Post on 24-May-2015
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Maximizing Treatment Effects with VPI and Cleft Lip and Palate
Scott Prath, M.A., CCC-SLPKeith Lebel, M.A., CCC-SLP
Photos courtesy of Operation Smile
TSHA Annual Convention March 9th, 2012- San Antonio, Texas
Structural Anomalies
Learner Objectives
•Describe how craniofacial differences occur and how they negatively impact intelligibility
•List underlying speech components that can be affected by VPI and Cleft Lip and/or Palate
•Identify intervention and evaluation strategies for working with a child with craniofacial anomalies
Defining VPI and VPD
•Velo-pharyngeal Insufficiency▫The velum (velo) is not contacting the
pharynx (back wall of the throat)▫Can be caused by:
Muscle weakness A large opening Insufficient muscle function Adenoids and tonsils
Defining VPI and VPD
• Velo-pharyngeal Dysfunction (VPD)▫ Increasingly VPD is being used as the umbrella
term as VPI can be confusing. ▫VPD does not exclude symptoms:
Anatomic Myoneural Behavioral Combinations of disorders
▫VPD includes: Velopharyngeal insufficiency (lack of closure) Velopharyngeal incompetence Velopharyngeal inadequacy Velopharyngeal incorrect learning
What is a Cleft?
• Clefts result from incomplete development of the lip and/or palate in the early weeks of pregnancy.
What types of clefts exist?
• A cleft lip (CL) is a separation in the upper lip.
• A cleft palate (CP) is an opening in the roof of the mouth.
• A cleft lip and palate (CLP) extends through both.
What types of cleft palates exist?
• A cleft palate can be:
▫ unilateral
▫ bilateral
▫ submucousal with bifid uvula
What is the prevalence?
• Clefts occur in ~ 1/750 live births
• Estimated prevalence by type:Lip only 14%Palate only 37%Lip and Palate 49% (77% are unilateral left)
• Estimated data by race:▫ Asian and Caucasian populations more susceptible▫ Black populations present with ½ the rate of Asians
and Caucasians▫ Hispanic data are inconclusive
When does a cleft occur?
4 and 5 weeks in utero
When does a cleft occur?
5 ½ and 6 weeks in utero
When does a cleft occur?
7 and 8 weeks in utero
When does a cleft occur?
What causes a cleft?
1. Gene Mutation2. Chromosomal Aberrations3. Teratogenic Agents4. Multifactoral Inheritance5. Mechanical Factors
How is a cleft repaired?
The repair of a cleft lip or palate is the process of taking
existing tissue that surrounds
the opening and rotating it or
moving it to close the opening.
What is the process for the family?
Influences on family effectiveness
Parent Reaction to a CleftChild Reaction to a CleftParent InvolvementMother-child Bond and Feeding
What is the process for the family?The Cleft Palate Team• Clinic Director• Audiologist• Craniofacial Surgeon• Geneticist• Neurosurgeons• Nurses• Occupational Therapists• Oral and Maxillofacial
Surgeons• Orthodontists• ENTs• Pediatrician• Pediatric Anesthesiologists
• Pediatric Dentists and Prosthodontists
• Pediatric Radiologists• Physical Therapists• Plastic Surgeons• Speech Language
Pathologists• Surgeon’s Assistant
Socio-emotional Development
“It is reasonable to assume that individuals with CLP should have relatively normal long-term health, as CLP is a reparable birth defect. However, several studies have suggested that individuals with CLP have a higher than expected incidence of psychiatric and behavior diseases, an increased risk for cancer, and increased mortality…”
Southern medical journal volume 99 number 11 oct 06 p 1112, Robin, Bates, etc.
The effects of CLP on the parent
Effects on the parent▫Blame due to improper love, nutrition, an
event during pregnancy▫Parent’s personality and their feeling of
control or lack of control▫Feelings of disappointment or resentment if
they feel that this event has dashed their hopes
The effects of CLP on the parent
Intervention:▫ Education!▫ Support!Research shows that when a family is in a
position where they feel that personal needs or aspects of their lives are governed by external forces or in a poor state, they exhibit negative feelings toward their child or event.
The effects of CLP on the child
Effects on the child▫Speech or hearing disorders▫Parents’ feeling of guilt
Can cause a parent to treat a child differently▫Anxiety
Regular or protracted doctor visits Parents’ ever-present fear of choking
▫Visible scars due to surgical procedures
The effects of CLP on the child
Intervention:The child’s psychosocial state is dependent
on how well or poorly the parent is dealing with everything.
It is our role to support and improve the lives of the child. This means direct social intervention with the parent.
When do emotions set in?
•Periods of: Anxiety Optimism Depression Acceptance
occur with each surgery or event.Edwards and Watson, 1980, found that there is an
optimistic period right after birth because the couple is happy that there are surgical options available, but soon after they can become disheartened.
•Take home message:Work to identify how a family is dealing with the process
in the time that we are serving them.
The Kubler-Ross Grief Cycle•Denial: Example - “She’s fine."; "This can't be
happening."
•Anger: Example - "Why me? It's not fair!" "NO! NO! How can you accept this!"
•Bargaining: Example - "Just let him talk fine, I don’t mind the scar."
•Depression: Example - "I'm so sad, why bother with anything?"; “Everything that we had planned for her isn’t going to happen."
•Acceptance: Example - "It's going to be OK."; "I can't fight it, I may as well prepare for it."
Parent Involvement
•Andhra Pradesh, India▫Tested:
Known context (rhymes, counting 1-10) Unknown context (family information)
▫There was a greater understandability of unknown contexts after treatment
Feeding and psychological development
•Children gain pleasure from oral stimulation and feeding
Feeding is impaired Feeding issues are one of the first problems
that families encounter so it is not an enjoyable event
•The early maternal-bonding process is often more disturbed by feeding problems than by the facial defect
Kalland, 1995
Feeding and psychological development
•CL (cleft lip only) -usually no major feeding problem (breast feeding possible)
•CP has difficulty feeding because of inability generating effective oral suction
Feeding •Children with CLP take in more air
▫They need to be burped more and fed more upright
•Feedings should last ~30 minutes.▫If they are needing 40 minutes, enlarge
and/or cross cut the nipple opening•Weight gain, feeding frequency, and
feeding amount are normally the same for a child with CLP
How is communication affected?
Speech DevelopmentArticulationVoiceResonance
Language DevelopmentHearing Development
Communication Characteristics
Children with CLP:•Show deficits in the size and
composition of their early sound inventories
•Reach the babbling stage later •Show less variety of speech forms
produced•Have a hypo-or hyper-nasal quality
Communication Characteristics
Children with CLP:•Often have voice problems (harshness)
due to overuse•Can have constant ear infections and
temporary hearing loss•Do not necessarily have cognitive
issues
Outcomes are influenced by severity and time of surgery
Language Development
•Study using the TOLD-P (63, 4-5 y.o.)▫21% manifested receptive impairments▫26% manifested expressive impairments▫General Population
3.3%•Take home message
▫Treat CLP as a comprehensive communication disorder, not just a speech disorder
Hearing development
Type of loss 4-5 years 14-15•WNL (0-26 dB) 78 88•Mild (2-40 dB) 22
12
22% exhibit hearing loss (1/5)
•Take home message▫Keep current on hearing status. Hearing
loss = speech and language loss
Successful Diagnostics:Using the VPI Pyramid for a bottom-to-top approach
Underlying Motor AbilitiesPurposeful Use of Motor AbilitiesTypical Focus of a Standard Speech Assessment
VPI Pyramid
Vertical Jaw Movement
A child’s ability to produce the full spectrum of sounds is dependent on jaw height.
•Is a child using the full range of possible movement?
•How expressive is she with facial movements such as smiling?
Vertical Jaw Movement
VPI Pyramid
Breath Support
An utterance is dependent on breath support.
•Can a child independently inflate the lunges and diaphragm?
•Can he inflate both together?•How is his posture?•Are you doing therapy in a chair or on the
floor?
Breath Support
VPI Pyramid
Anterior/Lateral Lip Movement
The sound repertoire is also dependent on manipulation of the oral chamber.
•Can the child produce:▫u-e▫a-o
Anterior/Lateral Lip Movement
VPI Pyramid
Tongue Placement
Consonant repertoires are dependent on tongue placement
•Can the child follow commands to:▫Touch the teeth▫Stick out her tongue
•Do consonants sound like their nasal pairs?▫/d/, /t/. /l/ = /n/▫/b/, /p/= /m/▫/g/, /k/, = “ng”
Tongue Placement
VPI Pyramid
Phonation
Differentiation between minimal pairs is dependent on the ability to control phonation.
•Can a child turn phonation on and off?•How long can she phonate for?
Phonation
VPI Pyramid
Imitation of a Movement
Therapeutic success is dependent on the child’s ability to imitate movements
•Does the child have experience following commands? (Simon says)
•Can they imitate articulator movements?
7/10
Imitation of a
Movement
Imitation of a Movement Imitation of a
Movement
VPI Pyramid
Imitation of a Vowel
•Vowels carry the message. The presence of vowels is something that we normally take for granted.
•Take a vowel inventory ▫Target vowels in isolation (a)▫In strings (a,a,a,a)▫In opposition (u-I, u-I a-o, a-o) 7/10
Imitation of a Vowel
VPI Pyramid
Imitation of a Consonant
Consonants require:▫Articuator movements (possibly tongue,
cheeks, and lips)▫Air manipulation (phonation or bursts)
•Can she imitate a consonant?•If not, what part of the lower pyramid is
she missing?
Imitation of a
Consonant
7/10
Imitation of a Consonant Imitation of a
Consonant
VPI Pyramid
Production of Sounds and Syllables
Syllable production is normally where therapy begins•Everything below on the pyramid needs to
be in place in order for “meaning” to occur
•The pyramid provides us with a lot of areas to focus on that are not dependent on surgeries
Production of
Sounds and
Syllables
Production of Sounds and Syllables
Production of
Sounds and
Syllables
Communication goals/ Outcomes for Structural Anomalies Increase Vowel Repertoire Increase Consonant Inventories Increase Vocabulary Increase Oral Airflow Decrease use of Nasal and Glottal Sounds
Increase Vowel RepertoireDate October 10th
a 10/10
e 3/10
i 0/10
o 10/10
u 4/10
a-o 0/10
u-e 0/10
Date October 10th November 15th
a 10/10
e 3/10 5/10
i 0/10 3/10
o 10/10
u 4/10 8/10
a-o 0/10 4/10
u-e 0/10 4/10
Date October 10th November 15th December 7th
a 10/10
e 3/10 5/10 10/10
i 0/10 3/10 7/10
o 10/10
u 4/10 8/10 10/10
a-o 0/10 4/10 6/10
u-e 0/10 4/10 7/10
Increase Vowel Repertoire
Increase Consonant Inventories
• Hi• Hello• Hey• Mommy• More• Me• No• Whoa• Wow• Honey
• Mamá• No • Mío• Niña• Niño• Ojos• En• Mano• Wawa – agua
BEFORE palate repairLOW pressure words to target
Increase Consonant Inventories
• Baby• Boy• Pop• Pooh• Pie• Toy• Doll• Daddy• Cookie• Go
• Papá• Bebé• Boca• Gato• Todo• Tú• Tío• Qué• Ten
AFTER palate repairHIGH pressure words to target
Increase Consonant Inventories
Increase Vocabulary
•Sounds and vocabulary develop in tandem•Do we:
▫Focus on articulation to give her the sounds to produce more language?
▫Focus on language to give her a way to practice her sounds?
Any ideas?
Increase Vocabulary
•Vocabulary development should be targeted with sound development▫Choose words that:
Are common and in their environment Are useful Are extremely fun(read: routines-based intervention)
•Syllable should be simple CV (consonant/vowel)
•Start with stops and bilabial sounds
Increase Vocabulary
Increase Oral Airflow
•A child with a cleft does not have control over the air leaving their throat
•In typical development we stop or slowly release this air to produce speech
•Regardless of what surgeries a child has undergone, we need to familiarize the child with airflow through the mouth
Increase Oral Airflow
•Request an easy repetition (muh,muh,muh)▫After the child starts repeating, plug his
nose•Inhale deeply, hold your breath, and
explode out with a single sound▫BUH!, PUH!
Increase Oral Airflow
Decrease use of Nasal and Glottal Sounds
13% of 63, 4-5 year olds presented with some form of voice disorder▫harshness, breathiness, nodules
• Growls and nasal sounds are typical for young infants but they are used less when consonants develop
• Children with clefts retain these sounds• Parents, wanting communication, reinforce
these sounds
Decrease use of Nasal and Glottal Sounds
•Acknowledge the child’s attempt but then requests other consonants or sounds
•Pair voiceless consonants with whispered vowels
puh/tuh/ku/huh•This keeps the glottis open and prevents
the glottal stop from occurring
Case StudyApplication to Academic Needs
Identification of Initial SoundWords Answers 09/29/2011
Tobillo /t/ 0
Zorro /s/ 1
Humano /u/ 0
Diamante /d/ 0
Planta /p/ 0
Jamon /j/ 1
Lluvia /y/ 0
Restaurante /r/ 0
TOTAL 2
01/24/2012
0
1
1
1
1
1
1
1
7
Identification of Final SoundWords Answers 09/29/2011
Entro /o/ 1
Tribu /u/ 1
Fotos /s/ 1
Nueve /e/ 1
Album /m/ 0
Estrella /a/ 1
Calidad /d/ 1
Caminar /r/ 0
TOTAL 6
01/24/2012
1
1
1
1
0
1
0
0
5
Identification of Final Sound
Union of SoundsWords Answers 09/29/2011
/t/ /e/ /ch/ /o/ Techo 0
/j/ /i/ /s/ Gis 1
/c/ /a/ /y/ /e/ Calle 1
/y/ /e/ /m/ /a/ Yema 0
/b/ /u/ /rr/ /o/ Burro 0
/v/ /e/ /l/ /o/ /s/ Veloz 0
/p/ /l/ /u/ /m/ /a/ Pluma 0
/r/ /e/ /g/ /l/ /a/ Regla 1
TOTAL 3
01/24/20121
0
1
1
1
1
1
1
0
6
Union of Sounds
Segmentation of SoundsWords Answers 09/29/2011
Ola /o/ /l/ /a/ 1
Mesa /m/ /e/ /s/ /a/ 0
Ella /e/ /y/ /a/ 1
Bello /b/ /e/ /y/ /o/ 0
Pina /p/ /i/ /ny/ /a/ 0
Jabon /j/ /a/ /b/ /o/ /n/ 0
Arbol /a/ /r/ /b/ /o/ /l/ 0
Verde /v/ /e/ /r/ /d/ /e/ 0
TOTAL 2
01/24/2012
0
1
1
1
1
1
0
0
5
Segmentation of Sounds
Omission of Initial SoundWords Omission Answers 09/29/201
1
Les /l/ (es) 1
Cama /k/ (ama) 0
Rojo /r/ (ojo) 1
Llave /y/ (ave) 1
Marco /m/ (arco) 0
TOTAL 3
01/24/2012
1
1
1
1
0
5
Omission of Initial Sound
Omission of Final SoundWords Omission Answers 09/29/201
1
Osa /a/ (os) 1
Solar /r/ (sola) 0
Hacen /n/ (hace) 1
Capaz /s/ (capa) 0
Pared /d/ (pare) 1
TOTAL 3
01/24/2012
1
1
0
1
1
4
Omission of Final Sound
Recognizing WordsWords 09/29/2011
Luz 0
Vive 0
Lleva 0
Voy 0
Hay 0
Tortuga 0
Caballo 0
Ensena 0
Hombres 0
Chocolate 0
Alfombra 1
Pequenos 1
TOTAL 2
01/24/20121
1
1
0
1
1
1
1
0
0
0
0
0
6
Recognizing Words
VPI Pyramid
Resources
•www.cleft.com•1-800-24CLEFT•www.operationsmile.org•www.widesmiles.org •The story of Lippy the Lion•The story of Thumper, the Cleft
Affected Bunny•www.bilinguistics.com
More Great Resources onCultural and Linguistic Diversity
A word from the parents
Parents in one study reported feelings of anxiety about how the baby would be able to eat.▫Set therapy goals to address feeding▫Work with nutritionists and the cleft palate
team
A word from the parents
Parents DID report positive feelings from professionals who did not ignore condition.▫Do not ignore the condition
A word from the parents
Many expressed desire to meet other parents of a child with CL/CP—to exchange thoughts and discuss practical problems.▫Seek out support groups, resources, or
other families to network with
A word from the parents
Negative reactions from other people were perceived through body language, such as keeping at a distance, looking away.▫Be aware of your body language as well
when interacting with child and family
A word from the parents
Parents often hear “He will be fine later” from staff and other professionals and interpreted this to mean that child was not considered fine at that moment.▫Be supportive and concerned about the
current condition▫Parents stated that they grew
tired of hearing these phrases
A word from the CLP teamWhat would you consider to be the most
important thing that a service provider should know when they are working with a child with VPI or a cleft lip and palate?
Kids with clefts can’t generate pressure to make sounds. Normally they just say “muh.” We need to brush up on our A&P so that we can provide good therapy.
A word from the CLP team
What should professionals educate parents on?
The second surgery normally occurs around 12 months so kids with clefts won’t develop speech sounds on time. Let the parents know that they should be looking for and practicing low pressure sounds to get the ball rolling.
A word from the CLP team
Is there anything that the parents could know from service providers to make the team and surgery visits easier?
Keep the child’s hearing status up to date. Hearing issues like infections can delay speech even further and cause schedules to be pushed back or visits to be cancelled.
A word from the CLP team
Is there anything problematic/difficult with family interactions that could be addressed by services outside of the team visits?
You need to do a full assessment to determine whether there are cognitive delays or other delays. Parents fear that their children are delayed in every way imaginable because of the cleft. Normally communication is the only, main issue.
Thank you!