• In this presentation you will learn to describe how craniofacial differences occur and how they negatively impact intelligibility, list underlying speech components that can be affected by VPI and Cleft Lip and/or Palate, and identify intervention and evaluation strategies for working with a child with craniofacial anomalies.

1. Maximizing Treatment Effects
withVPI and Cleft Lip and Palate
Scott Prath, M.A., CCC-SLP
Keith Lebel, M.S., CCC-SLP
Texas Speech-Language-Hearing Association
2012 Annual Convention
March 8-10, San Antonio,Texas

2. Do you need Continuing Education or want
to listen to this course live?
Click here to visit
the online courses.

3. Young Children
with a Cleft of
the Lip &/or
Palate
The physical and socio-emotional
effects on the family and child
Photos courtesy of Operation Smile

4. Learner Objectives
Participants will:
• Become familiar with what causes clefts
• Understand the process that a family through with a
child that has a cleft lip and/or palate
• Identify our role as service providers in working with
the family
• Identify intervention and evaluation strategies for
working with a child with a cleft lip and palate

5. 3 Great Reasons to Learn about CLP
1. Vocabulary
Salpingopharyngeus

6. 3 Great Reasons to Learn about CLP
Cleft Lip and Palate BINGO!
Generating
Suction
Maxillofacial
Surgeons
Maternal bonding unilateral Oral Airflow
Palatal obturator fistula Prosthodontists Lippy the Lion Teratogenic
Bilateral Oral Hygiene salpingopharingeous High Pressure CVCV
Tympanostomy
tube
Anxiety VPI
Andhra
Pradesh
Prevalence
Resonance Glottis Submucousal 7 weeks
Parent
Involvement

7. 3 Great Reasons to Learn about CLP
2. Faith in the Medical System
From age 0 – 17 a child will:
- attend 30+ visits
- will undergo 4-8 surgeries
- will interact with approximately 20
professionals

8. 3 Great Reasons to Learn about CLP
3. Emotional Satisfaction
The child born with a cleft is not the child that
the parents expect.
You may be the only outside resource that the
family has in understanding that everything
is going to be alright.

9. All of the documents and charts in this presentation
can be downloaded from our Free Resource Library.
Click here to visit the Resource Library

10. Click for Audio‐over‐Powerpoint Presentation

11. What is a Cleft?
• Clefts result from incomplete
development of the lip and/or
palate in the early weeks of
pregnancy.

12. What types of clefts exist?
• A cleft lip (CL) is a
separation in the upper lip.
• A cleft palate (CP) is an
opening in the roof of the
mouth.
• A cleft lip and palate (CLP)
extends through both.

13. What types of cleft palates exist?
• A cleft palate can be:
▫ unilateral
▫ bilateral
▫ submucousal with bifid
uvula

14. What is the prevalence?
• Clefts occur in ~ 1/750 live births
• Estimated prevalence by type:
Lip only 14%
Palate only 37%
Lip and Palate 49% (77% are unilateral left)
• Estimated data by race:
▫ Asian and Caucasian populations more susceptible
▫ Black populations present with ½ the rate of Asians and
Caucasians
▫ Hispanic data are inconclusive

15. When does a cleft occur?
4 and 5 weeks in utero

16. When does a cleft occur?
5 ½ and 6 weeks in utero

17. When does a cleft occur?
7 and 8 weeks in utero

18. When does a cleft occur?

19. What causes a cleft?
1. Gene Mutation
2. Chromosomal Aberrations
3. Teratogenic Agents
4. Multifactoral Inheritance
5. Mechanical Factors

20. How is a cleft repaired?
The repair of a cleft lip or palate is
the process of taking existing
tissue that surrounds the opening
and rotating it or moving it to
close the opening.

21. What is the process for the family?

22. What is the process for the family?
The Cleft Palate Team
• Clinic Director
• Audiologist
• Craneofacial Surgeon
• Geneticist
• Neurosurgeons
• Nurses
• Occupational Therapists
• Oral and Maxilliofacial
Surgeons
• Orthodontists
• ENTs
• Pediatrician
• Pediatric Anesthesiologists
• Pediatric Dentists and
Prosthodontists
• Pediatric Radiologists
• Physical Therapists
• Plastic Surgeons
• Speech Language Pathologists
• Surgeon’s Assistant

23. How is development affected?
1. Communication Development
1. Speech Development
1. Articulation (mouth)
2. Voice (throat)
3. Resonance (nose)
2. Language Development
3. Hearing Development
2. Socio-emotional Development

24. Diagnosis and Treatment
Characteristics
Treatment & Goals

25. Communication Characteristics
Children with CLP:
• Show deficits in the size and composition of
their early sound inventories
• Reach the babbling stage later
• Show less variety of speech forms produced
• Have a hypo-or hyper-nasal quality

26. Communication Characteristics
Children with CLP:
• Often have voice problems (harshness) due to
overuse
• Can have constant ear infections and
temporary hearing loss
• Do not necessarily have cognitive issues
Outcomes influenced by severity and time of
surgery

27. Communication goals/ outcomes
for ECI
1. Increase Consonant Inventories
2. Increase Vocabulary
3. Increase Oral Airflow
4. Decrease use of Nasal and Glottal Sounds

28. 1. Increase Consonant Inventories
• The sounds that a child with CLP can produce
are:
▫ Restricted by their structural abilities
 However, there many things that can be focused on
▫ Dependent on the surgeries
 Different sounds are addressed before and after the
palate repair
Don’t be scared! Most children with CLP are highly
intelligible by age 5 because of you!

29. 1. Increase Consonant Inventories
• Hi
• Hello
• Hey
• Mommy
• More
• Me
• No
• Whoa
• Wow
• Honey
• Mamá
• No
• Mío
• Niña
• Niño
• Ojos
• En
• Mano
• Wawa – agua
BEFORE palate Repair
LOW pressure words to target

30. 1. Increase Consonant Inventories
• Baby
• Boy
• Pop
• Pooh
• Pie
• Toy
• Doll
• Daddy
• Cookie
• Go
• Papá
• Bebé
• Boca
• Gato
• Todo
• Tú
• Tío
• Qué
• Ten
AFTER palate Repair
HIGH pressure words to target

31. A word on VPI
• Velo-pharyngeal Insufficiency
▫ The velum (velo) is not contacting the pharynx
(back wall of the throat)
▫ Can be caused by:
 Muscle weakness
 A large opening
 Insufficient muscle function
 Adenoids and tonsils

32. 2. Increase Vocabulary
• Sounds and vocabulary develop in tandem
• Do we:
▫ Focus on articulation to give her the sounds to
produce more language?
▫ Focus on language to give her a way to practice her
sounds?
Anyone want to guess?

33. 2. Increase Vocabulary
• Vocabulary development should be targeted with
sound development
▫ Choose words that:
 Are common and in their environment
 Are useful
 Are extremely fun
(read: routines-based intervention)

34. Consonants + Vocabulary
Syllable structure
• Syllable should be simple
▫ CV (consonant/vowel)
▫ CVC
▫ CVCV
Sound Class
• Start with stops and bilabial sounds
• Add fricatives later

35. 3. Increase Oral Airflow
• A child with a cleft does not have control over
the air leaving their throat
• In typical development we stop or slowly
release this air to produce speech
• Regardless of what surgeries a child has
undergone, we need to familiarize the child
with airflow through the mouth

36. 3. Increase Oral Airflow
• Request an easy repetition (muh,muh,muh)
▫ After the child starts repeating, plug his nose
• Inhale deeply, hold your breath, and explode out
with a single sound
▫ BUH!, PUH!

37. 4. Decrease use of Nasal and Glottal
Sounds
13% of 63, 4-5 year olds presented with some form
of voice disorder
▫ harshness, breathiness, nodules
• Growls and nasal sounds are typical for young
infants but they are used less when consonants
develop
• Children with clefts retain these sounds
• Parents, wanting communication, reinforce these
sounds

38. 4. Decrease use of Nasal and Glottal
Sounds
• Acknowledge the child’s attempt but then
requests other consonants or sounds
• Pair voiceless consonants with whispered vowels
puh/tuh/ku/huh
• This keeps the glottis open and prevents the
glottal stop from occurring

39. Language Development
• Study using the TOLD-P (63, 4-5 y.o.)
▫ 21% manifested receptive impairments
▫ 26% manifested expressive impairments
▫ General Population
 3.3%
• Take home message
▫ Treat CLP as a comprehensive communication
disorder, not just a speech disorder

40. Hearing development
• Type of loss 4-5 years 14-15
• WNL (0-26 dB) 78 88
• Mild (2-40 dB) 22 12
22% exhibit hearing loss (1/5)
• Take home message
▫ Keep current on hearing status. Hearing loss =
speech and language loss

41. Influences on family
effectiveness
Parent Reaction to a Cleft
Child Reaction to a Cleft
Parent Involvement
Mother-child Bond and Feeding

42. Socio-emotional Development
“It is reasonable to assume that individuals with CLP
should have relatively normal long-term health, as
CLP is a reparable birth defect. However, several
studies have suggested that individuals with CLP
have a higher than expected incidence of psychiatric
and behavior diseases, an increased risk for cancer,
and increased mortality…”

43. The effects of CLP on the parent
Effects on the parent
▫ Blame due to improper love, nutrition, an event
during pregnancy
▫ Parent’s personality and their feeling of control or
lack of control
▫ Feelings of disappointment or resentment if they
feel that this event has dashed their hopes

44. The effects of CLP on the parent
Intervention:
▫ Education
▫ Support
Research shows that when a family is in a position
where they feel that personal needs or aspects of
their lives are governed by external forces or in a
poor state, they exhibit negative feelings toward
their child or event.

45. The effects of CLP on the child
Effects on the child
▫ Speech or hearing disorders
▫ Parents’ feeling of guilt
 Can cause a parent to treat a child differently
▫ Anxiety
 Regular or protracted doctor visits
 Parents’ ever-present fear of choking
▫ Visible scars due to surgical procedures

46. The effects of CLP on the child
Intervention:
The child’s psychosocial state is dependent on how
well or poorly the parent is dealing with
everything.
It is our role to support and improve the lives of the
child. This means direct social intervention with
the parent.

47. When do emotions set in?
• Periods of:
Anxiety Optimism Depression Acceptance
occur with each surgery or event.
Edwards and Watson, 1980, found that there is an optimistic
period right after birth because the couple is happy that there
are surgical options available, but soon after they can become
disheartened.
• Take home message:
Work to identify how a family is dealing with the process in the
time that we are serving them.

48. The Kubler-Ross Grief Cycle
• Denial: Example - “She’s fine."; "This can't be happening."
• Anger: Example - "Why me? It's not fair!" "NO! NO! How
can you accept this!"
• Bargaining: Example - "Just let him talk fine, I don’t
mind the scar."
• Depression: Example - "I'm so sad, why bother with
anything?"; “Everything that we had planned for her isn’t
going to happen."
• Acceptance: Example - "It's going to be OK."; "I can't
fight it, I may as well prepare for it."

49. Parent Involvement
• Andhra Pradesh, India
▫ Tested:
 Known context (rhymes, counting 1-10)
 Unkknown context (family information)
▫ There was a greater understandability of unknown
contexts after treatment

50. Feeding and psychological development
• Children gain pleasure from oral stimulation
and feeding
 Feeding is impaired
 Feeding issues are one of the first problems that
families encounter so it is not an enjoyable event
• The early maternal-bonding process is often
more disturbed by feeding problems than by the
facial defect

51. Feeding and psychological development
• CL (cleft lip only) -usually no major feeding
problem (breast feeding possible)
• CP has difficulty feeding because of inability
generating effective oral suction

52. Feeding
• Children with CLP take in more air
▫ They need to be burped more and fed more
upright
• Feedings should last ~30 minutes.
▫ If they are needing 40 minutes, enlarge and/or
cross cut the nipple opening
• Weight gain, feeding frequency, and feeding
amount are normally the same for a child
with CLP

53. A word from the parents
Parents in one study reported feelings of anxiety
about how the baby would be able to eat.
▫ Set therapy goals to address feeding
▫ Work with nutritionists and the cleft palate team

54. A word from the parents
Parents DID report positive feelings from
professionals who did not ignore condition.
▫ Do not ignore the condition

55. A word from the parents
Many expressed desire to meet other parents of a
child with CL/CP—to exchange thoughts and
discuss practical problems.
▫ Seek out support groups, resources, or other
families to network with

56. A word from the parents
Negative reactions from other people were
perceived through body language, such as
keeping at a distance, looking away.
▫ Be aware of your body language as well when
interacting with
child and family

57. A word from the parents
Parents often hear “He will be fine later” from
staff and other professionals and interpreted this
to mean that child was not considered fine at
that moment.
▫ Be supportive and concerned about the current
condition
▫ Parents stated that they grew
tired of hearing these phrases

58. A word from the CLP team
What would you consider to be the most
important thing that a service provider
should know when they are working with a
child with a cleft lip and palate?
Kids with clefts can’t generate pressure to
make sounds. Normally they just say
“muh.” We need to brush up on our A&P so
that we can provide good therapy.

59. A word from the CLP team
What should ECI professionals educate parents
on?
The second surgery normally occurs around 12
months so kids with clefts won’t develop speech
sounds on time. Let the parents know that they
should be looking for and practicing low
pressure sounds to get the ball rolling.

60. A word from the CLP team
Is there anything that the parents could know
from the ECI agencies to make the team and
surgery visits easier?
Keep the child’s hearing status up to date.
Hearing issues like infections can delay
speech even further and cause schedules to
be pushed back or visits to be cancelled.

61. A word from the CLP team
Is there anything problematic/difficult with family
interactions that could be addressed by services
outside of the team visits?
You need to do a full assessment to
determine whether there are cognitive
delays or other delays. Parents fear that
their children are delayed in every way
imaginable because of the cleft. Normally
communication is the only, main issue.

62. When does a cleft occur?
7 and 8 weeks in utero
5.
Structural
Anomaly

63. A word on VPI
• Velo-pharyngeal Insufficiency
▫ The velum (velo) is not contacting the pharynx
(back wall of the throat)
▫ Can be caused by:
 Muscle weakness
 A large opening
 Insufficient muscle function
 Adenoids and tonsils
5.
Structural
Anomaly

64. Structural Anomalies
Communication goals/ Outcomes for Structural
Anomalies
• Increase Vowel Repertoire
• Increase Consonant Inventories
• Increase Vocabulary
• Increase Oral Airflow
• Decrease use of Nasal and Glottal
Sounds
5.
Structural
Anomaly

65. Increase Vowel Repertoire
• Take a vowel inventory
▫ Target vowels in isolation (a)
▫ In strings (a,a,a,a)
▫ In opposition (u-I, u-I a-o, a-o)
5.
Structural
Anomaly

66. Increase Vowel Repertoire
• Take a vowel inventory
▫ Target vowels in isolation (a)
▫ In strings (a,a,a,a)
▫ In opposition (u-I, u-I a-o, a-o)
5.
Structural
Anomaly

67. Increase Vowel Repertoire
• Take a vowel inventory
▫ Target vowels in isolation (a)
▫ In strings (a,a,a,a)
▫ In opposition (u-I, u-I a-o, a-o)
5.
Structural
Anomaly

68. Increase Consonant Inventories
• Hi
• Hello
• Hey
• Mommy
• More
• Me
• No
• Whoa
• Wow
• Honey
• Mamá
• No
• Mío
• Niña
• Niño
• Ojos
• En
• Mano
• Wawa – agua
BEFORE palate repair
LOW pressure words to target
5.
Structural
Anomaly

69. Increase Consonant Inventories
• Baby
• Boy
• Pop
• Pooh
• Pie
• Toy
• Doll
• Daddy
• Cookie
• Go
• Papá
• Bebé
• Boca
• Gato
• Todo
• Tú
• Tío
• Qué
• Ten
AFTER palate repair
HIGH pressure words to target
5.
Structural
Anomaly

70. Increase Vocabulary
• Sounds and vocabulary develop in tandem
• Do we:
▫ Focus on articulation to give her the sounds to
produce more language?
▫ Focus on language to give her a way to practice her
sounds?
Any ideas?
5.
Structural
Anomaly

71. Increase Vocabulary
• Vocabulary development should be targeted with
sound development
▫ Choose words that:
 Are common and in their environment
 Are useful
 Are extremely fun
(read: routines-based intervention)
• Syllable should be simple CV (consonant/vowel)
• Start with stops and bilabial sounds
5.
Structural
Anomaly

72. Increase Oral Airflow
• A child with a cleft does not have control over
the air leaving their throat
• In typical development we stop or slowly
release this air to produce speech
• Regardless of what surgeries a child has
undergone, we need to familiarize the child
with airflow through the mouth
5.
Structural
Anomaly

73. Increase Oral Airflow
• A child with a cleft does not have control over
the air leaving their throat
• In typical development we stop or slowly
release this air to produce speech
• Regardless of what surgeries a child has
undergone, we need to familiarize the child
with airflow through the mouth
5.
Structural
Anomaly

74. Increase Oral Airflow
• Request an easy repetition (muh,muh,muh)
▫ After the child starts repeating, plug his nose
• Inhale deeply, hold your breath, and explode out
with a single sound
▫ BUH!, PUH!
5.
Structural
Anomaly

75. Decrease Use of Nasal and
Glottal Sounds
• Growls and nasal sounds are typical for young infants
but children with clefts obtain these sounds later
• Parents, wanting communication, reinforce these
sounds
• Acknowledge the child’s attempt but then requests
other consonants or sounds
• Pair voiceless consonants with whispered vowels
puh/tuh/ku/huh
• This keeps the glottis open and prevents the glottal
stop from occurring
5.
Structural
Anomaly

76. VPI Pyramid
Click here to download this chart as a pdf.

77. Resources
• www.cleft.com
• 1-800-24CLEFT
• www.operationsmile.org
• www.widesmiles.org
• The story of Lippy the Lion
• The story of Thumper, the Cleft Affected
Bunny
• www.bilinguistics.com

79. Click to visit www.bilinguistics.com

80. Difference or Disorder?
Understanding Speech and Language
Patterns in Culturally and Linguistically
Diverse Students
Rapidly identify speech‐language
patterns related to second language
acquisition to
distinguish difference from disorder.