May not necessarily be related to the cleft Will respond to the same treatment as non-cleft children on your caseload

Distortion caused by a structural anomaly Will not respond to therapy, there is no need to treat. Some can be tested in evaluation, some can be tested in therapy

Difference in production caused by structural difference Acoustically appropriate Examples: [p,b,m] with macroglossia – [f,v] with anterior crossbite No need to treat!

July 2nd Slides Flashcards by Joanna Wende

What is STEP ONE of evaluation, Planning, and Treatment for the Child with Cleft Palate? What are 3 other things you should do within the first step?

Step One: Always have parents sign a release allowing you to communicate with the treating team
Also: 
Send your results 
Address your concerns 
Don’t hesitate to ask questions

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These slides discuss collaborative care in what 3 contexts?

Collaborative care in:

cleft palate
velopharyngeal dysfunction
craniofacial differences

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If you provide early intervention in the home what 2 things should you be familiar with?

Art and Science of the Home Visit:
Stredler Brown, A. (2005, Jan. 18).

The ASHA Leader, pp. 6- 7, 15.

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List reasons why you would sign off on early intervention in the home.

– If the parent requests it
– If the parent is willing and able to learn the new skill
– If the parent understands the reasons for using it
EDUCATE WELL!!!!!

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List reasons why you would not sign off on early intervention in the home.

– If the parent is stressed or not coping well
– If the parent may have difficulty learning a new skill
– If the parent may have trouble understanding the reasons for introducing sign
– If it may cause the parent to think their baby will not talk

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It may be inadvisable to spend time and resources on what with early intervention in the home for a child with cleft palate?

on a skill we will want the child to lose

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What may be a better use of resources for the child with a cleft palate instead of spending time and resources on a skill we will want the child to lose.

Teaching parents to be excellent language teachers

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What should you do if If maladaptive/compensatory articulations are present in early intervention age children with cleft palate? List 3 examples.

advise family on extinction techniques

Don’t imitate the troublesome sounds!
Model prolonged vowels
Model easy onset

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What should you teach the parent to teach in at home early intervention.

Good language stimulation • Helping the child to listen
Prolonging Vowels
Anterior articulation
Anterior blowing

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How many children with cleft palate will require speech therapy in childhood?

50% to 75%

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How many children with cleft palate will require secondary velopharyngeal management?

4-38%

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What is the most common speech disorder in children with cleft palate?

articulation

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What kind of speech should you expect in the neurologically normal child with a cleft?

normal speech

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What is the only way true velopharyngeal dysfunction can be treated?

with physical management, NOT with speech therapy

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What can kinds of errors can speech therapy correct?

maladaptive/compensatory errors

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What is the ONLY thing that can correct maladaptive/compensatory errors?

speech therapy

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What can speech therapy correct?

articulation

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Name 4 articulation error types.

Developmental
Obligatory
Maladaptive
Adaptive

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Developmental error.

May not necessarily be related to the cleft

* Will respond to the same treatment as non-cleft children on your caseload

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obligatory (passive)

Distortion caused by a structural anomaly
Will not respond to therapy, there is no need to treat.
Some can be tested in evaluation, some can be tested in therapy

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Adaptive error

Difference in production caused by structural difference
Acoustically appropriate
Examples: [p,b,m] with macroglossia – [f,v] with anterior crossbite
No need to treat!

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Maladaptive

or “Compensatory”(CMA) “ Active errors”

First described by Trost-Cardamone in 1981
Further delineated by Peterson-Falzone and others
Believed to develop as a compensation for defect of mechanism before or after palate repair

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Examples of Maladaptive

or “Compensatory”(CMA) “ Active errors”

glottal stop
pharyngeal stops and fricatives (and affricates)
mid dorsum palatal stops
posterior nasal fricative
velar fricatives (voiced and unvoiced)
ingressive fricatives

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How to test? Obligatory vs. Maladaptive

Velopharyngeal:

Do articulation testing with the nose plugged and unplugged

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How to test? Obligatory vs. Maladaptive | fistula

Test articulation with the fistula plugged and unplugged

How to test? Obligatory vs. Maladaptive | dental

Diagnostic therapy to see if changing tongue placement alters distortion

Form Hypotheses and Develop a Treatment Plan | Developmental: treat or not?

Same guidelines apply as with children without cleft

Form Hypotheses and Develop a Treatment Plan | Obligatory/passive:

do not treat with speech therapy

Form Hypotheses and Develop a Treatment Plan | Maladaptive/compensatory/active:

definitely treat

Form Hypotheses and Develop a Treatment Plan | adaptive

do not treat

Form Hypotheses and Develop a Treatment Plan | UNCERTAIN

begin diagnostic therapy

Phonological Cycle? • Despite two cited studies, most craniofacial SLPs DO NOT recommend a phonological cycle approach • Why?

– Seen as ineffectual in children returning for subsequent evaluations – Is this a concern for all children in phonological cycle approaches administered in school settings, or only children with cleft palate?

Most cleft-affected children will NOT benefit from these techniques used as techniques in and of themselves

``` Non-speech oral motor exercises • Icing, brushing, and massage • Blowing, sucking, and gagging exercises and programs (horns and straws) • Vibratory stimulation • Thermal stimulation ```

Specificity!

The best way to treat speech is to treat speech | Use a motor learning approach

Teach place of articulation | If you are uncertain as to the velopharyngeal contribution, when what?q

plug the nose

Work from what part to what part of mouth.

front of mouth to back of mouth

Defer [k,g] until when?

until late in therapy

What should you ask yourself when doing therapy. | hint: pedagogy

Why is therapy needed? • What needs to be changed? • What should be known before a consonant is taught? • Parts of the mouth and their names – (oral awareness?) – Difference between target and error • Give the sound a new name! – How to imitate

Teach from where?

similar place of articulation

for /p,b/

use /m/ and plug the nose

for /t,d/

use [n,l], plug the nose

for /s,z/

use [t,d] prolonged

for /k,g/

use “ng,” plug the nose

For [t,d]

• Teach fully protruded or interdentally Teach from excessively anterior place of articulation

For [s,z]

Teach from “th” | Then, gradually pull the tongue back to the correct placement

Remember that you are teaching a new motor pattern..how many times is a good start?

100 times is a good start!

What is the hierarchy of goals? GO!

``` Isolation Syllable Imitation Word Imitation Phrase Imitation Picture Naming Question Response Simple Sentence Complex Sentence ```

Describe foundational skills.

* Early discrim pedagogy * Establishment of consonant in isolation * Advancement to syllable segments * Use in word imitation and picture naming • Use in phrase imitation * Single-word question response

Foundational skills should always be carried to.....

100% accuracy

Failure to carry out foundational skills to

failure to do so may result in problems with carryover later

OK, but can you really do this with a two-year old?

yes

How can you make it fun?

* iPad apps * Puzzles * Mr. Potato Head • Hide and Seek * Bean Bag Toss • Ring Toss * Bead stringing * Angry Birds * Dot-to-Dots * Board games * Card games * Indoor basketball • Construction Toys • Stickersheets

Home assignments are essential! list examples

Gimme 5 Pick a vowel Word, phrase, sentence lists

• Target [p,b] first: Why?

– Anterior – Visible – Likely to achieve success – Will need for imaging

For [p,b]

use [m] for gabriella

When do I wean from nose- plugging?

After the syllable level...but ...reuse as complexity advances, to check for coarticulation, or with new consonant targets

When should you Introduce linguistic challenge?

after stability with phrase imitation. Don’t pull out the pictures or reading flash cards before then!

What about the velopharynx?

Stay in touch with the team Learn their imaging requirements Keep addressing articulation

If the articulation is correct and stable with | the nose plugged, then what?

move on

Can you fix the articulatory placement with therapy?

yes

Can you fix resonance disorder with therapy?

If the articulation does not sound correct with the nose plugged, then what?

you still need to work on placement.

[t,d] provide excellent foundation for teaching what?

central /s/

When do I wean from the nose plug? How do I do it?

Wean after 100% accuracy at syllable level, but don’t feel badly about a few minutes of plugging here and there as you advance.

Careful data collection in each therapy session is the best practice. What should you use?

pica scoring

Which format to use? What is individual pull out appropriate for?

``` Foundational Skills • Discrimin Pedagogy – Oral/nasal – Oral/glottal – Oral/pharyngeal • Placement teaching • Nose-plugging • Basic skill-building ```

What is classroom push in appropriate for?

``` • Classroom Push-in – Advanced Levels • Question response • Question asking • Sentence generation • Conversational speech ```

Examples of short sessions.

Speed speech Mini therapies Rapid 1:1

The articulation disorder may not be the same as others on your caseload...and the treatment techniques may....

differ as well

Consider the psychosocial issues...example....

If the techniques you need to use may expose a child to ridicule in a group, you may need to treat individually

How do you schedule an authorization by visit.

– Frequency determined by family schedule and number of visits authorized – Length: 60 minutes + – Schedule when family schedule allows best use of benefit

How do you schedule an authorization by calendar days?

– Frequency: as often as possible – Schedule when family schedule allows maximum # of sessions – Length: 60 minutes +