Common difficulties with speech
For the vast majority of children who were born with a cleft, their language development is unaffected, and they have a typically developing understanding of language, an age-appropriate vocabulary and understanding of language structure and conventions. As with any child, it is important to foster their development of language by regularly reading with them and including them in the literacy programme with the rest of the classroom.
It is not uncommon, however, for children with a cleft palate to have difficulties with their speech. Even after a cleft palate has been repaired, many children will still have lingering speech concerns. This can be for a number of reasons. For example, they may still have a residual hole (fistula) in the roof of their mouth which means they have no place to put their tongue to make certain speech sounds such as k, g, t, d, sh, ch, s and z. This is like trying to play a piano with one or more keys missing – no matter how great a pianist you are, you won’t be able to play those missing notes. Surgery is generally needed to replace the missing ‘keys’.
While they are waiting for this to be repaired, many children develop what is known as compensatory articulation where they substitute the target sound with a sound that they know how to make. A common example would be using a glottal stop, so instead of saying the ‘t’ in ‘bottle’, they use a glottal stop: ‘bo-le’. This often makes little sense to the uninitiated. After surgery to address the structural issues preventing them from making the right sounds, children will be trained out of using compensatory articulation through speech therapy.
It is incredibly frustrating to have intact language and know exactly what you want to say, but be unable to express yourself in a way in which others can understand you. Talk with those who know the child best to understand the sounds the child uses to compensate for the sounds that they may be missing, and take the time to give the child your undivided attention when they are communicating with you.
Even after surgery, there can be other factors which make it harder to be understood – for example missing teeth makes it more difficult to make certain sounds, and air escaping through the nose (known as hypernasality) can make it more difficult for others to understand. For many children, this is exacerbated by talking quickly, or when they are tired. In these cases, encouraging the child to slow down and almost exaggerate the pronunciation of the speech sounds could help (we call this a speed-accuracy trade-off).
It’s important to expose children to the right way to produce various speech sounds. One of the most effective ways of doing this is to simply model back, and expand upon what has already been said. For example, if a child with a cleft palate said ‘wa-er bo-le’ for water bottle, you could respond with “Yes, that is your water bottle.” In doing so, you have modelled the correct pronunciation of the t sound and expanded on the child’s utterance in a way that has validated their communicative intent (i.e. you are acknowledging that you understood the message they were attempting to convey). It’s important not to tell them their message was wrong as you do not wish to discourage them from speaking – rather, simply model back the correct pronunciation and then progress the conversation.
Another excellent opportunity for modelling is sounding out the words in a book while reading it aloud – for example “d-o-g, dog! k-a-t, cat!” (you may have heard of this referred to as phonics). In addition to providing a chance to practice the various sounds within a word, you are also teaching a child how the written form of language (print) links to the oral form of language (speech), a cornerstone for literacy development. Be sure to provide lots of specific praise when they do well – for example, “I loved the way you made that k sound at the start of cat!” rather than general praise such as “good job”.
Understand a child’s limits
It’s important to realise that if a child is awaiting a speech related surgery, chances are there are one or more sounds that they are not physically able to make. If a child is repeatedly asked to perform a task that they just are not able to do, they will become frustrated and unlikely to continue to cooperate. It is a far better use of time to focus on sounds which although the child finds hard, they are able to make with prompting and encouragement is (we call this being stimulable), rather than sounds which they are not stimulable for.
Keep a look out for hearing difficulties
With the palate and ears being so intimately connected, it is little surprise that many children with a cleft palate experience hearing difficulties as a result of otitis media (glue ear). In many cases, this is managed with grommets and usually is short-lived, although a small number of children with a cleft will have persistent hearing difficulties which may come and go. When hearing is impacted, it becomes difficult for a child to learn in the classroom environment, they may start to misbehave, and their speech may also be impacted as they cannot hear the speech that is modelled to them. If you suspect hearing difficulties, a referral to audiology would be prudent. Resolving any hearing difficulties will vastly improve the child’s engagement and ability to learn.
Kenny Ardouin – BSLP (Hons)
This article also appeared in Speech Link UK.