Cleft Palate Speech E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 694

Veröffentlichungsjahr: 2011

Beschreibung

The focus of this book is on speech production and speech processing associated with cleft palate, covering phonetic (perceptual and instrumental), phonological and psycholinguistic perspectives, and including coverage of implications for literacy and education, as well as cross-linguistic differences. It draws together a group of international experts in the fields of cleft lip and palate and speech science to provide an up-to-date and in-depth account of the nature of speech production, and the processes and current evidence base of assessment and intervention for speech associated with cleft palate. The consequences of speech disorders associated with cleft on intelligibility and communicative participation are also covered. This book will provide a solid theoretical foundation and a valuable clinical resource for students of speech-language pathology, for practising speech-language pathologists, and for others interested in speech production in cleft palate, including researchers and members of multi-disciplinary cleft teams who wish to know more about the nature of speech difficulties associated with a cleft palate.

Leseprobe

Table of Contents

Cover

Title page

Copyright page

List of Contributors

Preface

Part One: Speech Production and Development

1 Physical Structure and Function and Speech Production Associated with Cleft Palate

1.1 Introduction

1.2 The Hard and Soft Palates and the Velopharynx

1.3 The Tonsils and Adenoids

1.4 The Larynx

1.5 The Jaws, Dentition and Occlusion

1.6 Symmetry: Structure and Function

1.7 The Tongue

1.8 The Lips

1.9 Summary: Compensations Across Systems

2 The Development of Speech in Children with Cleft Palate

2.1 Overview

2.2 The Impact of Clefting on Speech Production

2.3 Variables Impacting Speech Development for Young Children with Cleft Palate

2.4 Speech Development: Birth to Age Five

2.5 Conclusion

3 The Influence of Related Conditions on Speech and Communication

3.1 Introduction

3.2 Conditions Related to Structural Etiologies

3.3 Conditions Related to Neurological Aetiology

3.4 Conditions Related to a Combination of Structural and Neurological Aetiology

3.5 Clinical Implications

4 Surgical Intervention and Speech Outcomes in Cleft Lip and Palate

4.1 Introduction

4.2 Basics of Surgery on Cleft Palate

4.3 Basics of Outcomes

4.4 Speech Outcomes

4.5 Conclusions

Appendix 4.A Review of Evidence and Methodology in Studies of Speech Outcome in Individuals Born with Cleft Lip and Palate

5 Secondary Management and Speech Outcome

5.1 Introduction

5.2 Secondary Surgical Management of Velopharyngeal Incompetence

5.3 Secondary Pharyngeal Flap

5.4 Posterior Pharyngeal Wall Augmentation by Muscle Transposition

5.5 Studies Comparing Treatments of VPI

5.6 Posterior Pharyngeal Wall Augmentation by Implants and Injections

5.7 Velarplasty

5.8 Other Considerations in Managing VPI

5.9 Complications Secondary to Pharyngoplasties

5.10 Conclusions

6 Cleft Palate Speech in the Majority World: Models of Intervention and Speech Outcomes in Diverse Cultural and Language Contexts

6.1 Introduction

6.2 Speech Outcomes in a Majority World Context

6.3 Different Models of Provision

6.4 Attitudes/Cultural Aspects

6.5 Conclusion

Part Two: Speech Assessment and Intervention

7 Phonetic Transcription for Speech Related to Cleft Palate

7.1 Introduction

7.2 What is Phonetic Transcription?

7.3 Why Transcribe?

7.4 What to Transcribe and How to Transcribe It

7.5 Features of Cleft Speech Production

7.6 Pitfalls of Transcription

7.7 Conclusion

Appendices

8 Instrumentation in the Analysis of the Structure and Function of the Velopharyngeal Mechanism

8.1 Introduction

8.2 Visualization of the Velopharyngeal Mechanism

8.3 Multiview Videofluoroscopy

8.4 Nasendoscopy Procedure

8.5 Magnetic Resonance Imaging (MRI)

8.6 Variability in Practice

8.7 Future

9 Cross Linguistic Perspectives on Speech Assessment in Cleft Palate

9.1 Introduction

9.2 Vulnerable Speech Sounds

9.3 Language Background of the Listener Assessing the Speech of Children with Cleft Palate

9.4 What Is Known about More Unfamiliar Languages?

9.5 Cross Linguistic Speech Samples

9.6 Influence on Assessment of Language Acquisition in the Young Child with Cleft Palate

9.7 Conclusion

10 Voice Assessment and Intervention

10.1 Introduction

10.2 Defining a Voice Disorder

10.3 Assessment

10.4 Instrumental Assessment

10.5 Vocal Handicap Measures

10.6 Treatment

10.7 Conclusion

11 Nasality – Assessment and Intervention

11.1 Introduction

11.2 Perceptual Assessment of Nasality and Nasal Airflow Errors

11.3 Instrumental Assessment of Nasality and Nasal Airflow Errors

11.4 Interpreting Results

11.5 Intervention

11.6 Conclusion

Appendix 11.A Temple Street Scale of Nasality and Nasal Airflow Errors

12 Articulation – Instruments for Research and Clinical Practice

12.1 Introduction

12.2 Electropalatography (EPG)

12.3 Imaging Techniques

12.4 Motion Tracking

12.5 Conclusion

Acknowledgement

13 Psycholinguistic Assessment and Intervention

13.1 Introduction

13.2 What is a Psycholinguistic Approach?

13.3 A Psycholinguistic Assessment Framework

13.4 Intervention from a Psycholinguistic Perspective

13.5 Literacy: Phonological Awareness and Spelling

13.6 Summary

14 Early Communication Assessment and Intervention

14.1 Introduction

14.2 Assessment

14.3 Intervention

15 Phonological Approaches to Speech Difficulties Associated with Cleft Palate

15.1 Introduction

15.2 Variability, Variation and Compensation

15.3 Classification of Speech Difficulties Related to Cleft Palate

15.4 Phonological Assessment of Speech Data Related to Cleft Palate

15.5 Phonological Consequences of Speech Production Related to Cleft Palate

15.6 Intervention

15.7 Summary

16 Speech Intelligibility

16.1 Introduction

16.2 Definition of Intelligibility and Related Concepts

16.3 Measurement Issues

16.4 Studies of Intelligibility in Speakers with Cleft Palate

16.5 Current and Future Developments

16.6 Conclusion

17 Communicative Participation

17.1 Introduction

17.2 ICF

17.3 Communicative Participation

17.4 Conclusions and Clinical Implications

18 Evaluation and Evidence-Based Practice

18.1 Introduction

18.2 Intervention for Speech Disorders

18.3 Evidence-Based Practice

18.4 The Systematic Review Process

18.5 Evidence Findings Establishing Therapy Effectiveness

18.6 Instrumentation – Visual Feedback

18.7 Surgery

18.8 Comments about Intervention Effectiveness

18.9 Intervention and the International Classification of Function (ICF)

18.10 Research Designs for Intervention Studies

18.11 Conclusions

Appendix 18.A Commonly Used Evidence Hierarchies for Intervention Studies

Index

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Library of Congress Cataloging-in-Publication Data

Cleft palate speech : assessment and intervention/ [edited by] Sara Howard and Anette Lohmander.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-470-74330-0 (pbk.)

 1. Cleft palate children–Rehabilitation. 2. Articulation disorders in children–Patients–Rehabilitation. 3. Cleft lip–Treatment. 4. Cleft palate–Treatment. 5. Speech therapy. I. Howard, Sara. II. Lohmander, Anette.

[DNLM: 1. Cleft Lip–rehabilitation. 2. Cleft Palate–rehabilitation. 3. Articulation Disorders–rehabilitation. 4. Speech Therapy–methods. WV 440]

RJ496.S7C557 2011

618.92'855–dc23

2011014942

A catalogue record for this book is available from the British Library.

This book is published in the following electronic format: ePDF 9781119998570; ePub: 9781119970644; MOBI: 9781119970651

List of Contributors

Martin Atkinson

Martin Atkinson, PhD, is Professor of Dental Anatomy Education in the Academic Division of Oral Pathology, University of Sheffield, UK. He has been involved in teaching anatomy, physiology and neuroscience to Speech and Language therapy students in Sheffield since the inception of the course in Sheffield in 1978 and has won several awards for his teaching innovations. He is co-author of ‘Basic Medical Science for Speech and Language Therapy Students’ (John Wiley & Sons Ltd).

Lesley Cavalli

Lesley Cavalli, MSc, Cert MRCSLT, currently combines her clinical work at Great Ormond Street Hospital, UK, with a lectureship in voice at University College, London. She has specialised in voice disorders throughout her career, in her clinical work, teaching and research. Her current clinical post involves the tertiary assessment and treatment of children and young people with a wide range of ENT-related conditions. She is the lead Speech and Language Therapist for the Joint Paediatric Voice Clinic at Great Ormond Street Hospital and overall SLT Service for ENT.

Kathy L. Chapman

Kathy L. Chapman, PhD is currently a Professor in the Department of Communication Sciences and Disorders at the University of Utah, USA. She currently teaches courses in phonological disorders in children, cleft palate, and research methods. Her research has focused on children with specific language impairment and language and phonological development of young children with cleft palate. She is especially interested in the impact of clefting on the developing speech sound system. Dr Chapman has numerous data-based articles and presentations related to these areas of study.

Fiona E. Gibbon

Fiona E. Gibbon, PhD, is a speech and language therapist and Professor and Head of Speech and Hearing Sciences at University College Cork, Ireland. Her research focuses on the use of instrumentation to diagnose and treat speech disorders, particularly those associated with cleft palate. She has published over seventy papers and book chapters, and has been awarded a number of research council and charity funded grants to investigate cleft palate speech. She is a Fellow of the Royal College of Speech and Language Therapists.

Carrie L. Gotzke

Carrie L. Gotzke is currently a Doctoral candidate in the Faculty of Rehabilitation Medicine at the University of Alberta, Canada. Her research interests include paediatric resonance disorders, perceptual-acoustic correlates of speech intelligibility, and measures of speech function and outcome for children with cleft palate.

Anne Harding-Bell

Anne Harding-Bell, PhD, East of England Cleft Lip and Palate Network, UK, and University teacher in the Department of Human Communication Sciences at University of Sheffield, UK. Anne led the first post graduate cleft palate studies course in Cambridge, UK, and now contributes to postgraduate teaching on distance learning courses in cleft palate at the University of Sheffield. Her research interests centre around transcribing, characterising, categorising and treating cleft speech and pre-speech patterns.

Christina Havstam

Christina Persson, SLP, PhD, is a lecturer at the Sahlgrenska academy at Gothenburg University and clinical Speech-Language Pathologist at Sahlgrenska University Hospital, Gothenburg, Sweden. Her main interest in clinical work, teaching and research is speech disorders in patients born with cleft lip and palate or 22q11 deletion syndrome. She has been a member of Gothenburg cleft palate team since 1991 and of the 22q11 deletion syndrome team since 1997.

Gunnilla Henniningsson

Gunilla Henningsson, PhD, is Associate Professor/Senior Lecturer in the Division of Speech and Language Pathology, Department of Clinical Science Intervention and Technology at the Karolinska Institute, Stockholm, Sweden. Her research is in the areas of velopharyngeal function and the development of universal speech samples for reporting speech outcomes in individuals with cleft palate.

Megan Hodge

Megan Hodge, PhD, is currently a Professor and heads the Children’s Speech Intelligibility, Research and Education Laboratory (CSPIRE) in the Faculty of Rehabilitation Medicine at the University of Alberta, Canada. Her research interests include developmental aspects of normal and disordered speech perception and production and perceptual-acoustic correlates of speech intelligibility.

Sara Howard

Sara Howard, PhD, is currently Reader in Clinical Phonetics in the Department of Human Communication Sciences at the University of Sheffield, UK, and an ESRC Research Fellow. Her research interests span clinical phonetics and phonology (with a particular interest in phonetic transcription and electropalatography) and developmental speech disorders, including cleft palate. She teaches on a series of postgraduate courses in speech disorders and cleft palate and is currently President of the International Clinical Phonetics and Linguistics Association.

Alice Lee

Alice Lee, PhD, is a Lecturer in the Department of Speech and Hearing Sciences, University College Cork, Ireland. Her research interest includes perceptual and instrumental investigations of speech disorders in individuals with structural anomalies and neurological impairment; and listener training for perceptual judgements of speech disorders. Her recent research and publications focus on electropalatographic studies of normal articulation and articulation disorders associated with cleft palate, as well as prosodic disturbance in Cantonese speakers with aphasia.

Anette Lohmander

Anette Lohmander, PhD, is a Professor and Head of the Division of Speech and Language Pathology, Karolinska Institutet, Stockholm, Sweden, and the specialist speech-language pathologist at Karolinska University Hospital. Her research interests in the area of cleft palate focus on the impact of surgical procedure, particularly on speech and language (and hearing) development and the development of efficient intervention procedures.

Brenda Louw

Brenda Louw, DPhil., is currently Professor and Chair of the Department Audiology and Speech-Language Pathology, East Tennessee State University, USA. Her research interests in cleft palate are early intervention, cross-cultural service delivery models and speech assessment. She is the Vice-President of the Pan African Association for Cleft Lip and Palate

Roopa Nagarajan

Roopa Nagarajan, PhD, is currently Professor and Chairperson, Department of Speech, Language and Hearing Sciences, Sri Ramachandra University, Chennai, India. She has been involved in the development of community-based rehabilitation services for individuals with cleft lip and palate in rural India and is currently the President of the Indian Society of Cleft Lip, Palate and Craniofacial Anomalies.

Valerie Pereira

Valerie Pereira is currently undertaking a PhD in the Institute of Child Health, University College London, UK, and is a specialist speech and language therapist with Great Ormond Street Hospital for Children and the North Thames Regional Cleft Service in London. Her clinical and research interests include the instrumental assessment and measurement of speech outcomes, with a particular interest in the impact of orthognathic surgery on speech in cleft lip and palate.

Christina Persson

Christina Persson, SLP, PhD, is a Lecturer at the Sahlgrenska Academy at Gothenburg University and clinical Speech-Language Pathologist at Sahlgrenska University Hospital, Gothenburg, Sweden. Her main interest in clinical work, teaching and research is speech disorders in patients born with cleft lip and palate or 22q11 deletion syndrome. She has been a member of Gothenburg cleft palate team since 1991 and of the 22q11 deletion syndrome team since 1997.

John E. Riski

John E. Riski, PhD, CCC-S, is the Clinical Director of the Center for Craniofacial Disorders and Director of the Speech Pathology Laboratory at Children’s Healthcare of Atlanta, USA. His research encompasses speech outcomes of surgical interventions for children born with cleft lip/palate and craniofacial disorders. He is a Fellow of the American Speech Language and Hearing Association and a past-president of the American Cleft Palate-Craniofacial Association.

Nancy Scherer

Nancy Scherer, PhD, is currently Dean of Clinical & Rehabilitative Health Sciences at East Tennessee State University, USA. Her research interests have focused on early developmental milestones of children with cleft lip and/or palate and children with velocardiofacial syndrome. She has been particularly interested in efficacy studies of early speech and language intervention for children with clefts and craniofacial conditions. She is currently Principal Investigator for a comparative study of the effects of a hybrid early intervention model for children with cleft lip and palate funded by the National Institutes of Health.

Debbie Sell

Debbie Sell, PhD, is the Lead Speech and Language Therapist for the North Thames Regional Cleft Service, Head of Department at Great Ormond Street Hospital NHS Trust and is Honorary Senior Lecturer Institute of Child Health, University College London and Visiting Professor at City University, London, UK. She has been an active clinical researcher in the cleft palate field for over 25 years. She has 50 peer-reviewed publications and has co-edited two books in this field. In 2006 she was awarded an OBE for services to the UK National Health Service.

Lotta Sjögreen

Lotta Sjögreen, PhD, is a speech-language pathologist at Mun-H-Center National Orofacial Resource Centre for Rare Diseases, Gothenburg, Sweden. Her doctorate was in medical sciences and her research focuses on evaluation and intervention for orofacial dysfunctions in rare diseases.

Joy Stackhouse

Joy Stackhouse, PhD, is Professor of Human Communication Sciences at the University of Sheffield, UK, where she teaches on the Distance Learning Programmes in Speech Difficulties and Cleft Palate. She is a Fellow of the Royal College of Speech and Language Therapists and a chartered psychologist. Along with Professor Bill Wells, she has developed a psycholinguistic approach to the assessment and management of children with speech and literacy difficulties which is used in research and training.

Triona Sweeney

Triona Sweeney, PhD, is the Senior Clinical Specialist Speech and Language Therapist, The Children’s University Hospital, Temple Street, Dublin, Ireland; Lead Speech and Language Therapist on the Dublin Cleft Team; and Adjunct Professor, Speech & Language Therapy Department, University of Limerick, Ireland. Her research interests focus on perceptual and instrumental assessment of nasality and nasal airflow errors, with emphasis on reliability of assessments.

Linda D. Vallino-Napoli

Linda D. Vallino-Napoli, PhD, CCC-SLP/A, FASHA, is Head of the Craniofacial Outcomes Research Laboratory and Senior Research Scientist in the Center for Pediatric Auditory and Speech Sciences at Nemours/Alfred. I. duPont Hospital for Children, Wilmington, Delaware, USA, where she is also a member of the Cleft Palate-Craniofacial team. She is an Adjunct Associate Professor in the Department of Linguistics and Cognitive Science at the University of Delaware. Dr Vallino-Napoli lectures in the area of orofacial anomalies and evidence-based practice and is the author of peer-reviewed articles and book chapters in these areas.

Tara L. Whitehill

Tara L. Whitehill, PhD, is a Professor in the Division of Speech and Hearing Sciences, University of Hong Kong and the specialist speech-language pathologist for the University of Hong Kong/Prince Philip Dental Hospital Cleft Lip and Palate Centre. Her research interests in the area of cleft palate currently focus on speech intelligibility and the relationship between intelligibility and other outcome measures

Mary Wickenden

Mary Wickenden, PhD, has worked in the United Kingdom and India, specialising in work with young children with complex disabilities, and more recently in Sri Lanka, running the first SLT training course there. Subsequently, building on an interest in cultural aspects of health and disability, she has trained as a medical anthropologist. She is a Senior Research Fellow at the Centre for International Health and Development, University College London, UK, teaching and researching on issues related to children and disability in middle and low income countries.

Elisabeth Willadsen

Elisabeth Willadsen, PhD, is currently an Assistant Professor in the Department of Scandinavian Studies and Linguistics at the University of Copenhagen, Denmark. She currently teaches courses in language development of young children, and cleft palate. Her research focuses on pre-speech and early speech and language development of young children with and without cleft palate, with a special interest in the interaction between early phonological and lexical development in children with cleft palate.

Preface

This book emerged out of conversations which we, the editors, enjoyed over a number of years both at conferences and on visits to each other’s institutions in Sheffield, Gothenburg and, latterly, Stockholm. Observing current developments in research into speech production in cleft palate, we both recognised the need for a book which reflected the increasing breadth of the research being carried out across the world. Whilst important work was being undertaken in the more traditional areas of speech, there was a growing body of research, which recognised the potential of certain aspects of language, to contribute significantly to the field. We were also keen to recognise the importance of cross-linguistic and cross-cultural issues in cleft speech research. In addition, we wanted to broaden our focus to include both the speaker’s own and the listener’s perspective on communication. Thus we chose to use the WHO-ICF framework as a backdrop to all of the work contained in this book. Finally, we aimed to include current evidence of best practice (EBP) regarding both assessment and intervention. Our contributing authors were thankfully very receptive to these ideas, and thus the concepts of the WHO-ICF structure and EBP are given specific attention and have been regularly applied throughout the book.

For one of us, there was also a more specific stimulus for this book: coincident with its development, a set of postgraduate courses in cleft palate were being introduced at the University of Sheffield, and this book was designed, in part, with the needs of these students in mind. From this perspective it can be seen as a companion text to Watson, Sell and Grunwell’s Management of Cleft Palate Speech. Where that book provides a picture of all aspects of the multidisciplinary care of individuals with a cleft, this book focuses specifically on speech, and on assessment and intervention for speech problems associated with a cleft. We have both learnt a lot from conversations with our postgraduate students, who come from all over the world, and hope that this book reflects that learning process and will, in turn, prove useful to all of our future students.

We have clearly been very lucky that such a strong and inspiring set of researchers agreed to collaborate with us on this project. It has been a pleasure and a privilege to work with them. And we have been lucky, also, in having a series of very supportive (and unflappable!) editors at Wiley-Blackwell, who guided us patiently throughout the process, with all its attendant hiccups and delays. Our families should get a mention, too, for their support and forbearance!

Sara Howard and Anette Lohmander

Part One: Speech Production and Development

Sara Howard1 and Anette Lohmander2

1 University of Sheffield, Department of Human Communication Sciences, Sheffield, S10 2TA, UK

2 Karolinska Institutet, Department of Clinical Science, Intervention and Technique, Division of Speech and Language Pathology, SE 141 86, Stockholm, Sweden

In this book we examine the nature and impact of speech difficulties associated with cleft. As with all developmental speech impairments, cleft speech problems have experienced a significant broadening of perspective over the last century. Following a long period when all children’s speech difficulties were seen as articulatory in origin, and as being wholly interpretable through a medical model (Macbeth, 1967), there has been a gradual but welcome transformation to the current position, where much more emphasis is placed on other potential areas of difficulty (including phonology, language, literacy and interpersonal communication and interaction, as well as psychological and psychosocial implications). Developmental speech impairment is thus now situated within a social context. This fits comfortably with developments over the last decade or so, which have sought to classify and consider speech, language and communication impairments using the ICF (the International Classification of Function, Disability and Health; WHO (World Health Organization), 2001). In this book we use the ICF throughout as a point of reference.

Even a glance at the structure and headings used by the ICF indicates how useful it can be for extending our understanding of the possible impact of a communication impairment associated with cleft palate. There are two main parts (‘Functioning and Disability’ and ‘Contextual Factor’) with subcomponents which include, for the former, Body Structures, Body Functions, and Activity and Participation, and for the latter, Environmental Factors and Personal Factors. Such is the value of this framework that in the United Kingdom the Royal College of Speech and Language Therapists, in its manual on commissioning and planning services for cleft palate and velopharyngeal impairment (VPI), provides a detailed description of the impact of a cleft which relates specifically to the ICF classification (RCSLT (Royal College of Speech and Language Therapists), 2009). The ICF provides what McLeod (2006) describes as as ‘biopsychosocial view of health’ and, thus, of communication impairment.

It is noteworthy, of course, that unlike many types of developmental speech impairment, cleft speech problems do, indeed, have a physical basis, and thus the ICF subcomponent Body Structures is relevant in a way which is not the case for most children with speech difficulties. Thus, we need to understand what the anatomical and functional constraints on speech production are likely to be, as well as being aware of how physical structure and function are likely to be affected, over the lifespan, and over the course of speech and language development, by surgical intervention. Chapters in the following section consider each of these issues and also reflect on current evidence for different methods of assessment and intervention. The ways in which speech development for a child with a cleft palate are likely to be similar to and different from speech development in children without a cleft is clearly a hugely important area, which is also addressed in this section.

To make clinical, diagnostic decisions and to plan effective intervention, we need to be able to distinguish between speech difficulties directly attributable to the cleft and its consequences (including the likelihood of hearing impairment), and the coexistence of more general phonological delay or disorder. Such diagnosis can only take place if we have detailed information about the typical course(s) of speech and language development for children with a cleft. The ICF component ‘Body Functions’ is relevant here, including, as it does, intellectual and cognitive function, and temperament and personality, as well as specific aspects of speech production, including articulation, voice, fluency and also hearing (McLeod and Bleile, 2004).

In seeking a wider, more holistic perspective on the impact of a speech impairment, the ICF can also help us to understand the effects of a cleft on a child’s ability to participate more broadly in social interaction, across different contexts, including vital areas such as education, family and social life. The ICF components remind us that a communication impairment is not just the property of an individual, but is constantly negotiated between different individuals, in different contexts: a child’s intelligibility, for example, will differ depending on when, why, where and with whom they are talking. As the title of McCormack et al.’s article (2010) eloquently puts it ‘My speech problem, your listening problem and my frustration …’. Later chapters in this book deal in detail with intelligibility and with the child’s ability to participate in society through effective use of communicate.

The second of the main parts of the ICF, Contextual Factors, encourages us to consider the impact of a cleft palate and cleft speech difficulties in terms of the systems, policies, services and attitudes existing in a particular society, country or culture that will exert an influence on the support a child is likely to receive. Taking this perspective, one can quickly see how the impact of a cleft could be very different in the developed versus developing (minority versus majority) world, where infrastructure and attitudes may differ significantly. One of the chapters in the following section addresses this important issue. Personal factors, such as age, gender, race, character and general psychological resilience and well-being, will also need to be taken into account when considering the impact of a cleft. Some children with severe speech disorders will nevertheless prove remarkably resilient in the face of their difficulties, whereas others may need specific help to adapt to even mild speech problems (Nash, 2006).

The ICF, then, provides us with a framework which can extend our thinking about the impact of a speech impairment associated with cleft palate and encourage us to take a more holistic view of individuals thus affected (Ma, Threats and Worrall, 2008). The material we cover in this book endeavours to do just that.

References

Ma, E.P.-M., Threats, T. and Worrall, L. (2008) An introduction to the International Classification of Functioning, Disability and Health (ICF) for speech-language pathology: its past, present and future. International Journal of Speech-Language Pathology, 10, 2–8.

Macbeth, E. (1967) Speech therapy as a paramedical subject. British Journal of Disorders of Communication, 2, 69–72.

McCormack, J., McLeod, S., McAllister, L. and Harrison, L. (2010) My speech problem, your listening problem, and my frustration: the experience of living with childhood speech impairment. Language, Speech, and Hearing Services in Schools, 41, 379–392.

McLeod, S. (2006) An holistic view of a child with unintelligible speech: insights from the ICF and ICF-CY. Advances in Speech-Language Pathology, 8, 293–315.

McLeod, S. and Bleile, K. (2004) The ICF: a framework for setting goals for children with speech impairment. Child Language, Teaching and Therapy, 20, 199–219.

Nash, P. (2006) The assessment and management of psychosocial aspects of reading and language impairments, Dyslexia, Speech and Language: A Practitioner’s Handbook, 2nd edn (eds M. Snowling and J. Stackhouse), John Wiley & Sons Ltd, pp. 278–301. Chapter 13.

RCSLT (Royal College of Speech and Language Therapists) (2009) RCSLT Resource Manual for Commissioning and Planning Services for SLCS: Cleft Lip/Palate and Velopharyngeal Impairment, RCSLT, London.

WHO (World Health Organization) (2001) ICF: International Classification of Functioning, Disability and Health, WHO, Geneva, Switzerland.

1

Physical Structure and Function and Speech Production Associated with Cleft Palate

Martin Atkinson1 and Sara Howard2

1 University of Sheffield, School of Clinical Dentistry, Sheffield, S10 2TA, UK

2 University of Sheffield, Department of Human Communication Sciences, Sheffield, S10 2TA, UK

1.1 Introduction

Speakers with a cleft lip and/or palate contend with unusual structure and function of the vocal organs from birth and physical abnormalities may persist after surgical intervention. (Surgery itself, for many individuals with a cleft, consists of a series of interventions over an extended period, so both structural and functional changes to the speech apparatus may be a feature of the entire period of speech development). These differences and changes may have a profound effect on speech production and speech development, and cleft lip and palate is one area where a significant proportion of the speech difficulties encountered (although not necessarily all) can be traced back in some way to an anatomical or physiological cause. This chapter explores some of the links between atypical vocal organ structure and function in cleft lip and palate, and those many and varied features encountered in speech production associated with cleft palate. Of course, some of these issues are also dealt with in other chapters in this book (Chapters 3, 5, 8, 10, 11 and 12), so the reader is directed, where appropriate, to seek further information from these chapters; this chapter, therefore, focuses on those issues not discussed elsewhere in the book. More detailed accounts of the physical structures and functions associated with speech production can be found in Atkinson and White (1992) and Atkinson and McHanwell (2002).

1.2 The Hard and Soft Palates and the Velopharynx

1.2.1 Anatomy of the Hard and Soft Plate

The palate comprises the rigid bony hard palate anteriorly and the mobile muscular soft plate (velum) posteriorly. The shape of the hard plate is variable but is usually a concave dome. However it may take on a V-shape with the apex superiorly, which narrows the hard palate. This configuration of the hard palate often accompanies a class II malocclusion (Section1.5.1); as the upper dental arch is narrowed the posterior teeth cannot align along a curved dental arch but follow the V-shape, pushing the anterior teeth forward. The bony plate is formed from components of two pairs of bones; the palatine plates of the maxilla form the anterior two thirds and the horizontal plates of the palatine bones form the remainder. The bones are joined at sutures. A midline suture marks the line of fusion of the two halves of the palate during palatogenesis and terminates anteriorly at the incisive foramen, another landmark relating to the development of the palate. The sutures are, of course, covered in life by the mucosa lining the mouth. However, the site of the incisive foramen is marked by a small incisive papilla visible just behind the central incisor teeth.

The soft palate extends from the posterior border of the hard palate. Four pairs of muscles form the soft palate (Figure 1.1). The tensor veli palatini tenses the velum by exerting a lateral force; these muscles are tendinous within the soft palate and the other muscles are attached to the tendons. The levator veli palatini raises the soft palate. Note that the tensor and levator palatini attach to the Eustachian tube and open it when the velum is raised or tensed, so that fluid drains from the middle ear cavity and air pressure is equalised on the either side of the eardrum. These two muscles are often inefficient in the early stages of cleft palate repair so that the Eustachian tube does not open. Drainage of the middle ear is therefore poor, accounting for the high incidence of ‘glue ear’ in cleft clients. The palatoglossus and palatophayngeus muscles depress the velum. The soft palate has a backward extension, the uvula which is very variable in shape and size.