When Amy’s nares were compressed, the clarity of vowel and
consonant productions (particularly for the ‘sh, ch, j, t/d, p/b, s/z’ sounds) improved.
These results indicated the presence of nasality during a variety of speaking tasks.
A See-Scape is used to measure the occurrence of nasal air emission during speaking
tasks. A flexible tube positioned in the student’s nose is connected to a vertical rigid tube
that houses a small piston. Air movement in the tube will displace the piston upward.
Movement can range from 1 to 7. A one indicates minimal airflow through the nose. A
seven indicates maximum airflow through the nose. Movement will be greatest during
nasal consonant productions of /m, n, -ing/ sounds. Movement will be least during vowel
and non-nasal consonant productions, e.g. /p, t, d, k/ sounds. This device is only sensitive
to the presence or absence of airflow. It does not provide data regarding how much
airflow is occurring, where the air leak is occurring, or how large the air leak is.
Treatment data from Amy's therapy sessions this school year (08-09) indicated that
movement of the See-Scape was minimal (1-3) for vowel productions. The amount of
movement increased (3-7) for single words, phrases, and sentences that contained non-
nasal consonant productions. These results indicated the presence of abnormal levels of
nasal air emission in Amy’s vowel and non-nasal consonant productions.
Descriptive Features Evaluation: There are forty-four sounds in the English language.
Each sound is described with respect to three basic dimensions: voice, placement, and
manner. Voicing simply indicates whether or not the vocal folds are vibrating, while
place of articulation tells where a sound is formed. The sites of production include the
lips, teeth, tongue, hard and soft palates, and laryngeal glottis. The manner of articulation
tells how a sound is formed. Stops (p/b, t/d, k/g) are produced by a closed vocal tract and
are followed by a sudden release of sound though the mouth. Fricatives (f/v, th, s/z, sh)
are produced with a narrow constriction through which air escapes with continuous noise
through the mouth. Combining a stop closure with a fricative segment produces affricates
(ch, j). Nasals (m, n, -ing) are produced like a stop but with air traveling out through the
nose. With regard to placement and voicing, Amy correctly produced all consonant
sounds in the English Language (including the ‘l/r’ and ‘th’ sounds that were addressed in
previous IEP goals). However, Amy demonstrated eleven errors in manner for ‘ch/sh/j,
s/z, f/v, t/d, p/b’ sounds. These sounds were characterized by nasalized distortions and
were often perceived as sounding imprecise. The high number of distortions in Amy’s
speech made some words more difficult to understand and reduced her overall
intelligibility to about 85% in connected speech. The presence of nasalized fricatives,
affricatives, and stops indicated abnormal levels of nasality.
An Oral Peripheral Examination was performed to reveal any structural and functional
abnormalities that would contribute to speech production problems. Labial and lingual
strength and range of motion were judged as normal during non-speech tasks.
Approximate velar movement was observed during the production of a sustained /a/
sound but movement of the pharyngeal walls could not be visualized by the examiner. As
stated earlier in this report, Amy was born with craniofacial abnormalities secondary to
Pierre Robin Syndrome including a bilateral cleft of the hard and soft palates and
recessed chin. Amy had an artificial palate implanted at one time and now has a palate
constructed of her own tissue. She does not have tonsils or adenoids. A structural
abnormality, related to velopharyngeal dysfunction, is suspected based on Amy’s medical
history and clinical signs observed during assessment and on-going therapy in 07-08 and
08-09 school years.
Informal Observations and Treatment Data: Amy’s willingly accompanied the examiner
to the testing session and was pleasant and cooperative throughout our time together.
Amy conveyed her thoughts and ideas about school using language that was concise and
coherent. Her speech was fluent and developmental speech sound errors related to
voicing and placement were not noted. Words containing the ‘sh/ch/j, s/z, f/v, t/d, b/p’
sounds were produced in a distorted, nasalized manner and Amy’s overall intelligibility
was reduced at the conversational level. Data from previous therapy sessions indicated
that Amy’s use of over-annunciation and a slower speaking pace reduced the amount of
movement in the See-Scape and seemed to improve the examiners understanding of some
single-words. However, Amy was not able to use these techniques effectively in
connected speech and improvement in regard to nasality has not been documented over
the course of several years of treatment. Overall results are judged as a valid estimation
of Amy’s communication skills based on her level of cooperation and the consistency of
results across the current and past test batteries.
CLASSROOM OBSERVATION:
Fifth grade teachers, Ms. Macker and Ms. Caterman, were asked to rate Amy’s speech
using a scale of 1 to 7. A rating of one corresponds to “needs more work” and a rating of
seven corresponds to “100% intelligible”. Amy received scores between 4 and 6. Ms.
Macker wrote “Amy tries really hard but it varies” and Ms. Catterman wrote “I listen
very carefully to understand Amy-I can understand when I focus on her words”.
INTERPRETATION
During normal speech, air from the lungs and sound from the vocal folds travel upward in
the throat. In order to produce most speech sounds, the air and sound need to be directed
into the mouth and blocked from entering the nasal cavity. This occurs when the soft
palate raises and contacts the back wall of the throat during speech and is called
“velopharyngeal closure”. Problems with velopharyngeal closure can cause a resonance
disorder that is characterized by hyper nasality (too much sound in the nose during
speech and a student sounds as if he/she is talking through the nose), nasal emission (air
escapes out of the nose and can be heard during production of certain consonants such as
/p/,/t/, /k/, /s/, /sh/, and /ch/), and weak or imprecise sounding consonants (due to
inadequate air pressure in the mouth). Velopharyngeal dysfunction is common in children
with a history of cleft palate and also can occur after adenoidectomy. Amy has a medical
history of both of these.
Successful evaluation and treatment of velopharyngeal dysfunction involves the
combined specialties of speech language pathology (SLP) and otolaryngology (ENT).
The SLP evaluates resonance, nasal emission during speech, and speech sound
production while the ENT usually determines the cause, size, and location of the
velopharyngeal dysfunction. This information is needed so that the appropriate
intervention can be determined. Treatment may include surgical intervention, such as a
pharyngeal flap, sphincter pharyngoplasy, or posterior pharyngeal wall implant.
Prosthetic devices can also be used on a temporary or permanent basis in some cases.
Amy’s aberrant nasality and reduced intelligibility is consistent with a clinical picture of
a resonance disorder related to structural abnormality called velopharyngeal dysfunction.
Evaluation results indicated that Amy had an abnormal amount of nasal resonance and
nasal emission during a variety of speaking tasks and that her productions of ‘sh/ch/j, s/z,
f/v, t/d, /p/b’ consonants were imprecise sounding. These symptoms have not improved
with direct speech therapy, as significant changes in Amy's nasality and overall
intelligibility have not been documented at a connected speech level and IEP goals have
remained relatively the same over the course of the past several years. Continued speech
therapy, in a school-based setting, is unlikely to effect further change in Amy’s speech at
this time. It is recommended that special education service be discontinued. Reevaluation
should be considered at a later date when Amy’s medical status has changed or new
treatment options have become available. Ms. Peterson will be provided with additional
information about velopharyngeal dysfunction and cleft palate, as well as the name and
telephone number to a clinic specializing in craniofacial disorders in the Twin Cities
Metropolitan Area.