Running head: Cleft Lip and Palate

Cleft Lip and Palate in Adolescents

Marlee Cohen

Seton Hall University

Cleft Lip and Palate 2

Cleft Lip and Palate in Adolescents

Background of Cleft Lip and Palate

According to the Center for Disease Control and Prevention [CDC], [It is] estimated

that, each year in the United States, about 2,650 babies are born with a cleft palate and 4,440

babies are born with a cleft lip with or without a cleft palate (2015, para. 4). Meaning that it is

not a rarity to see an adolescent born with either a cleft lip or cleft palate or both. Cleft lip and

cleft palate can develop in a range of ways. It can affect just the lip or just the palate or both.

Additionally, cleft lip and cleft palate can appear bilaterally, on both sides of the lip and palate,

or unilaterally, only affecting one side. The American Speech-Language Hearing Association

[ASHA] defines cleft lip as a split in the sides of the upper lip, which can include the bones of

the upper jaw or gums (2017a). Cleft palate, on the other hand, is defined by ASHA (2017a) as a

fissure in the roof of the hard and/or soft palate as a result of incomplete development in utero. A

cleft lip and cleft palate can be overt, meaning that they are visible. However, cleft palate can

also result in a submucous cleft as well (ASHA, 2017b). A submucous cleft is a result of muscle

and bones in the roof of the mouth not fully developing, however, a mucous membrane covers

the cleft (ASHA, 2017a). Since the cleft is covered it makes identifying this type of cleft more

difficult than the others. Some symptoms an adolescent may exhibit if they have a submucous

cleft are a split uvula, nasalization of speech, or midline groove on their hard, other times

adolescents will not show any signs till further development takes place (ASHA, 2017a).

There has not been one confirmed reason for the development of cleft lip and palate in

adolescents. However, the most common belief is that a change in genes during development can

result in an underdeveloped lip or palate (CDC, 2015). Furthermore, in many studies it has been

observed that ethnicity and geographical region can also effect the development of a cleft
Cleft Lip and Palate 3

(Ururena, Balcazar, Lozano, Collins, & Patio, 2015). That is an adolescents environment can

affect the development. Besides geographical region, the adolescents mothers health history

and actions during her pregnancy can also result in an adolescent developing a cleft (Ururena,

2015). Additionally, cleft lip and palate has been observed to be more prevalent males and on the

left side of the face (Raducanu et al., 2015). However, in a study conducted by Raducanu et al.

(2015), while clefts were seen as more prevalent in males and on the left side, it was not

statically significant. This same pattern has been observed in prior studies as well.

While the main domain that affects adolescents with cleft lip and palate is speech and

language, the cleft can also influence other areas of their life. Some areas that are influenced are

an adolescents hearing, swallowing and feeding, memory, and psychological well-being. Thus,

in order to get a full grasp on an adolescent with cleft lip and palates abilities, all areas must be

looked at.

Facial Structure

Adolescents with cleft lip and palate have many facial structure abnormalities, which can

result from developmental differences. According to Ysunza et al. (2015) the normal

development of the palate and facial structure is as follows:

Development of the palate begins around week 6 of gestation in humans and is

identifiable by the appearance of palatal primordia at the lateral edges of the maxillary

prominences. These processes fuse coordinately to form the nostrils, upper lip, and

palatal shelves that will, in turn, give origin to both primary and secondary palate.

[Week 9 in humans] the bilateral palatal shelves that had been allowed to elevate above

the dorsum of the tongue as consequence of the lengthening of the mandible towards the

front of the dace grow toward each other and will forms the midline edge seam that
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consists of epithelial cells that produce a glycoprotein coat and desmosomal junctions

that allow cell-cell interactions. The process of palatal fusion is completed by week 12 in

humans and is marked by the complete disappearance of the midline edge seam (p. 6).

Thus, an adolescent that has a cleft palate would have experienced a breakdown in the

development of the palate and depending on where in the developmental process it can determine

the severity of it.

Additionally, as a result of a cleft lip and palate, other structures within the oral cavity

can be effected. One of those structures is an adolescents dentation. Oral clefts are commonly

associated with dental anomalies of number, size, shape, structure, position and eruption

affecting both detentions (Raducanu et al., 2015, p. 453). Also, adolescents that are born with

cleft lip and cleft palate often have missing, extra, or shifted teeth. These abnormalities in

dentation can result in an under bite, the bottom teeth are shifted forward over the upper teeth

(NSW Government, 2014). In a study conducted by Raducanu, Didilescu, Feraru, Dumitrache,

Hantoiu, and Ionescu found that there was a positive correlation between how severe the cleft a

child had and the amount of tooth anomalies that they had (Raducanu et al., 2015). Dental

Malformations may affect the development growth and functions of the dento-maxillary

apparatus (chewing, aesthetics, speech), thus making the treatment more difficult and reducing

the later treatment options, especially prosthetic and orthodontic (Raducanu et al., 2015, p.

453). That is when looking into treating adolescents with cleft lip and palate, one must pay

attention to the dental structure because of its effects on other parts of the oral cavity.

Co-occurrence

An adolescent with cleft lip and palate can also experience other syndromes,

which are commonly seen as co-occurring. Some of these syndromes are strickler syndrome,
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pierre robin syndrome, van der woude syndrome, and treacher-collins syndrome (ASHA, 2017b)

However the most common co-occurring syndrome that is genetically based is 22q11.2

microdeletion syndrome. Ysunza et al. (2015) states that 22q11.2 microdeletion syndrome is the

most common syndrome related to cleft palate. 22q11.2 microdeletion syndrome results in delays

in physical development, language development, and some learning disabilities (Genetics Home

Reference, 2017). A common symptom of 22q11.2 microdeletion syndrome is an

underdeveloped palate, which is why it is believed to be so closely tied to cleft lip and palate

(Genetics Home Reference, 2017).

Additionally, an adolescent can be diagnosed with velopharyngeal insufficiency.

According to Ysunza et al. (2015), velopharyngeal insufficiency (VPI) is defined as an inability

to create a seal during speech production in the velopharyngeal port, resulting in a change in

resonance. The pathology of VPI can either be anatomical, in the case of cleft palate, or can be

functional, in the case of myasthenia gravis (Ysunza et al., 2015). Diagnoses of VPI are usually

made after an assessment of articulation based on place and manner and an examination of the

oral cavity and pharynx (Ysunza et al., 2015)

Compensatory Articulations (CA) can also occur as a result of a cleft lip and palate.

Compensatory articulations are defined as changes in speech patterns that occur due to the

abnormal structure as a result of the cleft. The speech patterns are atypical and are often used as

compensation for sounds that they are unable to produce due to their abnormal facial and oral

structure (Ysunza et al., 2015). Since the speech patterns being heard in compensatory

articulations are not normal, they can also affect an adolescent with cleft lip and palates

intelligibility (Ysunza et al., 2015). Additionally, while the reason for CA may originally be the

cleft lip or palate, these compensatory errors can be generalized into the adolescents developing
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phonetic inventory. Due to the change in the adolescents intelligibility and the phonetic errors

that are occurring from the compensation, one could classify this disorder as phonologic (Ysunza

et al., 2015).

Identification and Diagnosis of a Cleft Lip and Cleft Palate

Identification and diagnosis of cleft lip and palate can occur before or after a child is

born. Diagnosing a cleft after birth can be done by either having a screening or a comprehensive

assessment. The screening consists of having the anatomical and structural features looked at.

These can include the lips, palate, teeth, and uvula (AHSA, 2017b). Also, a perceptual evaluation

of nasal airflow, resonance problems, articulation errors that adolescent may make, which are not

considered normal (ASHA, 2017b). If any of these problems are observed or heard further

evaluation may be required to make a correct diagnosis. A speech-language pathologist can also

conduct a comprehensive assessment, which consists of using standardized and non-standardized

measures (ASHA, 2017b). When an assessment is being made the World Health Organizations

(WHO) International Classification of Functioning, Disability and Health (ICP) framework is

used to determine the adolescents ability. The framework consists of five subsets, which are

impairments in body structure and function, co-morbid deficits, limitations in activity and

participation, environmental and personal factors, and quality of life (ASHA, 2017b). An

adolescent can be assessed either in early intervention programs or can be done in a school

setting (ASHA, 2017b). In early intervention, the adolescents vocalization complexity and

diversity, along with their communicative gestures are assessed (ASHA, 2017b). Also, it is very

important to take the adolescents culture into consideration when assessing them, in order to

make sure they are correctly being evaluated (ASHA, 2017b).

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On the other hand, some prefer to know if their child will have a cleft prior to birth,

which results in them seeking out ultrasonography of the facial features. A three-dimensional

ultrasonography is based on two reconstructions, a multiplanar or a tomographic (Levillant,

Nicot, Benouaiche, Couly, & Rotten, 2016). However, in order to achieve a high-quality image,

the head, face, and mouth must be in a very specific positon. According to Levaillant et al.

(2016):

The fetal head must be in a slightly deflected position and the fetal face in an anterior

position, facing the transducer, in order to minimize shadowing from the malar bones and

allow visualization of the posterior limit of the bony palate. The mouth of the fetus

should be open or half opened, and the tongue separated from the palate, in order to

benefit from a good contrast thanks to the present of amniotic fluid in the oral cavity (p.

836).

After imaging takes place and the images are analyzed the results are presented to the family and

they can decide what course of action is the best. To this day, the best way to determine a cleft is

still debated because of quality of images and other and inaccuracies that can occur.

Even with imaging prior to birth and further referral to a doctor to check the child,

sometimes identifying a cleft is very difficult. A cleft may not be able to be diagnosed until the

child has difficulty feeding. The liquid may be coming out of their nose and they are not

receiving the nutrients that they need. The reason for this may be a submucous cleft (ASHA,

2017a). After the diagnosis of cleft lip and palate, a referral to the appropriate doctors and

clinicians must be made in order to set up an individualized treatment plan to help that

adolescent.

Swallowing and Feeding

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Feeding and swallowing is another domain that can directly affect an adolescent with

cleft lip and palate. However, depending if that adolescent is diagnosed with either a cleft lip or a

cleft palate their feeding is affected differently. According to AHSA (2017), babies with cleft lip

are most likely to breastfeed or use a normal bottle. However, babies with cleft palate may

require specialized bottles in order to feed properly. Additionally, the use of a feeding specialist,

many times a speech-language pathologist, may be required to help make sure the baby is getting

enough nutrition and feeding correctly. (ASHA, 2017a). Many feeding difficulties appear at birth

for an adolescent with cleft lip and palate and are observed in their suction and swallowing

abilities (Duarte, Ramos, & Cardoso, 2016). Duarte, Ramos, and Cardoso (2016) discovered that

suction is important for a developing adolescent, not just for feeding purposes, but for soothing

and building a relationship with the child and caregiver. It also helps develop oral motor

movements, which will be needed for speech production later on (Duarte et al., 2016). One way

that Duarte et al. found to help feeding in those with cleft lip and palate was by using a syringe

(2016). It was an easy method to increase the volume and reduced the regurgitation of the food

that the child needs to be healthy. Also, the time spent on feeding significantly reduced when

using the syringe (Duarte et al., 2016). Surgical repair can also aid in feeding for an adolescent

that has a cleft lip and palate. According to Duarte et al. (2016), after the surgical repair most

adolescents feeding issues will dissolve or become less of a problem due to the repair to the cleft

(Duarte et al., 2016).

Hearing

Hearing problems are also very common in adolescents with cleft lip or cleft palate. The

reason for this is that the facial structure that results in a cleft can affect the structure of the ear as

well. Ma, Li, Ma, and McPherson (2016) reported that:

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several studies have found that children with cleft palate or cleft lip and cleft palate

more commonly had hearing impairment than children with cleft lip only, and that

children with bilateral cleft palate had a higher prevalence of middle ear disorder

associated with hearing loss than children with unilateral cleft palate (2016, p. 118).

Ma et al. also hypothesized that the different facial structure can cause a change in structure and

function of the middle ear (2016). That is the structure abnormalities of the palate can affect not

just the structure of the ear but the function of the muscles within the ear as well. The change in

structure and musculature can lead to fluid building up behind the ear drum resulting in otitis

media, ear infections. One common side effect of otitis media is a decreased ability to hear,

which can be classified as a conductive hearing loss (ASHA,2017a). When one has reduced

hearing ability it can lead to an issue in speech production because the adolescents perception of

the sound is incorrect, leading to the misarticulation of speech sounds.

Memory

It has been observed that adolescents with cleft lip and palate also have deficits in their

memory, which can be seen in cognitive and language difficulties (Young et al., 2012). These

difficulties are commonly observed in lower academic performance by these adolescents.

Studies investigating the STM abilities of monolingual children with CLP have used models of

developmental dyslexia and neuropsychology to examine a variety of cognitive processes and

their relationships to reading (Young et al., 2012, p. 1315). In this study conducted by Young et

al. a positive relationship was found between verbal and visuospatial short term memory and

their working memory (Young et al., 2012). That is their verbal and visuospatial STM had a

direct effect on their working memory. In another study conducted by Richman et al. it was

discovered:
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that even those children with memory deficits, who showed poor recall visually

presented information did not show this deficit on verbally presented content that was

similar. This suggests that they do not have an inherent deficit in verbal memory, but

only in verbally labeling visual information to aid memory (2005, p. 568).

This illustrates that children with cleft lip and palate are better with verbal memory than their

visual memory. By understanding the memory process of adolescent with cleft lip and palate, it

allows one to understand the more effective way to help them academically and speech and

language wise.

Language

Many of the early language developmental milestones have been identified as

problematic for children with cleft lip and palate. Some of these difficulties include their

consonant inventory size, complexity of babbling, onset of first words, and vocabulary

development (Scherer, Boyce, & Martin, 2013a). It is also commonly seen that babies with cleft

lip and palate vocalize less than those without and use less variety in babbling (ASHA,2017b).

The reduced complexity in babbling in babies with cleft lip and palate can result in a restricted

consonant inventor leading to fewer consonant productions (ASHA, 2017b). For children with

clefts who have impaired early speech production, understanding the relationship between

communicative acts and early vocal development would provide information regarding how

delays in vocal development may impact the communicative context in which word development

occurs (Scherer et al., 2013a, p. 587). In a study focusing on pre-linguistic development of

adolescents with cleft lip and palate it was found that they vocalized just as much as the children

without clefts, however, the complexity of the vocalizations made by the CLP group were

deficient and were delayed in word use. (Scherer et al., 2013a). Exhibiting the correlation
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between the complexity of the vocalization and if the adolescents word use will be delayed or

not. In that same study, it was found that communicative acts increased between 17-34 months as

the children went from babbling to word use (Scherer et al., 2013a). According to Chapman et al.

(2003), Canonical babbling deficits have been described in the pre-linguistic development of

children with CLP, due largely to the presence of an open hard palate prior to palate repair (as

cited in Scherer et al., 2013a, p. 591). That is the cleft palate can have a direct effect on early

vocalizations that the child is making.

Furthermore, the delays in language and phonological errors can also cause children with

cleft lip and palate to have a greater risk of having reading difficulties (NSW Government,

2014). These reading difficulties have been linked to expressive language problems (Richman,

Wilgenbusch, & Hall, 2005). In a study conducted by Richman and associates, they found that

rapid naming and verbal expressive fluency were two issues that contributed to a reading

disability in children with cleft lip and palate (Richman et al., 2005). Thus, the difficulties in

naming and expressive language had a greater effect on the adolescents academic performance.

Also, it was found that children with CLP do not use verbal language as much in

communicative interactions (Scherer et al.,2013a). Further research found that there is an inverse

relationship between early rates of gestural use and the childs word use. The children that had

high rates of gestures use has low rates of word use (Scherer et al., 2013a). It was inferred that

the increased rates of gesture use were used as compensation for the decreased intelligibility of

children with cleft lip and palate. However, it was observed that as their intelligibility increased

their gesture use decreased (Scherer et al., 2013a).

Speech, Voice, and Resonance

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Children with cleft lip and palate experience difficulties in their articulation ability along

with their language ability. There are two types of articulatory errors that can occur because of

the presence of a cleft, obligatory and compensatory. Obligatory errors are directly related to the

structural abnormalities of the cleft, while secondary compensatory errors are learned (ASHA,

2017b). These errors can further be classified as passive or active errors. Passive errors are errors

that are produced in the correct place, but the manner is not. Passive errors occur because of an

unrepaired cleft or VPI and usually do not respond as well in therapy. They may require some

surgical procedure (NSW Government, 2014). Some common passive errors that are often heard

are, Absence of pressure consonants predominance of nasals and approximants /m, n,, w, j,

h/, weak articulation, passive nasal fricative, voiceless /h/ for voiceless plosives, nasal realization

of voiced plosives /b d g/-> /m n /, Nasal air emission accompanying consonants (NSW

Government, 2014, para. 3). On the other hand, active errors are considered to be compensatory

errors. They compensatory errors because the sounds are being produced in the incorrect

placement due to the presence of the cleft. These errors will remain present even after repair to

the cleft. The reason for this is that the errors have become a part of the childs phonological

system. Unlike passive errors, active errors are able to be targeted during therapy (NSW

Government, 2014). Some common active errors that are often heard are, Lateral fricatives,

gliding fricatives, palatal stop, generalized backing, pharyngeal articulation, glottal stop,

nasalization, double articulationarticulating at two places of articulation simultaneously

(NSW Government, 2014, para. 5).

In a study conducted by Scherer, Oravkinova, and McBee (2013b), The predominant

production used [by an adolescent with a cleft] was the glottal stop, with pharyngeal fricatives

and pharyngeal stop used only once by three children with CLP. This pattern suggests that as the
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children gained more consonants in their inventories, backed compensatory productions were

replaced with oral consonants. (p. 413). Also, due to the dental abnormities present in

adolescents with cleft lip and palate many constants errors are made. Phonemes, such as /s/, /z/,

//, / t/, /d /, become lateralized or interdentalized because of missing teeth or extra teeth in the

mouth (NSW Government, 2014). Tongue placement can be effected by the dental abnormalities

as well, which results in labiodentals (/f/ and /v/) being inverted. Instead of the use of the upper

teeth for production, the lower teeth are the ones that make contact with the lip (NSW

Government, 2014).

At the preschool age problems with alveolar consonants are continued to be a struggle for

the adolescents and usually become a focus of speech therapy in the future (Scherer, Oravkinova,

& McBee, 2013). According to Scherer, Orakinova, and McBee, Our children with CLP

showed substantial increases in their consonant inventories between 18 and 24 months of age

which may have allowed them to replace the backed compensatory productions with other

developmentally appropriate patterns (Scherer et al., 2013b, p.417). This results in

compensatory articulatory productions of phonemes to be produced by the adolescent, due to the

different structure of the palate. In a study conducted by Scherer et al. it was found that

adolescents began to use compensatory productions around the same time they acquire their first

word, around 18 months of age, but the use the productions decreases by 24 months (2013b).

However, these compensatory errors will still not fully subside unless the structure of the cleft is

addressed through some type of surgery or prosthetic intervention (ASHA, 2017b). Without

addressing the structural problems, an adolescent with cleft lip and palate will continue to have

their speech affected. According to ASHA (2017a):

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In order to produce speech, the soft portion of the palate (called "soft palate") needs to

elevate and make contact to the back of the throat. This closes off the mouth (the oral

cavity) from the nasal cavity so that sounds can come out of your mouth and not your

nose. When we produce nasal sounds, such as "m" and "n," the soft palate stays down so

sound can travel out the nose to produce the nasal sound. Velopharyngeal Insufficiency

(VPI) is when the soft portion of the palate does not reach the back of the throat to

produce normal sounding speech. This results in unwanted escape of air or sound through

the nose during speech. A child who has VPI may have nasal sounding speech (2017,

para. 9).

Thus, velopharyngeal insufficiency can lead to unusual types of resonance that is heard when the

adolescent speaks. According to Ysunza et al., Cleft palate speech is associated with VPI and

includes deviations in the resonance such as hypernasality, or hyponasality, errors that are

obligatory with VPI like nasal emission and weak pressure consonants, and compensatory

articulation (2015, p.5). Hypernasality occurs when all sounds, mostly vowels, are produced

with a high nasal resonance. Hyponasality occurs when there is some type of obstruction

stopping air from being released from the nasal cavity, which results in a reduced nasal

resonance (Ysunza et al., 2015). Hyponasality usually occurs on nasal consonants. Another type

of resonance that can often been heard is cul-de-sac resonance. Cul-de-sac resonance is a

variation of hyponasality associated with tight anterior nasal constriction producing a muffled

quality to sounds (Ysunza et al., 2015, p. 5). All of these changes in resonance are a result of

VPI, which occurs because of the presence of a cleft.

Cleft lip and palate can also affect the voice quality of an adolescent. Two common voice

problems that are heard are laryngeal hyperfunction and soft voice syndrome. According to
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ASHA (2017b) laryngeal hyperfunction occurs because of over compensation because of the loss

of pressure due to velopharyngeal insufficiency. Resulting in the muscles of the vocal folds then

to be over worked, which can lead to development of vocal nodules and/or inflammation and

edema (ASHA,2017b). Soft voice syndrome also occurs because the loss of pressure due to VPI,

but instead of increasing vocal fold tension it reduces the tension of the vocal folds. This results

in the voice of an adolescent with a cleft to be horse or soft (ASHA, 2017b). Additionally, there

are some laryngeal disorders associated with cleft lip and palate which can affect the

adolescents vocal quality. Some of these disorders are calcification of the larynx, vocal fold

paralysis, and glottal webbing (ASHA, 2017b).

Treatment and Intervention

Before even starting any intervention or treatment a cleft palate team must be consulted.

The team consists of at least a plastic surgeon, orthodontist, and a speech-language pathologist.

When the cleft is more complex however, the team can extend to pediatricians, ear-nose and

throat doctor (ENR), and social workers (AHSA, 2017). By these professionals all working

together a child with cleft lip and palate will receive the best care possible covering all aspects of

their life. One intervention strategy that is often used to fix the cleft is a surgical procedure.

According to Fukushiro, Ferlin, Yamashita, & Trindade (2014), pharyngeal flap surgery is used

to reduce velopharyngeal insufficiency by closing the cleft palate (Fukushiro, Ferlin, Yamashita,

& Trindade, 2014). Another reason to perform pharyngeal flap surgery is to reduce

hypernasality, nasal emission, and weak intraoral pressure (Fukushiro et al., 2014). However,

according to ASHA (2017a), even after the surgery is performed about 20% of child will still

have VPI, which may require further speech therapy or even more surgeries (ASHA, 2017a).
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Besides VPI, another area that should be a focus of intervention for an adolescent with

cleft lip and palate is language. Children with clefts have been found to be at risk of learning and

language delays as well, which needs to be included in the speech-language therapy that they

receive (Pamplona, Silis, Ysunza, & Morales, 2015). They went on to discuss how these areas

have less attention drawn towards it because the main focus are the speech aspects related to VPI

rather than the language and learning skills (Pamplona et al., 2015). In order to target all of these

areas, Pamplona et al. used an intervention model called the whole language model to treat

children with cleft lip and palate (2015). The whole language model was coined by Norris and

Hoffman and focuses on higher levels of language in children with articulation deficits

(Pamplona et al., 2015). Metacognitive strategies are the focus of the whole language model,

which involves activating prior knowledge, anticipate, clarify, question, making connections,

summarize, and evaluate in order to increase reading comprehension (Pamplona et al., 2015). It

was found that the children that used the whole language model in therapy not just improved

their speech, but also improved their language skills more than the children that received

traditional intervention (Pamplona et al., 2015). The children that received the whole language

model therapy also were able to give more details when telling a story and switch perspectives

(Pamplona et al., 2015). These findings highlight the reason to incorporate not just articulation

therapy, but other aspects of language in order to improve the overall language of the child with

cleft lip and palate. This way all the deficits faced, articulation and language learning issues, are

being identified in therapy and treated.

Another study conducted by Pamplona, Ysunza, and Morales (2017) discovered that

songs and stories that use audiovisual materials allow more context for simulating articulation

along with giving information about narrative structure. That is because it gives the child the
Cleft Lip and Palate 17

structure they need to developed the skills and provides it in a fun way, using music and rhythm

Pamplona et al., 2017). By using the audiovisual materials, it allows the child to have audio,

visual, and phonological information on where the placement, manner, and voicing of the sound

patterns, which can be carried over into their conversational speech (Pamplona et al., 2017).

Additionally, early intervention is often used with children with cleft lip and palate

because of the prevalence of speech and language delays (Hardin-Jones & Chapman, 2008). The

focus of early intervention for many of the children with cleft lip and palate that experience

speech and language delays are expanding their lexicon (Hardin-Jones et al., 2008). Many prior

studies have focused on early intervention programs to be implemented in the childs natural

environment, their home. The reason for home programs is that it is believed that by using the

childs natural setting for intervention it has better outcomes and allows those children to

generalize the skills better (Hardin-Jones et al., 2008). In a prior study conducted by Scherer and

her associates, they found that the children with cleft lip and palate that received early

intervention increased their vocabulary and reduced use of the glottal stop. However, even with

the expansion of their vocabulary they still were not at the level of their non-cleft peers (as cited

in Hardin-Jones et al., 2008, p. 90). Also, it was discovered that early intervention programs for

children with cleft lip and palate were the most successful when parent involvement was

incorporated. Without parent involvement, the childs progress would be hindered (Hardin-Jones

et al., 2008).

Direct speech therapy is also needed to help fix the articulation errors that are made as a

result of the cleft. The focus of speech therapy interventions for an adolescent with cleft lip and

palate are on correcting the misarticulations and establishing the correct airflow for all sounds

(ASHA, 2017b). These goals can be a focus before and after repair of the cleft to make sure
Cleft Lip and Palate 18

correct articulation and airflow is taking place. A clinician should first focus on addressing the

adolescents compensatory articulations over developmental and phonological errors. The reason

for this is have greater impact on the adolescents intelligibility (ASHA, 2017b). According to

ASHA (2017b) some common compensatory therapy targets are:

Sounds for which the child is stimulable, nasal and low-pressure consonants, if they are

produced or co-produced with glottal stops, high-pressure consonants that are not in the

inventory, are age appropriate, or have high impact on intelligibility/understandability,

and anterior consonants that are visible (e.g., p, b, t, d, f), given that children often

compensate with posterior placement (Treatment Strategies, para. 2).

In order to target these compensatory behaviors in therapy many different strategies and

techniques. To target placement of phonemes it is often seen a clinician starting with bilabial

sounds and then moving back to alveolar (ASHA, 2017b). A common articulatory error made by

adolescents with cleft lip and palate is putting in a glottal stop. Two strategies that are often used

to reduce the use of the glottal stop and keep the glottis open are using a whisper or inserting a

/h/ after oral stops (ASHA, 2017b). Additionally, it is important to help the adolescent be able to

auditorily discriminate between the correct and incorrect phoneme (ASHA, 2017b). The reason

for this is to help the child understand why the incorrect phoneme is wrong and possibly aid

them in self-correcting their own speech. Cues can also be very helpful to aid in teaching the

adolescent correct phonemes. Cues can be either visual, verbal, or tactile. Some visual cues that

can be used are a visual representation of a mouth and showing on there, pointing to the lips and

tongue, or using a mirror to show the sound placement on themselves (ASHA, 2017b). Verbal

cues are just verbally telling the child where and how to make the sound. Tactile cues can range

from using a finger on the lips to feel the lip closure during bilabials to pinching the nose to give
Cleft Lip and Palate 19

feedback to the child of nasal closure (ASHA, 2017b). Depending on the type and severity of

articulatory errors, certain cues may be more useful than others.

Additionally, technology can be a good tool used to aid in the direct speech therapy. The

technology can be either low-tech or high-tech. Some common low-tech tools that can be seen

used in therapy are a stethoscope, to hear the release of air through the nasal cavity, dental mirror

under the nose, to see the release of air through the nasal cavity, and plastic tubing, to hear and

feel the release of air through the nasal cavity (ASHA, 2017b). Some high-tech tools which can

be used in intervention are a nasometer, gives visual feedback of nasalization, a

nasopharyngoscopy, gives visual feedback of the velopharyngeal port during speech, and a

electropalatography, computer program used to correct oral misarticulations and visual feedback

of tongue placement (ASHA, 2017b). Depending on the setting of intervention certain

technology may be more readily available than others, but all can aid in treating an adolescent

with cleft lip and palate.

Social and Psychological Effects

Cleft lip and Palate can also effect an adolescent in all parts of their life, including

socially and psychologically. According to Gkantidis, Papamanou, Karamolegkou, and

Dorotheou (2015) how severe the cleft is and how long that the child receives treatment can have

a major impact on the social and psychologic development of that child. This can manifest itself

in the child having bad self-concept, low self-confidence, anxiety, depression, and trouble

making and maintaining friendships (ASHA, 2017b).

However, it does not just affect the child, it can expand to family members as well. In a

study conducted by Gkantidis et al., In contrast to their children, parents reported a significant

impact of the cleft in family life, while they both assessed the impact of the cleft in social and

professional/school life as minor (Gkantidis et al., 2015, p. 4). Parents were more concerned
Cleft Lip and Palate 20

about how it would affect the life of their child more than the child actually was. It was reported

that the parents biggest concern was the appearance of the lips and the nose after treatment and

the effects that would have on their childs life (Gkantidis et al., 2015). However, the issues

extend past just the appearance of the cleft before and after repair, ones social and professional

life can be effected due to the speech implications of the cleft. They were worried that by having

the speech errors it would negatively impact their child. However, over time these seem to

decrease in some instances (Gkantidis et al., 2015).

Controversies

Velopharyngeal insufficiency is one of the co-occurring disorders that can result from

cleft lip and palate. The best way to treat and diagnosis VPI is one of the most controversial

issues surrounding cleft lip and cleft palate (Ysunza et al., 2015). One way that velopharyngeal

insufficiency is observed is by looking at the function of the port through using

videonasopharyngoscopy (VNP) along with and multiplanar videofluriscopy (MPVF) (Ysunza et

al., 2015). By using these techniques, a possible diagnosis of insufficiency can be made while

watching the patient speak. Some clinicians use a sagittal or lateral view of the velum and the

posterior pharyngeal wall during speech, along with the VNP. It is important to have a three-

dimensional view, coronal, sagittal, and axial planes, of the valve in order to make an appropriate

plan for that patient (Ysunza et al., 2015). However, unlike the VNP, the MPVF can show the

velopharyngeal sphincter actually moving during speech production by using x-ray technology

(Ysunza et al., 2015). There is still debate on which process is the best to use to see the function

of the sphincter and depending on who one talks to the opinion on which is better will change.

However, one major issue with both VNP and MPVF is that neither of them are standardize,

which results in only perceptual scores being obtained. Ysunza et. al. reported that, Since VNP
Cleft Lip and Palate 21

does not provide real size measurements, the use of movement ratios of each of the structures of

the velopharyngeal sphincter seems to be the best approach for describing velopharyngeal

function (Ysunza et al., 2015). However, this concept is not believed by all.

Another major controversy that follows cleft lip and cleft palate, are the corrective

surgeries, pharyngeal flap and sphincter pharygoplasics, to fix velopharyngeal insufficiency

(Ysunza et al., 2015). The major controversy that surrounds these surgeries is that they are not

always successful and vary in effectiveness and in order to actually benefit the patient, the

surgery has to be individualized to meet that specific patients needs (Ysunza et al., 2015).

Additionally, studies also show that the pharyngeal flap may present risks to upper airway by

the very nature of the procedure, which creates a mechanical obstruction to airflow, thus

reducing the airspace (Fukushiro et at., 2014). This can result in other disorders occurring,

meaning one has to decide if the surgery is worth the risk of the other possible etiologies taking

place and causing further complications.

Research

The research that surrounds cleft lip and palate exhibits how the goal of these adolescents

is to increase their skill levels to their peers who do not present with any cleft. In a study

conducted by Hardin-Jones and Chapman (2008), the focus was on early intervention in order to

help reduce the articulation errors that appear due to the presence of a cleft. The sample size for

this study was 40 total participants (30 repaired cleft and 10 without cleft), which was about the

average size of most sample sizes for clefting studies. However, in a study conducted by

Pamplona, Ysunza, and Morales (2017) the sample size was a total of 88 participants, which was

very large compared to others. Also, the design for most of the research is between group design.

This means the research is comparing one group to another. The groups being compared are
Cleft Lip and Palate 22

usually a group of children with cleft lip and palate compared to children without cleft lip and

palate, which is seen in the study conducted by Hardin-Jones el al. (2008). By having a typically

developing group the researchers are able compare the experimental group to it and see if their

scores line up or not. This helps to see if the treatment or intervention is effective or not. For the

between group designs the procedure is usually involved the intervention group receiving some

type of therapy and the control not receiving any. Overall, the studies conducted on children with

cleft lip and palate were valid in the sense that they were measuring what they intended to

measure, however, they were not as reliable. That is because when different researchers tried to

find similar trends some were found, but there was always an outlier that did not match up.

Conclusion

The major deficit an adolescent with cleft lip and palate is in their speech production. The

cleft can result in many errors in articulation happening in either place or manner. Many of these

errors can later be learned into that childs phonological system unless addressed in early

intervention and/or therapy following any reconstructive surgery (AHSA, 2017b). While the

change in facial structure can affect the speech of an adolescent with cleft lip and palate, it can

also have greater effects on the adolescents functioning. Hearing can be effected because fluid

from the middle ear is not being drained. Feeding can be effected because the child is not taking

enough in for nutrition. An adolescent can be psychologically effected because of self-esteem

issues related to the clefts appearance. (ASHA, 2017b). All of these areas need to be taken into

consideration in order to fully comprehend how an adolescent with cleft and palate functions in

their everyday life.

Cleft Lip and Palate 23

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