Comparison of motor-phonetic versus phonetic-phonological speech therapy approaches in patients with a cleft (lip and) palate: a study in Uganda

Management of Speech and Hearing in Low-Income and Middle-Income Countries: Current Conditions, Problems, Future Directions

Management of speech and hearing issues in low-income and middle-income countries (LMICs) has been challenging, considering the population size and availability of resources. There is a need to investigate the depth of these challenges and explore the efficacy of strategies to overcome them. This review aimed to delineate the speech and hearing issues in individuals with cleft lip and palate and how they have been managed in the context of LMICs. Keywords were developed based on the objectives of the study to search for literature published during the period 2010 to 2023. Articles from PubMed, Google Scholar, Science Direct, and ProQuest databases were retrieved using appropriate keyword searches. The titles and abstracts were screened to delete the unsuitable articles. Relevant gray literature and hand-searched articles published were also included. The findings are summarized under the following heads in the context of LMICs: incidence and severity of speech and hearing issues, challenges, and barriers in providing speech and hearing services, methods of developing manpower and training, methods of assessing speech and hearing outcomes, service delivery models employed, and the recent advances relating to management of speech and hearing. A wide range of topics revolving around managing speech and hearing issues in individuals with cleft lip and palate has been researched in the context of LMICs. Scattered and fragmented solutions have been provided to overcome the varied challenges in LMICs. The gaps in the literature and the future directions for research have been identified.

Gradient speech change during intervention for school-aged children and adults with cleft palate ± lip

Gradient speech change, where speech sound production develops in a broadly step-wise fashion towards the standard adult form, is a well-recognised phenomenon in children developing typical speech, but is much less studied in speakers with developmental speech sound disorders. Instrumental techniques, such as electropalatography (EPG), may be useful for identifying gradient speech change and may supplement phonetic transcription in important ways. This study investigated whether gradient speech change occurred in six participants with cleft palate ± lip undergoing intervention within a usage-based phonology framework (2/6 participants with speech distortions; 4/6 with pattern-based speech substitutions; combined total of 25 speech sounds targeted for intervention). Participants received weekly therapy in a hospital setting and were aged 10-27 years. Gradient speech change with target speech sounds was examined using EPG analysis, which was undertaken after every fifth session of therapy. The presence of gradient change was determined by visually examining EPG palatograms and EPG indices for target speech sounds across successive EPG test points. This study found gradient speech change occurred in 22/25 target sounds over the course of intervention. This gradient change occurred for both speech distortions and pattern-based speech substitutions. The remaining 3/25 target sounds showed categorical change. Usage-based phonology was suggested as a theory with potential for explaining gradient speech change, with both typical and atypical speech, and with speech distortions and pattern-based speech substitutions. This finding adds to other research showing that the objective data provided by instrumental techniques, such as EPG, may be a valuable complement to phonetic transcription.

Telepractice Parent Training of Enhanced Milieu Teaching With Phonological Emphasis (EMT+PE) For Persian-Speaking Toddlers With Nonsyndromic Cleft Palate: Protocol for a Randomized Controlled Trial

BACKGROUND

Children born with a cleft palate with or without a cleft lip (CP/L) are at increased risk for delayed language development and speech sound disorders. Enhanced Milieu Teaching with Phonological Emphasis (EMT+PE) is a recommended naturalistic intervention for toddlers with CP/L. The parents' role in providing naturalistic interventions is critical and they need training based on learning principles to implement these interventions. Telepractice is an appropriate method for training parents and children with various speech-related disorders.

OBJECTIVE

This study aims to determine and compare the effectiveness of telepractice and the parent-implemented EMT+PE intervention on language and speech measures in toddlers with CP/L with usual interventions and determine the effectiveness maintenance of the intervention.

METHODS

A randomized controlled trial (RCT) will assess the efficacy of telepractice and the parent-implemented EMT+PE intervention in enhancing speech and language measures in toddlers with CP/L. Eligible participants will be randomly assigned to one of 2 groups: the conventional intervention group and the EMT+PE intervention group. Participants' speech and language measures will be evaluated remotely by trained raters before and after the intervention and 2 months after the intervention. Parents of participants in the intervention group will receive 3 months of training in speech and language supportive strategies from trained therapists using telehealth fidelity scales. Parents of participants in the control group will receive the conventional speech and language intervention by cleft team therapists. Study outcomes will include language variables (mean length of utterance) and speech production variables (percent correct consonants).

RESULTS

The protocol was approved by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences in February 2022. The selection process of participants, as well as training therapists and raters, commenced in January 2022, the therapy and follow-up period ended in June 2023, and pre- and postintervention assessments have been conducted. Data analysis is ongoing, and we expect to publish our results by the summer of 2024. Funding is yet to be received.

CONCLUSIONS

The results of this study may help us develop a speech and language intervention with a different delivery model for toddlers with CP/L, and the cleft team care can use these results in service delivery. Consistent with our hypothesis, speech and language measures are expected to improve.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54426.

How differences in anatomy and physiology and other aetiology affect the way we label and describe speech in individuals with cleft lip and palate

BACKGROUND

Speech in individuals with cleft lip and/or palate (CLP) is a complex myriad of presenting symptoms. It is uniquely associated with the structural difference of velopharyngeal insufficiency (VPI), together with a wide and heterogeneous range of other aetiologies which often co-occur. The nature of the speech sound disorder (SSD) including VPI may also change over the course of an individual's care pathway. Differences in terminology and approaches to analysis are currently used, resulting in confusion internationally. Additionally, current diagnostic labels and classification systems in SSD do not capture the complexity and full nature of speech characteristics in CLP.

AIMS

This paper aims to explore the different aetiologies of cleft palate/VPI speech and to relate aetiology with speech characteristic(s). In so doing, it attempts to unravel the different terminology used in the field, describing commonalities and differences, and identifying overlaps with the speech summary patterns used in the United Kingdom and elsewhere. The paper also aims to explore the applicability of current diagnostic labels and classification systems in the non-cleft SSD literature and illustrate certain implications for speech intervention in CLP.

METHODS AND PROCEDURES

The different aetiologies were identified from the literature and mapped onto cleft palate/VPI speech characteristics. Different terminology and approaches to analysis are defined and overlaps described. The applicability of current classification systems in SSD is discussed including additional diagnostic labels proposed in the field.

OUTCOMES AND RESULTS

Aetiologies of cleft palate/VPI speech identified include developmental (cognitive-linguistic), middle ear disease and fluctuating hearing loss, altered oral structure, abnormal facial growth, VPI-structural (abnormal palate muscle) and VPI-iatrogenic (maxillary advancement surgery). There are four main terminologies used to describe cleft palate/VPI speech: active/passive and compensatory/obligatory, which overlap with the four categories used in the UK speech summary patterns: anterior oral cleft speech characteristics (CSCs), posterior oral CSCs, non-oral CSCs and passive CSCs, although not directly comparable. Current classification systems in non-cleft SSD do not sufficiently capture the full nature and complexity of cleft palate/VPI speech.

CONCLUSIONS AND IMPLICATIONS

Our attempt at identifying the heterogeneous range of aetiologies provides clinicians with a better understanding of cleft palate/VPI speech to inform the management pathway and the nature and type of speech intervention required. We hope that the unravelling of the different terminology in relation to the UK speech summary patterns, and those used elsewhere, reduces confusion and provides more clarity for clinicians in the field. Diagnostic labels and classification require international agreement.

WHAT THIS PAPER ADDS

What is already known on the subject Speech associated with cleft palate/velopharyngeal insufficiency (VPI) is a complex myriad of speech characteristics with a wide and heterogeneous range of aetiologies. Different terminology and speech summary patterns are used to describe the speech characteristics. The traditional classification of cleft palate/VPI speech is Articulation Disorder, although evidence is building for Phonological Disorder and contrastive approaches in cleft speech intervention. What this paper adds to existing knowledge This paper explores the range of aetiologies of cleft palate/VPI speech (e.g., altered oral structure, abnormal facial growth, abnormal palate muscle and iatrogenic aetiologies) and attempts to relate aetiology with speech characteristic(s). An attempt is made at unravelling the different terminology used in relation to a well-known and validated approach to analysis, used in the United Kingdom and elsewhere. Complexities of current diagnostic labels and classifications in Speech Sound Disorder to describe cleft palate/VPI speech are discussed. What are the potential or actual clinical implications of this work? There needs to be a common language for describing and summarising cleft palate/VPI speech. Speech summary patterns based on narrow phonetic transcription and correct identification of aetiology are essential for the accurate classification of the speech disorder and identification of speech intervention approaches. There is an urgent need for research to identify the most appropriate type of contrastive (phonological) approach in cleft lip and/or palate.

The retrospective acceptability of high intensity versus low intensity speech intervention in children with a cleft palate: A qualitative study from the parents' point of view using the Theoretical Framework of Acceptability

BACKGROUND

Increasing attention is paid to the effectiveness of high-intensity speech intervention in children with a cleft (lip and) palate (CP±L). It is, however, unknown if high-intensity intervention is acceptable to the intervention recipients. Parents have an integral role in supporting their children with intervention highlighting the importance of intervention acceptability to parents.

AIMS

To compare the retrospective acceptability of high-intensity speech intervention (10 1-hr speech therapy sessions divided over 2 weeks) with the retrospective acceptability of low-intensity speech intervention (10 1-hr speech therapy sessions divided over 10 weeks) for children with a CP±L from the parents' point of view.

METHODS & PROCEDURES

Twelve parents of 12 children, aged 6-0 years who received high-intensity speech intervention (n = 6) or low-intensity speech intervention (n = 6), were invited to participate in this study. Seven parents (n = 3 in the high-intensity group and n = 4 in the low-intensity group) agreed to participate (total response rate: 7/12, 58.33%). A qualitative study design using semi-structured interviews was applied. To investigate the retrospective acceptability of the two intervention intensities, deductive coding according to the Theoretical Framework of Acceptability (TFA) was used.

OUTCOMES & RESULTS

With regard to the TFA construct 'affective attitude', results demonstrated that parents had positive feelings about the provided speech intervention regardless of the intensity. Parents of children who received high-intensity speech intervention reported two specific benefits related to the high intervention intensity: (1) it improved their relationship with the speech-language pathologist and (2) it improved their child's ability to make self-corrections in his/her speech. Even though both high-intensive and low-intensity speech intervention were considered burdensome (TFA construct 'burden'), parents were less likely to drop out of high-intensity intervention because the total intervention period was kept short.

CONCLUSIONS & IMPLICATIONS

In conclusion, high-intensity speech intervention seemed acceptable to parents. More positive codes were identified for some of the TFA constructs in the high-intensity intervention group than in the low-intensity intervention group. Considering that some parents doubted their self-efficacy to participate in high-intensity speech intervention, speech-language pathologists need to counsel them so that they can adhere to the high intervention intensity. Future studies should investigate whether high-intensity speech intervention is also acceptable to the children who receive the intervention and to the speech-language pathologists who deliver the intervention.

WHAT THIS PAPER ADDS

What is already known on this subject Increasing attention is paid to the effectiveness of high-intensity speech intervention in children with a cleft (lip and) palate (CP±L). Different quantitative studies have shown positive speech outcomes after high-intensity cleft speech intervention. Despite this increasing attention to high-intensity speech intervention, it is unknown whether high-intensity intervention is also acceptable to the intervention recipients. This study compared the retrospective acceptability of high-intensity speech intervention (10 1-hour speech therapy sessions divided over 2 weeks) with the retrospective acceptability of low-intensity speech intervention (10 1-hour speech therapy sessions divided over 10 weeks) in children with a CP±L from the parents' point of view. What this paper adds to existing knowledge More positive codes were identified for some of the TFA constructs in the high-intensity intervention group than in the low-intensity intervention group. Nevertheless, some parents doubted their self-efficacy to participate in high-intensity speech intervention. What are the potential or actual clinical implications of this work? The findings of this study forces us to reconsider the traditional cleft speech intervention delivery models which usually consist of low-intensity intervention. Speech-language pathologists need to counsel parents and so that they can adhere to the high intervention intensity.

Influence of an Intensive Speech Therapy Program on the Speech of Individuals with Cleft Lip and Palate

Introduction  Compensatory articulations are speech disorders due to the attempt of the individual with cleft palate/velopharyngeal dysfunction to generate intraoral pressure to produce high-pressure consonants. Speech therapy is the indicated intervention for their correction, and an intensive speech therapy meets the facilitating conditions for the correction of glottal stop articulation, which is the most common compensatory articulation. Objective  To investigate the influence of an intensive speech therapy program (ISTP) to correct glottal stop articulation in the speech of individuals with cleft palate. Methods  Speech recordings of 37 operated cleft palate participants of both genders (mean age = 19 years old) were rated by 3 experienced speech/language pathologists. Their task was to rate the presence and absence of glottal stops in the 6 Brazilian Portuguese occlusive consonants (p, b, t, d, k, g) distributed within several places in 6 sentences. Results  Out of the 325 pretherapy target consonants rated with glottal stop, 197 (61%) remained with this error, and 128 (39%) no longer presented it. The comparison of the pre- and posttherapy results showed: a) a statical significance for the p1, p2, p3, p4, t1, k1, k2 and d6 consonants (McNemar test; p  < 0.05); b) a statistical significance for the p consonant in relation to the k, b, d, g consonants and for the t consonant in relation to the b, d, and g consonants (chi-squared test; p  < 0.05) in the comparison of the proportion improvement among the 6 occlusive consonants. Conclusion  The ISTP influenced the correction of glottal stops in the speech of individuals with cleft palate.

Compensatory Articulation Errors in Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

The aim of this study was to assess the frequency and types of compensatory articulations (CAs) in nonsyndromic patients with velopharyngeal dysfunction (VPD) and various palatal anomalies and to determine the relationship between the frequency of CAs, type of palatal anomaly, and phonological errors.

METHOD

A total of 783 nonsyndromic, Hebrew-speaking patients with VPD and various palatal anomalies (cleft lip and palate [CLP], cleft palate [CP], submucous CP [SMCP], occult submucous CP [OSMCP], or non-CP) were studied retrospectively. Perceptual VPD tests, including articulation and phonological assessment, were conducted. CAs were described as below the level of the defect in the vocal tract (abnormal backing of oral targets to post-uvular place) or in front of it within the oral cavity (palatalization) and at the velopharyngeal port.

RESULTS

Among 783 patients, 213 (27.2%) had CAs. Most CAs (18.4%) occurred below the level of the defect, followed by CAs at the velopharyngeal port (12.0%) or in front of it (4.9%). No differences were found in the frequency of CAs between patients with CP (47.8%) or CLP (52.6%) and between those with non-CP (13.6%) or OSMCP (14.7%). SMCP patients had lower frequency of CAs (29.8%) than CP (p = .003) and CLP (p =  .002) patients but higher frequency than OSMCP (p = .002) and non-CP (p =  .002) patients did. Among the 783 patients, 247 (31.5%) had phonological errors. A higher frequency of phonological errors was found in patients with CAs (55.4%) compared to those without (22.6%) and in all palatal anomaly groups except CLP (31.4% vs. 23.9%).

CONCLUSIONS

CAs in nonsyndromic patients with VPD remained relatively high in all age groups, up to adulthood. CAs are influenced by inadequate velar length following palatal repair, as well as by oral structural abnormalities, whereas poor muscle function due to OSMCP and/or abnormal size and/or shape of nasopharynx has less influence. Errors produced in front of the velopharyngeal port are influenced by the structural anomaly of CLP. This information may contribute to general phonetic and phonological theories and genetic investigations about CP anomalies.

On the Benefits of Speech-Language Therapy for Individuals Born With Cleft Palate: A Systematic Review and Meta-Analysis of Individual Participant Data

PURPOSE

Cleft lip and/or palate (CLP) is a common birth defect, and after reconstructive surgery, about 50% of children at 5 years of age have speech deviations and are referred to speech-language therapy (SLT). The peer-reviewed evidence for the benefit of SLT has been uncertain. Our objective was to systematically review and meta-analytically summarize the benefit of SLT for individuals born with CLP.

METHOD

A systematic search was conducted (last search on February 19, 2021) on studies evaluating SLT with pre and post measures on speech production, language ability, intelligibility, and/or patient-reported outcomes. We sought individual participant data (IPD) and evaluated on an individual level if the outcome measure had improved to a clinically relevant degree during SLT and if the outcome measure was on a level with peers or not after SLT. Meta-analyses and meta-regressions were applied to synthesize IPD across studies.

RESULTS

Thirty-four eligible studies were found. Nineteen studies provided IPD (n = 343) for the main analysis on speech production. The synthesized information suggests that, during SLT, speech production improved to a clinically relevant degree for many individuals (95% CI [61%, 87%]) and that speech production was on a level with peers for some individuals after SLT (95% CI [10%, 34%]).

CONCLUSIONS

The main strength of this meta-analysis is that we evaluated on an individual level pre- and post-intervention data based on considerations of clinical relevance. This approach allowed us to conclude that many individuals benefit from SLT and that further work on evaluating SLT in this patient group is meaningful. Supplemental Material https://doi.org/10.23641/asha.17700992.

Is High-Intensity Speech Intervention Better? A Comparison of High-Intensity Intervention Versus Low-Intensity Intervention in Children With a Cleft Palate

Purpose The purpose of this study was to compare the effect of speech intervention provided with a low intensity with speech intervention provided with a high intensity on the speech and health-related quality of life (HRQoL) in Dutch-speaking children with a cleft palate with or without a cleft lip (CP ± L) between 4 and 12 years. Method A longitudinal, prospective, randomized controlled trial with a multiple baseline design was used. Twelve children with a CP ± L (M _age = 8.0 years, SD = 1.54) were divided into two groups using block randomization stratified by age and gender: One group received low-intensity speech intervention (LISI; n = 6) and one group received high-intensity speech intervention (HISI; n = 6). Children in the LISI group received intervention with a session duration of 1 hr, a dose frequency of 1 session per week, and a total intervention duration of 10 weeks. Children in the HISI group received intervention with a session duration of 1 hr, a dose frequency of 5 sessions per week, and a total intervention duration of 2 weeks. The cumulative intervention intensity was kept constant. Both groups received identical therapy programs provided by the same experienced speech therapist. Perceptual speech assessments were performed on baseline and posttreatment data points. Changes in HRQoL were assessed using the Velopharyngeal Insufficiency Effects on Life Outcomes (VELO) questionnaire. Both groups were compared over time using (generalized) linear mixed models. Results No significant Time × Group interactions were observed for the percentage of correctly produced consonants at the word and sentence levels, indicating no differences in evolution over time among the two groups. The variables speech understandability, speech acceptability, and the total VELO scores significantly improved following HISI, but not following LISI. Conclusions Children in the HISI group made equal and, for some variables, even superior progress in only 2 weeks of therapy compared to children in the LISI group who received 10 weeks of therapy. HISI is a promising strategy to improve speech outcomes and HRQoL in a shorter time period.

Enhanced Milieu Teaching with Phonological Emphasis: A Pilot Telepractice Parent Training Study for Toddlers with Clefts

OBJECTIVE

the purpose of this study was to evaluate the effects of training caregivers to use intervention strategies from the Enhanced Milieu Teaching with Phonological Emphasis (EMT + PE) program, delivered via telepractice, and to examine the effects on child speech and language outcomes for children with repaired cleft lip +/- palate (CL/P).

DESIGN

A multiple baseline within subject design across parent behaviors was replicated across three participating dyads. A pre-post intervention comparison was provided with a non-cleft twin.

PARTICIPANTS

Three mother-child dyads participated in this study. Children ranged in age from 21 to 27 months at the beginning of the study and all had a diagnosis of CL/P. A noncleft twin without CL/P was assessed pre- and post-intervention to provide a normative comparison.

RESULTS

Parents demonstrated a positive intervention effect by substantially increasing their use of EMT + PE intervention strategies during telepractice intervention sessions (Tau 0.675 to 1.1333). Following the conclusion of intervention, parents were able to maintain their use of strategies once direct coaching had been discontinued. Children demonstrated increased talking rate, improved speech production and expanded expressive vocabulary measures over the course of intervention. Speech and language development of a child without cleft palate was provided as a comparison.

CONCLUSIONS

Parents were trained through telepractice to effectively deliver EMT + PE speech and language facilitation strategies that resulted in increased language and speech outcomes for their children with CL/P.

Non-Oral Compensatory Misarticulations Revisited

Non-oral compensatory misarticulation patterns are often associated with the speech of children with cleft palate. Despite their saliency, the etiology, frequency, and treatment of these misarticulations have not been studied extensively. The purpose of this commentary is to review what we know about these atypical patterns of articulation and address clinical assumptions regarding their etiology and treatment.

Effectiveness of Speech Intervention in Patients With a Cleft Palate: Comparison of Motor-Phonetic Versus Linguistic-Phonological Speech Approaches

Purpose The purpose of this study was to compare the effect of two different speech therapy approaches, a traditional motor-phonetic approach and a linguistic-phonological approach, on the speech and health-related quality of life in Dutch-speaking children with a cleft palate with or without a cleft lip (CP ± L) between 4 and 12 years old. Method A block-randomized, sham-controlled design was used. Fourteen children with a CP ± L (M _age = 7.71 years) were divided into two groups using block randomization stratified by age and gender: one receiving motor-phonetic intervention (n = 7) and one receiving linguistic-phonological intervention (n = 7). Each group received 10 hr of speech therapy divided over 2 weeks. Perceptual speech assessments were performed on several baseline and posttreatment data points. The psychosocial effects of the intervention were assessed using the patient-reported Velopharyngeal Insufficiency Effects on Life Outcomes questionnaire. Both groups were compared over time using (generalized) linear mixed models. Within-group effects of time were determined using pairwise comparisons with post hoc Bonferroni correction. Results Significant Time × Group interactions with large effect sizes were revealed in terms of consonant proficiency, indicating significant differences in evolution over time among the two groups. Only in the group receiving linguistic-phonological intervention, percentage of correctly produced consonants and places significantly improved after the treatment. Total Velopharyngeal Insufficiency Effects on Life Outcomes scores of the parents significantly improved in both groups after the intervention. Conclusions Both motor-phonetic and linguistic-phonological speech interventions can have a positive impact on the occurrence of cleft speech characteristics and consonant proficiency in children with a CP ± L. A linguistic-phonological approach, however, was observed to be more effective in terms of improving these speech outcomes compared with a motor-phonetic approach. Speech intervention, irrespective of the used approach, significantly improved the participant's health-related quality of life.

A cleft care workshop for speech and language pathologists in resource-limited countries: The participants' experiences about cleft care in Uganda and satisfaction with the training effect

OBJECTIVES

workshops and specialized training programs are often inaccessible for speech and language pathologists (SLPs) based in resource-limited countries given the lack of supply, the long travel distances and the excessive participation fees. To stimulate life-long learning opportunities for all, this study described and measured the effect of a free, two-day cleft care workshop for SLPs in Uganda. The workshop included different topics related to the assessment and treatment of children with a cleft of the palate with or without a cleft of the lip (CP ± L).

METHODS

The participants who presented during the two-day course were asked to complete a pre- and post-workshop questionnaire to evaluate their satisfaction. The pre-workshop form also included some questions concerning cleft care in Uganda. Both the pre- and post-workshop forms included three visual analogue scales to investigate the evolution of the participants' estimation of their knowledge regarding speech in patients with a CP ± L and to assess the changes in their self-confidence in the diagnosis and treatment of this population.

RESULTS

seventeen SLPs completed the pre- and post-workshop questionnaires. In general, the participants were highly satisfied with the different themes covered in the program. After the training course, the participants rated their general knowledge about CP ± L and their self-confidence in the diagnosis and treatment of children with a CP ± L significantly higher than before the workshop.

CONCLUSION

the vast majority of the SLPs reported that cleft care was not easily accessible in Uganda. The most commonly reported obstacle for cleft care was a lack of knowledge about this matter in the SLPs themselves highlighting the importance of the organization of additional education opportunities. The participants reported a significantly higher level of self-confidence in diagnosing and treating children with a CP ± L after the workshop. The content of this workshop can form the basis for future learning opportunities for SLPs based in resource-limited countries.