Dr. Maram Al-Khaledi
Assistant Professor (PhD)
Department of Communication Disorders Sciences, College of Life Sciences
Kuwait University
Children with cleft lip and/or palate can develop speech and communication difficulties in different ways. There are differences in how children with a cleft lip and/or palate will develop in terms of their speech and language. It is usually not until the child begins to speak and form speech that the problems in his/her speech will be clear. Most children with a cleft lip and/or palate will need speech therapy at some point in their life. Any problems noticed in the child’s speech or language must be treated early, therefore, a child with a cleft lip and/or palate will have an many assessments from birth onwards. Speech and communication monitoring begins from birth, however a speech and language assessment begins at around 18-24 months of age, and another assessment is done at around 3 years of age. Treatment and management will be recommended if the speech-language pathologist (SLP) thinks it is necessary.
Speech-Language Pathology
Speech-Language Pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of speech and language problems that children with cleft lip and/or palate may have, along with the feeding and swallowing problems that may also be present at birth. This is because a cleft lip and palate will affect the lip, nose, gum and/or palate leading to many problems including swallowing and feeding difficulties. Sometimes the ears are also affected indirectly, causing hearing problems. It is important that hearing is also checked for children with a cleft lip/palate.
The first two years of a child’s life are the most critical years for speech and language development. This is why newborns with cleft lip and/or palate will require continuous monitoring and management by a team of professionals that includes the SLP. If a child has a cleft lip only, speech should be typical or very close to typical as long as there is no hearing loss or other problems. A SLP should see a child with cleft lip and/or palate often in the first two or three years of his/her life to monitor the speech and feeding development over time and watch for any changes.
The SLP’s professional roles include the diagnosis, assessment, planning, and treatment of speech, language and feeding problems that a child with a cleft lip and/or palate may have. The SLP will work very closely with other healthcare professionals in a team (Cleft Lip/Palate or Craniofacial Team). More importantly, the SLP will work with the parents. Parents will be the “therapist at home”, and they will follow and encourage correct speech habits and correct the wrong speech habits that can cause more problems for the child.
Working with the child on his/her speech and language will begin early before they have surgery to correct their cleft lip and/or palate and will continue as they grow older. The aim of speech therapy is to have the child gain good quality (clear), intelligible (understandable) speech by age 5 or 6 years.
Speech Development
Children with cleft lip and/or palate may develop speech and language at a slower rate compared to other children, and will have speech that does not sound clear or typical before surgery is performed.
Another common problem is the delay in language development for some children with a cleft lip/palate. This is usually because parents and caregivers may not understand a child’s early attempts at words; therefore, they will not reinforce or encourage the child’s speech to help in the development process of language.
The speech of children with cleft palate tends to improve and recover after the surgical repair of the cleft, and as a result speech will take around 5 years to “catch up” with the speech development of other children their age. During this critical time, some children will require more surgeries, or a speech aid prosthesis (devices) as well as speech therapy to help them catch up and improve their speech. This is why it is important that there is continuous follow up with a SLP who is experienced in cleft lip and palate care to assess and monitor progress of the child.
Timeline
Speech, language and feeding assessment is usually done by a Speech-language pathologist (SLP). This is to help in diagnosing a speech, language, resonance (forming speech sound) and/or voice problems as well as any feeding difficulties at birth. A speech assessment also helps to understand the type of speech and/or language problem the child may have, its severity, and what is causing it. More importantly, it will help with knowing if speech therapy will be needed and when.
Speech therapy is usually initiated anytime from 20 months to 2 years of age or even later. This depends on if the child shows unclear speech, nasal sounding speech or if there is a delay in language skills.
Below this article a file is included which is an example of a timeline that is generally used for speech issues during the first few years of the child’s life.
Newborns and Babies (0 – 5 Months)
- Feeding and swallowing assessment are the main concerns at this stage.
- The speech and language of a baby can be assessed at this stage even before they develop their first real words.
- Babies follow a specific course of speech and language development.
- Observing the baby’s sucking, blowing, and chewing is important at this stage. This is because these activities involve using the muscles of the mouth, which are important for speaking. Therefore, they can tell a SLP about a baby’s ability to speak and eat later in life
- Babies make many sounds like cooing and babbling before they start talking (e.g.,/ooooh/, /eeeeh/, /dadada/).
- These sounds and other social behaviors like eye contact are important indications of speech and language development (communication).
Toddlers (6-12 Months)
- Screening is usually the first step in a speech/language assessment. The screening procedure involves the SLP observing the child for signs of:
- Problems seen inside and/or outside the structures of the child’s mouth and throat (e.g., an opening in the tissue). This is called an Oral-motor exam.
- Nasal airflow problems when the child is speaking or communicating, causing nasal sounding speech.
- Speech sound errors; difficulty forming and producing some speech sounds that may be due to problems in the structure of the mouth or palate
- The SLP must counsel and educate parents on how to communicate with their infant who is developing speech and language.
- The SLP will tell parents to not use “glottal-play sounds” when playing with their baby. These are sounds produced in the back of the throat and needs putting pressure. Parents are asked to use babbling sounds instead, which are easier for the baby to imitate and do and to use anterior phonemes (frontal sounds like /w/ /j/ /m/ /n/ /p/ /b/).
- Speech and language are typically assessed 6-8 weeks after surgery by the SLP.
- Resonance is how airflow is passed through the mouth and nose during speech. Children with cleft palate will usually have a problem with resonance. Resonance is the quality of sound, and a problem with resonance happens when the soft palate in the back of the throat, fails to go up and close against the back of the throat. This causes increased airflow through the nose and nasal-sounding speech when the child speaks.
- Children with a cleft lip/palate will have difficulty shaping the sounds in their throat and mouth because of the cleft or opening in the palate, which will cause too much air to go through the nose (Hypernasality).
- The SLP will have to monitor the child for a resonance disorder (nasal sounding speech)
1 to 3 Years
- Speech is assessed every 4-6 months after surgery to make sure the child’s speech is clear and non-nasal. Monitoring for a resonance disorder or nasal-sounding speech is important.
- A further assessment takes place at around 3 years of age and treatment is recommended for speech and language disorders, if needed.
- Assessments for speech problems at this stage and even later, may involve an imaging procedure to see the structures in the mouth and make sure there are no problems in the structures (openings in the roof of the mouth) This imaging procedure is known as Nasoendoscopy or Videofluoroscopy “VFS”.
Young Children (3 - 5 Years)
- A Screening test may be done to check the development and changes in the child’s speech.
- A detailed assessment may also be done at this stage. This is usually a longer process to see the bigger picture. It includes a hearing test as well as speech and language tests.
- A detailed assessment is done if the SLP suspects delays in speech and/or language in a child with cleft lip and/or palate, after the screening is done. Some infants and toddlers with clefts may be assessed by an SLP even before they are seen by the team.
- An assessment is needed at this stage to also determine if there is a problem with air flowing through the mouth or nose during speech (nasal sounding speech).
- If the SLP suspects nasal sounding speech, it will be reported and imaging will be requested to check the structures of the child’s oral cavity.
- There may also be continued assessment and therapy for articulation (forming and producing speech sounds correctly) and language disorders.
School-age Children, Adolescents and Adults (6 + Years)
- There is continuous assessment and management of speech and language problems the child with a cleft lip/palate may continue to have.
- There is usually speech therapy for the correction of any articulation errors (forming and producing speech sounds correctly) and language disorders that continue to be present.
- (see previous section for explanation of speech and language difficulties)
Speech Therapy
Early intervention is very important in the correct development of speech and language in children with cleft lip and/or palate. These children can have problems with language and difficulties producing some speech sounds making their speech unclear and difficult to understand. Speech therapy will focus on speech skills and language before and after surgery. This helps prevent further problems with speech and/or language delays that can happen later in the child’s life.
Speech and language difficulties can be any of the following:
- The baby’s babbling (early speech) is limited (few sounds produced).
- Delay in developing words and word combinations (the beginning of making sentences).
- Slow growth in the child’s vocabulary.
- Limited sounds produced in older children.
- Speech sound and articulation errors (difficulty producing and placing sounds correctly), making speech unclear.
Communication problems can be identified before a baby begins to speak; therefore, to prevent future speech and language problems and help normal development, SLPs must see the baby early.
Parents can help in this process by being involved early on with their child’s speech therapy. This can be by:
- Early stages (before surgery): Parents can help by saying speech sounds to their baby to help them babbling (make early sounds), teaching the child their first words and playing games to teach them vocabulary or new words.
- Later stages (after surgery): Parents can teach new sounds to their child. If the child does not develop new sounds over time or makes errors this may indicate a problem and that means the child will need to be checked again by the team.
- Lastly, as the child grows older, teaching him/her correct airflow through the mouth and nose for certain speech sounds is important. This can be done through blowing activities the SLP will teach the parent. This helps the child improve the way their speech sounds making it clear and easy to understand.
If you have any further questions, contact a speech-language pathologist.
Find a speech-language pathologist near you:
- Salem Al-Ali – Department of speech-language pathology
- Jaber hospital – Department of speech-language pathology
Helpful Links
References
- King Faisal Specialist Hospital & Research Center
- American Speech-Language Hearing Association (ASHA)
- American Cleft Palate-Craniofacial Association (ACPA)
- Kummer, A.W. (2008). Cleft Palate and Craniofacial Anomalies: The Effects on Speech and Resonance, 2nd Edition. New Albany, NY: Delmar Cengage Learning
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