An overview of speech and language therapy in a cleft lip and palate team part 6

Description of patient group

Fundamentally, there are two types of patient that a Specialist Speech and Language Therapist in a cleft lip and palate team is involved with:

A complete or incomplete cleft lip only is not likely to impact on speech, although it is possible for a child with a cleft lip to have a speech and language problem, like any other child, but this will be unrelated to the cleft lip. However, it needs to be emphasized that a submucous cleft palate (SMCP) is more likely to co-exist with a cleft lip. Although it is a congenital defect, an SMCP may not be detected at birth. In an SMCP, the structures of the oral surface are intact, whereas the underlying structures of the palate are abnormal.

An SMCP is rare and occurs in between 0.02 and 0.08% of the population.⁵ However, 13% of children with a cleft lip may have an SMCP.⁵ Therefore, a child with an SMCP is as likely to have speech, language and resonance problems as a child with a cleft palate. Between one quarter and one half of children with an SMCP will have hypernasal resonance (too much air flow resonating in the nasal/oral cavities). Similarly, the incidence of VPI following primary repair of the cleft palate is reported to be between 5 and 40%.^6,7

Children with CLP/VPI may present with any, or a combination of, the following which the SLT will become involved with: language, articulation, resonance and/or phonation difficulties. Some children may also need support with feeding and/or swallowing difficulties in conjunction with the clinical nurse specialist.

The role of the Specialist Speech and Language Therapist (SLT) in a cleft palate team

The Specialist SLT is an integral member of the cleft lip and palate team. In the CSAG report⁸ it states that speech and facial growth are the primary outcomes in determining surgical success. The list below gives a reasonable outline of the duties of the SLT:

Speech and language therapy assessments

In addition to assessing a child's language levels and listening skills, there are three key areas to assess in a child with CLP/VPI:

It is crucial that a correct diagnosis is made regarding resonance as the diagnosis will influence the management. For example, if a child is hyponasal (not enough air resonating in the nasal chambers), a referral to ENT would be most appropriate. However, if the child sounds hypernasal (too much air resonating in the nasal chambers), this is more likely to be due to there being a velopharyngeal gap, and palatal surgery may be indicated, after a detailed assessment by the Specialist SLT in the CLP team. A wrong diagnosis could be disastrous to the child, therefore, it is imperative that the child is differentially diagnosed by the Specialist SLT and members of the cleft palate team before any surgical intervention.

The speech errors or cleft type characteristics that a child with a cleft palate can make are complex. For more information on cleft type (speech) characteristics, the reader is advised to read Chapter 16 in Management of Cleft Lip and Palate by Watson, Sell and Grunwell.⁹

A detailed speech and language therapy assessment always includes obtaining a spontaneous speech sample, if the child is capable and/or old enough, as well as rote speech (such as counting), imitation of a few sounds and repetition of standard sentences. A national assessment form is used called the GOS.SP.Ass,¹⁰ which allows the speech to be systematically recorded using phonetic transcriptions. Audio recordings are usually made at the time of assessment.

Speech and language therapy assessment care pathway

There are national guidelines for the timing of Speech and Language Therapy Assessments, to which all 11 regional centres in the UK adhere, with some variation across centres regarding the timing and format of assessments under age 5.

Children with CLP/VPI are assessed at the following ages in the Northern and Yorkshire Regional Cleft Lip and Palate Service:

It is the remit of the SLT to assess, manage and treat the speech and language needs of children and young people with CLP/VPI. Following the 18 months–2 year assessment, a child's speech and language will be categorized in the following ways:

If the child is in categories 2 or 3, he/she will be carefully monitored and reviewed by the Specialist SLT in conjunction with the Community SLT and/or Link SLT, who is usually a Community SLT specifically trained to support children with CLP/VPI. Early diagnostic SLT may be offered in order to gain more information about the nature of the difficulty. In addition, a child with a cleft palate demonstrating developmental delay and associated speech and/or language difficulties, such as in the case of a child with an associated syndrome, may be referred to a community SLT for more generic help, support and advice.

If a sufficient speech and language sample is obtained at the 3-year assessment, the SLT can more confidently hypothesize about the child's velopharyngeal status. If hypernasality is suspected, a period of diagnostic therapy may be offered to try to establish whether there is any variability in hypernasality or not, and the degree of hypernasality, ie mild, moderate or severe. If the hypernasality is perceived as consistent, and the degree of severity is noted, the child will be referred back to the multidisciplinary team for further assessment and discussion of whether further objective assessment, such as videofluoroscopy, is required to determine the function of the velopharynx. (A nasendoscopy may be indicated but not, however, until the child is 4–5 years of age, as he/she is unlikely to tolerate it when younger.)

If a lateral videofluoroscopy is undertaken and there is evidence of a velopharyngeal gap, the child may then be referred for further palatal surgery, if appropriate.

All children who require surgery to correct VPI will be offered a full speech assessment immediately prior to surgery, six weeks post palate repair and then one year post palate repair. Although the exact timings for assessments may vary across centres, this is the general approach. At each assessment, an audio recording will be made for the records.

Influencing factors

Speech and language therapy may be offered to children with articulation and/or language difficulties from infancy up to teenage years and sometimes beyond, where appropriate. Speech and language therapy will not correct hypernasality as this is a structural problem, but can be very successful in ameliorating speech difficulties. The success of speech and language therapy intervention, however, will be influenced by many factors.

A child with an articulation problem may have co-occurring hypernasality, which may make it much more difficult for the child to produce the targeted sounds in SLT owing to a reduction in intra-oral airflow. It is the task of the Specialist SLT to target appropriate sounds which are achievable for the child.

A fistula or hole in the hard or soft palate can also make it challenging for the child to produce a sound with enough intra-oral air pressure, so the SLT must take this into account when working on speech sounds.

A child's hearing levels have a huge influence on how successful speech and language therapy intervention will be. It is vital that a child with CLP/VPI has regular hearing checks.

A child's age can also influence success or otherwise of SLT. A pre-school child may be easier to influence in terms of sounds, however, his/her concentration/attention span may make it difficult to target speech sounds specifically. A school-aged child may be more used to adult led activities, but it may be that his/her speech pattern has become more entrenched and therefore harder to ameliorate, especially if he/she started talking at a young age.

Establishing a child's cognitive level is vital as it will influence the type and frequency of SLT that is implemented.

The level of motivation that the child and family show should not be underestimated. It is often a balancing act, between trying to encourage the child to produce new and unfamiliar sounds, but not overdoing it so that the child becomes demotivated.

The logistics of offering SLT appointments can also be challenging. In the UK today, the majority of SLT is delivered in school where the Specialist SLT works in collaboration with teachers/special educational needs co-ordinators and/or teaching assistants. It is of great value to collaborate with our education peers; however, it can be challenging working in schools as staff may not be sufficiently informed regarding SLT. They may know even less about CLP. It is the task of the Specialist SLT, therefore, to inform and educate staff and deliver appropriate therapy at a suitable level for the child and his/her staff in school, in collaboration with the family.

Summary

The Specialist SLT is an integral member of the cleft palate team as speech is one of the outcome measures of surgical success. It is important to adhere to a standardized assessment protocol and care pathway. A representative speech sample of the child's speech must be obtained at the outset in order to determine appropriate and timely management. Resonance is outlined briefly in this article. It is crucial that an accurate diagnosis is made as management will differ according to whether the child is hyper or hyponasal. Finally, factors influencing outcome are briefly mentioned, such as the structure of the palate, hearing and cognitive levels. The motivation of the family and child should not be underestimated. Finally, effective collaboration between parents, colleagues in health, education and social care is the aim for the most successful outcomes.