When a parent first finds out their child has a cleft lip or palate, they often have many questions about whether their child will need speech therapy. After all, their child will have a surgery in their mouth as a baby. As a speech-language pathologist with over ten years of experience working on cleft palate teams, I’ve been able to meet thousands of families of kids with cleft palate or other craniofacial anomalies. Speech makes up a big part of the journey of little ones born with a cleft—but how do you know if your child with cleft palate needs speech therapy?
How does a cleft palate affect communication development?
A cleft palate does create differences in how young children learn to develop speech sounds. The main issue is that babies with a cleft palate struggle to seal the nose from the mouth when trying to build up pressure for sound play and early consonants. You can read more about the impact of a cleft on speech development and more about early articulation development if interested.
Because babies can’t experiment with early oral pressure build up, they struggle with learning consonant sounds that depend on pressure build up to sound accurate. As a result, a baby with an unrepaired cleft palate may be reliant on sounds like /m/, /n/ and /y/. They may also start to experiment with growling sounds, which are a form of early sound play in the throat.
What are the goals of cleft palate speech services?
Speech therapy focuses on two main goals for young kids with cleft palate. First, we want to improve speech intelligibility, or how well others understand a child. Second, we want to closely monitor the little one to make sure their palate works well for speech.
Goal 1: Improving intelligibility
When we talk about improving intelligibility, we want to help kids communicate clearly to express their wants and needs. To reach this goal for kids with clefts, articulation therapy often focuses on teaching placement for specific sounds. Because the cleft palate reduces the baby’s ability to practice pressure build up for speech sounds, some kids with cleft palate mislearn how to make consonant sounds. Instead of making consonants in the mouth, they may make these sounds, like /b/, /p/, /t/, and /s/, in the throat. Substituting throat sounds for mouth sounds makes a speaker hard to understand! And, if these errors become habits after many years of speaking, the habits become harder to change. Luckily, speech-language pathologists have many techniques to help correct these error patterns, which we’ll discuss in the next section.
Goal 2: Monitoring how the palate functions for speech
This goal requires teamwork! It’s important to have ongoing communication between the family, the cleft palate team, and the therapist who sees the child for regular sessions (for more about how to choose a therapist for your child with cleft, read this article). The team SLP and treating SLP will both listen as your child says different pressure consonants to make sure there is no air leaking from the nose. When a child makes sounds in the throat, it’s impossible to know how well the palate works because they’ve learned a clever trick to avoid needing to use it. So the two goals of speech therapy for cleft palate go hand in hand—as a child learns to make more sounds, we can learn more about how the muscles of the palate work. And working palate muscles help support further articulation progress. The need for these two hands of therapy to work together leads to routine team check ups, and regular speech therapy sessions for many kids.
How does speech therapy work for kids with cleft palate?
Now that we’ve introduced the two main goals of speech therapy for cleft palate speech problems, let’s talk about how speech therapists address these goals!
Speech therapy for cleft palate articulation errors
When a child has cleft palate related articulation errors, this means they’ve learned to use a different placement of articulation for a pressure consonant. So, the speech-language pathologist will use techniques to help teach them the correct placement. The overall sequence of this therapy uses principles of motor learning to teach a new motor skill and then provide many opportunities for practice so that the new skill becomes automatic.
Here are a few ways that therapists teach sound placement:
- Use an existing sound to teach a new sound. For example, if a /t/ sound is prolonged, it often sounds like /s/.
- Use a facilitating context. Some sounds are just plain harder in certain words. For example, when a child substitutes a pharyngeal (throat) stop for a /k/ or /g/, it can be really hard to make the /k/ sound around a vowel like “oo” or “uh” because these vowels are made farther back in the mouth. The back vowel in the same word just makes it too easy to slip back into the throat for the /k/ or /g/. Instead, putting the /k/ or /g/ in front of a high front vowel like “ee” can make it much easier for a learner to succeed, so early targets may include short words or syllables like “key” or “gih.”
- Give lots of information about how the sound is made. We call these “verbal placement cues” and they basically involve telling the child how to make the sound. Depending on the age and language ability of the child, these could be very simple, like “use your lips not your throat,” to more sophisticated instructions for older children, teenagers, or adults, like “that error is the pharyngeal fricative we learned about, remember you need to hold your tongue just behind your upper teeth and let the air flow over it.”
- Use mirrors or show the child a visual of how the sound is made. Visual cues are helpful for learning and self-monitoring. By letting the child see themselves alongside an adult model, it can be easier to match the movement. Using diagrams of how the sound is produced is another kind of visual aid that can support learning.
- Use nostril occlusion along with any of the above techniques. Therapists cover the nose to help kids experience the sensation of pressure build up in the mouth when learning these oral consonants for the first time. Read here for a description of nostril occlusion along with tips to use this when teaching a /b/ for the first time.
- Whatever works! Speech-language pathologists are professional trouble-shooters when it comes to helping kids learn how to make sounds. There are endless variations of the techniques above, plus many more, that an experienced clinician may draw from to help a speaker learn to make a sound.
After the child has learned to make a sound, then the next step of therapy is to practice, practice, practice. We call the goal of this repetition “generalization.” This means that we want the newly learned motor habit to become automatic enough that it starts to replace the error in conversational speech. Once the child can produce the sound correctly, then the more practice the better! That’s why Verboso includes access to our articulation games as part of our therapy subscription. The therapist teaches your child to produce the sound, and then they practice, practice, practice with our games designed for speech motor learning.
Speech therapy for cleft palate structural problems
Can a speech therapist correct nasal speech? The short answer is no, but the long answer is, it depends on why the child sounds nasal.
As mentioned above, routine monitoring of how the cleft palate repair is working for each child makes up a major goal of speech therapy management for kids with cleft palate. When children are seen for their annual team appointments, the team SLP will conduct an assessment to listen for any cleft articulation errors and note any potential concerns with palatal function. The term for problems leaking through the nose is Velopharyngeal Dysfunction. The goal of the cleft team therapist is to determine if any nasality or airflow leak points to mislearning or a structural problem.
When the conclusion of the testing is that a structural problem exists, then only a structural solution can correct the airflow leak. The two main types of solutions are surgery and prosthetics. A plastic surgeon, ENT, or oral surgeon completes the surgery, and an orthodontist, dentist, or prosthodontist makes prosthetics for speech. The SLP collaborates with these professionals to help ensure the best outcome for speech. However, it’s important to note that an SLP cannot eliminate hypernasality with exercises in speech therapy. Activities like blowing bubbles and sucking through straws, no matter how big or small, will not strengthen the palate to reduce nasal speech. Unfortunately, these activities only take time away from focusing on the critical goals that speech therapy can improve, like working on correct articulation placement for better ability to be understood.
But how do I know if my child with cleft palate needs therapy?
Some figures report that over half of kids with cleft palate will need speech therapy. In a research study that I was part of with some colleagues, we found that over 80% of about 140 kids with cleft palate in the study had some history of speech therapy. Based on these reports, most kids born with a cleft palate will need speech therapy, but not all. The best way to help get the best possible outcome for your child is to find a team that treats a lot of kids with cleft each year. From there, the cleft team SLP can help you understand if your child needs regular therapy also.
At Verboso, we’re happy to be a part of your cleft palate team by providing direct one-on-one teletherapy sessions with our licensed and certified SLPs! Want to learn more about Verboso’s solutions for cleft palate speech problems? Learn more or sign up for your free screening!