Can Speech Therapy Help a Child with Repaired Cleft Palate?

Who Provides Therapy? Individuals who provide speech therapy are called Speech-Language Pathologists (SLPs). SLPs usually have at least master’s level graduate training (they must have a master’s degree to be certified by the American Speech-Language-Hearing Association, ASHA). Similar to medical doctors, SLPs usually specialize in certain areas and with certain age groups — for example, childhood speech and language disorders, adult neurogenic disorders, voice disorders, cleft palate or craniofacial disorders. A parent of a child with a repaired cleft palate should seek the services of a SLP who works extensively with children. Although experience with cleft palate is a plus, it is not required in all cases. The SLP that you select should not only be knowledgeable about childhood speech disorders, but also possess good interpersonal skills and be able to relate well to children. Don’t be afraid to trust your instincts. And don’t be afraid to change therapists if one doesn’t seem right for your child.

Therapy for What? This might seem like a silly question, but it is perhaps the most important one to ask. In the traditional sense, speech therapy is meant to help children who have disorders of speech and/or language. In my local newspaper (Cary, NC), an advertisement for a SLP states that services are provided for problems such as “lisping” and “baby talk.” While children with repaired cleft palate may “lisp” and/or use “baby talk,” they may do so for different reasons than children without cleft palate. The key is for the SLP to know which problems can be successfully treated and which ones cannot be successfully treated.

Developmental and/or Phonological Articulation Errors. Approximately 6 to 10% of all children (boys somewhat more frequently than girls) will exhibit difficulty in learning the sounds of English and will require speech therapy. This therapy is usually provided through the school. Most of these children will have no obvious structural problems with the mouth and no major hearing problems, yet they will omit, distort, or substitute certain speech sounds. Difficulty with sounds such as /r/, /l/, and /s/ are very common in young children. The reason for such errors might be related to subtle problems with hearing and/or learning. Regardless of cause, the majority of these children will learn to correct their speech errors through therapy and go on to lead normal lives. Children who are born with cleft lip and/or palate are not immune from these types of speech problems. If a child with a repaired cleft palate has developmental speech errors, then traditional types of speech therapy should be successful.

At times, a young child with repaired cleft palate may use primarily nasal substitutions. That is, the phonemes /m/ and /n/ are used pervasively for all oral pressure consonants (e.g., bye sounds like my). Some SLPs believe that this is a sure sign that the child needs additional palatal surgery. Recent research, however, has shown that this may actually be a developmental/phonological error in some children and speech therapy, not surgery, is needed.

Obligatory Symptoms of VP Inadequacy. About 20 to 30% of children with repaired cleft palate will not have adequate velopharyngeal (VP) closure for speech. In these children, either the soft palate is too short to reach the back throat wall (insufficiency) or the soft palate does not move enough to reach the back throat wall (incompetency). When either VP insufficiency or incompetency is present, obligatory symptoms such as hypernasality and audible nasal escape will occur to various degrees. Hypernasality is primarily an acoustic/resonance phenomenon that occurs on vowels and voiced consonants. Nasal air emission is primarily an aerodynamic event that occurs on consonants, especially voiceless ones. Even if the child does not have articulation errors, these symptoms may be distracting to the listener and cause speech to be difficult to understand. At times, well-meaning surgeons will prescribe speech therapy for these symptoms, especially following unsuccessful secondary palatal surgery. Parents and SLPs, however, need to be informed that speech therapy – even by the most experienced SLP – will not correct obligatory symptoms. There is one exception, perhaps, that is discussed below. Because obligatory symptoms are the result of inadequate physical separation of the mouth and nose, surgery or prosthetic management, not speech therapy, is needed to correct these problems.

Parents need to be warned that some SLPs will nevertheless recommend non-speech oral exercises for obligatory symptoms in the mistaken belief that the child has weak VP muscles. One such exercise is sucking thick liquids such as a milkshake through a straw. Children with repaired cleft palate do not have weak muscles – unless they also have cerebral palsy – and sucking exercises will not eliminate hypernasality. Parents need to reject any recommendations to treat hypernasality by non-speech exercises such as sucking.

As mentioned above, there is one type of obligatory symptom that might respond to speech therapy – audible nasal turbulence (also called “rustle” by some clinicians). This is a rather loud and distracting form of nasal air escape that often occurs during stop consonants when there is a small VP gap. Because the VP port is almost closed, the escaping air causes the tissue of the port to flutter, similar to a raspberry that can be produced with the lips. Because VP flutter, like a lip raspberry, is caused by relatively high oral air pressure, reducing vocal effort should theoretically stop the flutter. We recently reported a case where a 4-year-old boy with repaired cleft palate had frequent nasal turbulence with flutter (Zajac and Eshghi, 2018). He also had an excessively loud voice that we thought was contributing to the flutter. We asked his SLP to target reduced loudness during speech therapy. After only a few sessions, the boy’s excessive loudness was reduced and nasal turbulence with flutter was largely eliminated.

Compensatory Articulation Errors. Some children with repaired cleft palate may develop non-oral articulations to compensate for velopharyngeal (VP) inadequacy. This means that the child will produce sounds in the throat and voice box rather than the mouth. For example, instead of using the lips to stop airflow to produce /p/, the child might use the vocal folds, called a glottal stop substitution. Or, instead of using the front of the tongue to constrict airflow to produce /s/, the child might use the back of the tongue in the throat, called a pharyngeal fricative substitution. Because the child is not attempting oral articulations, he/she is circumventing a defective VP valve that largely eliminates nasal air escape. Often, however, the child will sound hypernasal due to VP inadequacy. Many SLPs will tell parents that they cannot do anything to help the child until additional surgery is completed. Unfortunately, this is only half true. Although surgery may be needed to improve VP function and reduce hypernasality, it will not correct compensatory articulations. Speech therapy, therefore, can begin before surgery as long as the SLP targets articulation, not hypernasality or nasal air escape. To do so, the SLP may need to occlude the child’s nose during therapy to prevent nasal air escape and allow the child to focus on correct oral placements for articulation.

Obligatory Oral Distortions. Typically, many children with clefts that involve the gum (alveolar) ridge will distort the sounds /s/, /z/, /ʃ/ (as in shoe), and /ʒ/ (as in measure). These sounds are called sibilants. To produce these sounds, air must be channeled over the tongue and strike the front teeth. This causes the air to become turbulent (a hissing-like sound). If teeth are missing or misaligned, then the sound will be distorted. Many children with clefts of the gum ridge also have restricted (or collapsed) upper dental arches. This condition may cause a posterior cross bite (upper teeth not meeting lower teeth) that allows lateral escape of air, a distortion called a lateral lisp. A posterior cross bite may also distort /tʃ/ (as in chew) and /dʒ/ (as in judge). We have also reported that posterior cross bites are associated with backed (palatalized) distortions of the stop consonants /t/ and /d/ (Zajac et al., 2012). Depending on the type and severity of the dental anomaly, speech therapy might or might not help to correct sibilant distortions or palatalized stops. If the child is stimulable to correct the distortion, he/she will need to consciously monitor his/her speech until the dental anomaly is corrected with orthodontics. This is an effort that most young children are not likely to make. Following orthodontic treatment, one might expect that sibilant distortions and/or palatalized stops might spontaneously resolve. This may or may not occur. Regardless, the benefits of speech therapy should be greater following orthodontic treatment. For this reason, we typically do not recommend speech therapy for obligatory oral distortions until completion of orthodontic treatment.