ACPA Family Services

February 2014

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Part 6–One From the Team: Speech Therapy and the School-Aged Child

 

Tips for families about timing of speech therapy

Early intervention is often beneficial with the right approach!  Knowing what sounds to target and how to target them is important to later speech success.  If your child’s palate is not yet repaired, some early intervention teams will provide home-based speech therapy to facilitate vocabulary and receptive language development. Prior to a palate repair your child’s speech sounds will be limited to primarily /m/, /n/ and vowels.  Many children like to produce and experience grunting and growling sounds at this stage as well.

Emphasis on other sounds too early (sounds that require a completed palate surgery) can produce compensatory sound errors due to the limits of the palate; targeting these other sounds can create cleft palate speech errors that have to be corrected later.  Fortunately, there are many therapeutic activities including sound play and verbal cues that can be helpful and introduced in very early speech therapy. Many children do not receive early intervention services until the palate is repaired. At that time specific sound play goals can facilitate speech in the context of play.

On our team we like to evaluate the development of sounds approximately 3 months after the palate repair to determine the time to initiate speech therapy. Speech therapy is recommended if the child is not developing what are considered “high pressure” sounds. These are sounds that require that the palate seal off the nose from any air loss during production of these sounds, a function not possible until the palate is repaired!  These include sounds like “b, p, t, d, k, g, sh, f”.  Sound development is also driven by age, so the lack of an ‘f’ for example would not alone indicate poor palate function in a 2 year old. However, if that 16 month old or 2 year old is only producing nasal sounds (m, n, ng) and vowels, this would indicate a need for early speech therapy.

Speech therapy will look like play time but helps the speech therapist and child accomplish their work in the most productive ways.

Speech therapy will look like play time but helps the speech therapist and child accomplish their work in the most productive ways.

Speech therapy for young children is presented in the context of play! Since play is the strategy of speech therapy for toddlers to preschool, it is important to make note that although it appears the child and speech therapist are simply playing together, specific goals and strategies should be obvious to you as the parent. If goals are not explained or do not lead to increased sound play or expressive language, be sure and discuss further with your child’s speech therapist or on the team the examples of progress you are looking for.

Speech therapy ultimately determines the need for what is considered secondary palatal management which is a surgery to improve the function of the palate for speech.  If a child’s palate is too short, too immobile (doesn’t move well) or the gap between the palate and the back wall of the throat is too large, additional surgery may be necessary. However, speech therapy is the first intervention, often, throughout the toddler-to-preschool years.  In the past, five-years-of-age was the most common age for a  second a second surgery to address the function of the palate.  Now, with improved technology to help assess the function of the palate, some teams and surgeons are recommending them as early as 3 ½ years though again, most commonly only after a period of direct speech therapy.

The child’s ability to fully participate in speech therapy is significant by age 3 and beyond.  Targeting, for example, the sound being produced too far back in the throat or all out the nose (sound errors both common with cleft palate) requires that the child’s cognitive development allows him or her to understand the changes being targeted.  Determining that a non-cooperative 2 year old leaks air out the nose because of the structure of the palate may be premature conclusion!  For success at school, most teams like to see that by 5 years, or prior to kindergarten, the child’s speech is understandable to his peers. If your child’s speech quality suggests a surgical procedure may be needed, it is important to have the full participation of the cleft treatment team to help with making this decision.

Finally, some children do require a break during the time they are preparing for bone graft or during orthodontic expansion. Some of our older patients (teenagers) may have some errors on sounds like /s, z, sh/ due to the position of their jaw or tooth eruption. If these sounds will change with a change in structure, it is often recommended they follow up after any additional procedures. A short-term period of speech therapy might be recommended at that time.

Miss earlier posts in this series?

Part 1Speech with the Team, Speech at School here.

Part 2–Building the Relationship Between Parents, Team and School here.

Part 3–Timing and Need for Speech Therapy here.

Part 4–Why Aren’t we Done Yet? here.

Part 5–Surgery and Speech Therapy here.

About this series: We recently asked Theresa M Snelling, M.A.,CCC-SLP, to help us learn more about speech development and support for the school-aged child. We are so pleased to share her response with you in this special eight-part, One From the Team series, Speech Therapy and the School-Aged Child.

Teresa is clinical coordinator for the Cleft Palate and Craniofacial Center at Rose Medical Center, Denver, CO and has been working with patients and families affected by clefts for more than 30 years. If you need assistance locating a team or a cleft-specializing speech therapist, please, drop us a line or give us a call! 1.800.242.5338 or info@cleftline.org.

Part 5–One From the Team: Speech Therapy and the School-Aged Child

Surgery and Speech Therapy

My child just had a jaw surgery to get ready for braces.  Will surgery and braces make more problems for his speech?

Palatal expanders. Many children report additional speech problems related to palatal expanders which are often worn before the bone graft surgery on the alveolar ridge (gum line).  During this time, children may struggle for as long as two weeks with poorer speech clarity and problems managing their saliva (spit).  After about two weeks most children have adapted to the appliances and things improve. This is not a good time for speech therapy as your child’s dental structures are moving and changing.  As the structures stabilize, speech therapy may or may not be needed. Certainly any new speech errors created by the expander (an example only, I’m not picking on palatal expanders or my orthodontic partners!) should disappear after the expander is removed or your child has adapted to its presence.

Some children require orthognathic surgery that moves upper and/or lower jaws forward (or back). Even though many of these larger surgeries are done during the teen or young adult years, there is a possibility with some of these procedures that a child’s palate becomes “short” in proximity to the back of their throat. If your child had a surgery to improve speech, such as a pharyngeal flap, when younger, the flap may create some pull on the movement the oral surgeon is trying to create. Releasing the flap may assist with the orthognathic surgery; however, this should be done in coordination with the team to minimize a negative impact on speech. There are many factors that feed into the outcome if this situation presents itself and too many factors to detail here, but this is an example of how critical the team consultation is to those outcomes.

speech mechanism

 Human speech is produced by the functioning of many complex structures in the mouth and throat.

Changes to the structure around the soft palate (back roof of mouth)–even without surgery or use of an appliance like an expander–can affect speech. This is another great opportunity to resource all the expertise available through your cleft palate team treatment team. Input from the speech pathologist, surgeons and dental professionals are needed to monitor, anticipate or minimize the effect the physical changes may have on speech and healthy speech development.  If your child’s speech changed/worsened as a result of another medical procedure, the team assessment will include a plan for improving speech. Although sometimes this can mean another surgery, the goal  is normal speech and resonance and so it should not be assumed, without further assessment or input from the whole team, that things cannot be improved upon.

Finally, by the time your child is involved in some of these orthodontic or oral surgery procedures, he or she is old enough to be actively involved in the discussion about treatment planning and follow up care. Engaging the child/patient in this way minimizes surprises for them and contributes to better outcomes–and that’s the ultimate common goal for parents, patients, and healthcare providers!

Miss earlier posts in this series?

Part 1Speech with the Team, Speech at School here.

Part 2–Building the Relationship Between Parents, Team and School here.

Part 3–Timing and Need for Speech Therapy here.

Part 4–Why Aren’t we Done Yet? here

About this series: We recently asked Theresa M Snelling, M.A.,CCC-SLP, to help us learn more about speech development and support for the school-aged child. We are so pleased to share her response with you in this special eight-part, One From the Team series, Speech Therapy and the School-Aged Child.

Teresa is clinical coordinator for the Cleft Palate and Craniofacial Center at Rose Medical Center, Denver, CO and has been working with patients and families affected by clefts for more than 30 years. If you need assistance locating a team or a cleft-specializing speech therapist, please, drop us a line or give us a call! 1.800.242.5338 or info@cleftline.org.

Part 4–One From the Team: Speech Therapy and the School-Aged Child

Why Aren’t We Done Yet?

My child already had speech therapy when she was preschool age.  Why does she need speech therapy again when she’s school-age?  

First, keep in mind that “speech” includes many different areas that change over time.  Ongoing changes with your child’s mouth, muscle control, dental development and learning can lead to some periods of a break from speech therapy followed with a course of speech therapy. Some children require secondary surgeries on the palate to improve and normalize speech and resonance (oral speech vs nasal speech).

In early childhood and preschool programs, the emphasis of the speech therapy may have been to target language skills. This includes comprehension of language, vocabulary, grammar usage and the development of more complex language that precedes reading and writing in school. If your child needed this type of intervention, the quality of the speech may have been considered less a concern at that time.

Learn more about cleft care and the school-aged child, here.

Learn more about cleft care and the school-aged child, here.

As children progress into elementary programs, the differences between their speech and resonance and that of their peers may draw unwelcome attention to your child. He or she may be in need of a secondary surgery on the palate to improve their speech production. Children may get lost to follow-up with their cleft team due to family relocations, changes in insurance or just because parents and school professionals may believe that the child’s speech problems have settled down and now seem to be fine. However, if the school-based speech pathologist suggests the need for additional speech therapy it is very likely needed.  Remember the importance of your regularly scheduled treatment team evaluations in supporting the timing of speech therapy.  Additionally, your team will help minimize the delay in identifying the need for additional surgical management for speech.  Although your school-based speech pathologist may suspect speech issues are related to the palate, he or she may not feel qualified to make the recommendation. The coordination between the two settings is critical to the correct timing and outcome of surgical management, if needed.

Secondly, some speech error patterns, even in the presence of normal palate structure and function (meaning they are not in need of an additional palate surgery for speech) can take years to correct.  If this is the case for your child, consideration of additional speech therapy with a specialist in cleft palate may be needed.  The school-based speech pathologist may be hesitant to recommend additional speech therapy outside of school, suggesting that they are not doing it correctly or worried about the school having financial liability. However, it is often a very specialized speech approach that is needed and not all school-base speech pathologists have the expertise in this unique specialty area.

Finally, as you consider speech therapy for your school-aged child, always:

  1. Consult with your team speech pathologist about the progress or lack of progress.
  2. Discuss the need for possible additional speech therapy with a speech pathologist specialized in cleft palate.
  3. Share your questions and concerns regarding insurance coverage and funding or consult with the social worker on your team.

Speech and resonance issues can certainly require speech therapy into the school years but you should see continued progress over time. It’s important that all providers, including the treating Speech Pathologist, have an understanding of structural limitations and how these limitations will be managed over time to promote solid speech development.

Miss earlier posts in this series?

Part 1Speech with the Team, Speech at School here.
Part 2–Building the Relationship Between Parents, Team and School here.
Part 3–Timing and Need for Speech Therapy here.

About this series: We recently asked Theresa M Snelling, M.A.,CCC-SLP, to help us learn more about speech development and support for the school-aged child. We are so pleased to share her response with you in this special eight-part, One From the Team series, Speech Therapy and the School-Aged Child.

Teresa is clinical coordinator for the Cleft Palate and Craniofacial Center at Rose Medical Center, Denver, CO and has been working with patients and families affected by clefts for more than 30 years. If you need assistance locating a team or a cleft-specializing speech therapist, please, drop us a line or give us a call! 1.800.242.5338 or info@cleftline.org.