Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 3: speech outcomes.

OBJECTIVE: To summarize speech outcomes in children born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. DESIGN: Prospective descriptive study on a cross-sectional sample of children. PATIENTS/PARTICIPANTS: Data were collected for 238 5-year-olds (born between April 1, 1989, and March 31, 1991) and 218 12-year-olds (born between April 1, 1982, and March 31, 1984) with complete UCLP. MAIN OUTCOMES: Ratings of intelligibility, nasality, "speech cleft type characteristics" and speech therapy intervention. CONCLUSIONS: Nineteen percent of 5-year-olds and 4% of 12-year-olds were judged to be impossible to understand or just intelligible to strangers. Thirty-four percent of 5-year-olds and 17% of 12-year-olds had at least one serious error of consonant production. Eighteen percent of 5-year-olds and 12-year-olds had consistent hypernasality of mild, moderate, or severe degree. Approximately two-thirds of both age groups had undergone speech therapy.

A six-centre international study of the outcome of treatment in patients with clefts of the lip and palate: the results of a cross-linguistic investigation of cleft palate speech.

Speech samples of 131 subjects with complete unilateral clefts of the lip and palate from six European cleft palate centres were analysed and assessed using a specifically designed phonetic framework. This framework focused on consonants that are "vulnerable" in speech associated with cleft palate and common to the five languages of the project. The methodology used and the results of the reliability study are reported. Consonant articulation, resonance, and voice quality are also evaluated. The results show good outcomes with regard to consonant articulation across the whole study group with common areas of minor difficulty across languages. The results for resonance were less good, with slight hypernasality in 20% of subjects. There were, however, few indications of seriously disordered speech. The detectable differences between centres match the findings of the Eurocleft Orthodontic Group particularly in regard to the ranking of the centres.

GOS.SP.ASS.'98: an assessment for speech disorders associated with cleft palate and/or velopharyngeal dysfunction (revised).

In 1994 the present authors proposed a speech assessment protocol for speech disorders associated with cleft palate and/or velopharyngeal dysfunction known as GOS.SP.ASS. (Great Ormond Street Speech Assessment). In a recent survey undertaken to review the different speech assessment protocols used in six cleft palate centres in the UK, GOS.SP.ASS. was selected from six protocols as the optimal procedure for clinical and research purposes. The process of identifying an optimal procedure involved analysis of completed forms for each assessment. Analysis of the completed GOS.SP.ASS. forms revealed significant ambiguities in the protocol which led to differences in form completion. This paper describes important revisions to the original GOS.SP.ASS. protocol in order to ensure comparable data from different clinicians. This detailed speech assessment is now complemented by the Cleft Audit Protocol for Speech (CAPS), a tool recommended for clinical audit. As a result of close collaboration in their preparation, the results are directly comparable. In addition, the speech elicitation sentences and the phonetic diagram have been modified.

A study of idiom comprehension in children with semantic-pragmatic difficulties. Part I: Task effects on the assessment of idiom comprehension in children.

In the apparent absence of suitable measures of idiom comprehension in normally developing and clinical populations, this study examined the relationship between a newly developed play task and a more conventional definition task. On the play task, children listened to a 1.5-minute, tape-recorded story into which were embedded 12 common idioms drawn from recordings of classroom teaching and children's television. As the story was then played again, sentence by sentence, the children were required to act it out using a play set and props. For each idiom, it was possible to act out either the idiomatic or literal meaning, but only the idiomatic meaning made sense in the context. The children's actions were video-taped and then played back to the child during the definition task. For this task, the video was stopped after each idiom occurred and the children were asked what they thought each idiom meant. Four groups of children were included. Twenty-six children (aged between 6-11 years), considered to have semantic-pragmatic difficulties, were compared with two groups of mainstream children (aged 6;6-7;6 and 10;6-11;6, respectively) and with a group of children (aged between 8-11 years) diagnosed with (other) language disorders not primarily of a semantic or pragmatic nature. The results indicate that the definition task underestimated common-idiom comprehension in normally developing children and, in particular, in children diagnosed with semantic-pragmatic difficulties or (other) language disorders. Furthermore, a significant difference in idiom comprehension between the two clinical groups evidenced on the play task was entirely masked on the definition task. It appeared that the expressive and metalinguistic demands of the definition task had a greater negative effect on the group of children with language disorders than on the children with semantic-pragmatic difficulties. Possible mechanisms through which the play task might have overestimated or underestimated idiom comprehension in these groups are examined and discussed. Although the nature of the play task probably facilitated idiom comprehension in these children, analysis supports the results of the play task being a reflection of true ability rather than an overestimation of idiom comprehension. A considerable incidence of false positive results on the definition task, coupled with its masking of significant differences in idiom comprehension across clinical groups militates against the use of definition tasks to assess idiom comprehension in research and clinical settings. In comparison with definition and multiple choice methodologies, the play task emerged as a more valid measure of common- and concrete-idiom comprehension in normally developing and clinical child populations.

A study of idiom comprehension in children with semantic-pragmatic difficulties. Part II: Between-groups results and discussion.

Using a play-based methodology and a symptom checklist, this study investigated idiom comprehension in 26 children aged between 6-11 who were considered to have semantic-pragmatic difficulties. This group was compared with two groups of mainstream children and a group of children with (other) language disorders not primarily of a semantic or pragmatic nature. The results indicate that the children with semantic-pragmatic difficulties did, as a group, demonstrate significantly fewer appropriate idiomatic interpretations and significantly more inappropriate interpretations than did any of the other three groups. However, the higher level of inappropriate scores in the semantic-pragmatic difficulties group reflected a large number of 'fuzzy' actions rather than significantly higher rates of literality. This may indicate an awareness among these children that the literal meaning is inappropriate in the absence of adequate idiom vocabulary. It may also reflect difficulty in retrieving known idioms from memory and/or in selecting the most appropriate meaning from several possibilities in context. Despite relative weakness, the children with semantic-pragmatic difficulties displayed appropriate interpretations considerably more often than they evidenced inappropriate ones. Within-group analysis reveals that the children diagnosed with Asperger syndrome or high-functioning autism performed less well than did those diagnosed with 'semantic-pragmatic disorder'. Nevertheless, both of these subgroups encompassed a considerable range of comprehension ability with regard to the 12 common idioms tested. Analysis of the play task performance and symptom checklist suggests that this variation probably reflects differences in the critical semantic and pragmatic skills underpinning idiom comprehension. These include flexibility of thought, theory of mind, attention to context, prosody and overall coherence, as well as the ability to integrate world knowledge and current contextual information to guide inferencing. In combination with definition task data and broader knowledge of symptomatology, the play task may be used to identify the sites and sources of idiom comprehension breakdown in individual children. It is probable that idiom comprehension in this group of children with semantic-pragmatic difficulties was facilitated by the inclusion of only concrete idioms and by the visual support provided by the play set. Nevertheless, the moderate to age-appropriate ability displayed by this group in this context suggests that the characterization of children with semantic-pragmatic difficulties as predominantly literal needs to be revised. Rather than seeking a blanket characterization of an essentially heterogeneous group, it may be more useful to consider idiom comprehension a secondary manifestation of semantic and/or pragmatic difficulties. Since the children who exhibit these difficulties vary in symptomatology and, probably, in aetiology, it follows that they will also vary with respect to idiom comprehension and the reasons for its breakdown.

Active versus passive cleft-type speech characteristics.

Cleft palate speech is generally described in terms of nasal resonance, nasal emission and compensatory articulations. A longitudinal study of children at different stages of surgical treatment revealed a distinction between passive and active cleft-type speech characteristics whereby passive characteristics were thought to be the product of structural abnormality or dysfunction and active characteristics were specific articulatory gestures replacing intended consonants. Passive and active patterns of articulation are described and defined in the context of three longitudinal studies of subjects who were at various stages of two different surgical regimes: five bilateral cleft lip and palate (BCLP) subjects aged 1;6-4;6, 12 mixed unilateral cleft lip and palate (UCLP) and BCLP subjects aged 4;6-7;6 and nine mixed UCLP and BCLP subjects aged 9;0-11;0. Reference is also made to data from 12 mixed cleft-type subjects aged 13;0 who had been treated with different surgical timing regimes. Comparison is made between the incidence of active versus passive processes in relation to oral structure. At age 4;6 speech samples taken from BCLP subjects who had been treated with 1-stage versus 2-stage palate repair all evidenced both active and passive processes. The lack of differentiation in speech results irrespective of their current surgical status, i.e. completely repaired palates versus residual cleft of the hard palate, was unexpected. Cleft-type processes in completely repaired subjects might be accounted for by the inevitable anterior defect following repair of a bilateral cleft. Older subjects with structural defects also evidenced more cleft-type processes. The relevance of distinguishing between active and passive processes is underlined by consideration of the effects of structural changes following surgery. The effect of surgery on seven subjects' speech is discussed using the active/passive distinction. Active cleft-type characteristics did not change as a direct result of surgery, whereas passive characteristics were largely eliminated following surgery. A specific distinction is made between active and passive nasal fricatives, with the implication that active nasal fricatives may not be affected by surgical intervention, whereas passive nasal fricatives may be eliminated by surgery. Accurate distinction between active and passive patterns of articulation may serve to identify those cleft-type speech error patterns most likely to respond to surgical intervention. Indications from this study are that active cleft-type characteristics require destabilization in a course of speech and language therapy before the potential benefits of surgery can be properly assessed. An analytical protocol for the interpretation of speech samples is presented and some therapy strategies are proposed for active and passive processes.

A play-based methodology for assessing idiom comprehension in children with semantic-pragmatic difficulties.

In response to the lack of suitable material for assessing idiom comprehension in children with semantic-pragmatic difficulties, a new, play-based methodology is presented. The child listens to a tape-recorded story into which are embedded a range of idiomatic expressions. The child then acts out the story as it is played again, sentence by sentence. The play is video-recorded and transcribed. Actions for each idiom are categorised and are then amenable to within-child, between-child, and between-group analyses. The results of a pilot project indicate that this methodology overcomes may of the problems inherent in assessing children identified as having semantic-pragmatic difficulties.

Characteristics of cleft palate speech.

In recent years, interest in the nature of cleft palate speech and the influences on speech quality has increased. This overview of contemporary research reveals new perspectives on cleft palate speech development and the phonological consequences of early articulatory constraints. Cleft palate speech is perceived as the result of the synthesis between physical, physiological, cognitive and linguistic development. Developmental influences on cleft palate speech are considered in the context of early vocalisations of cleft and non-cleft children, followed by an examination of the literature on the development of babble, the emergence of early words and consonant development in children born with cleft palate. Speech development is then discussed from a phonological perspective interpreting reported characteristics as 'cleft-type developmental processes', for example, lack of target stabilisation; compensatory articulations; active/passive strategies; and systematic sound preference. Given these influences on speech development the extent to which cleft palate speech should be regarded as an 'articulatory disorder' has been reconsidered. Descriptions and interpretations of nasal resonance, nasal emission, and nasal turbulence are followed by discussion of articulatory errors in place and manner and patterns of change in cleft palate speech. Finally, some of the available evidence on speech in relation to structural imperfections, such as unrepaired clefts, velopharyngeal insufficiency, oro-nasal fistulae, dental and occlusal deviations, and open-mouth posture is summarised briefly. These new perspectives aim to facilitate more effective clinical management and to provide indications for future research.

A screening assessment of cleft palate speech (Great Ormond Street Speech Assessment).

This paper presents a comprehensive screening procedure for describing the speech characteristics commonly associated with cleft palate and/or velopharyngeal dysfunction. A unique method of representing the information visually is proposed. The theoretical background and recommendations for clinical application are discussed. This procedure is designed for use by specialist and non-specialist speech and language therapists working in this field. It has been developed primarily with a child population but can be used with all age groups. It provides a structure for assessment, record keeping, report writing and research, thereby facilitating the development of intercentre studies.

Speech studies and the unoperated cleft palate subject.

This paper is a critical review of the studies of patients who have established their speech in the presence of an unoperated cleft palate. The review details the weaknesses of many of the studies in this area, and in so doing highlights the methodological issues that need to be considered in the investigation of cleft palate speech. For example, issues such as the method of speech analysis and the importance of reliability studies are discussed. The need to control for variables such as age at palatal surgery, cleft type and patients' surgical experience is highlighted. Such principles are equally applicable to those studies in which palatal surgery is carried out at more conventional ages. more conventional ages.

Processes of phonological change in developmental speech disorders.

Two analytical frameworks for identifying and measuring the processes of phonological change in the speech of children with developmental speech disorders are described. The frameworks are illustrated by an examination and evaluation of longitudinal data from children with this type of disorder. The ways in which clinicians can use the two frameworks to guide treatment planning are discussed.

Training counterparts in cleft palate speech therapy in the less developed world: an extended report.

This paper describes the training of five counterparts in cleft palate speech therapy which took place in Sri Lanka. The context in which this training occurred is described. The original aims of the training, and criteria drawn up for the selection of the counterparts, are contrasted with the modifications required to these once the British therapists started working in Sri Lanka. Information is given on the training objectives, syllabus, curriculum and methods of evaluation of the counterparts' progress. The achievements of the counterparts are described, and factors relating to the difficulties and ease with which the counterparts were trained are discussed. The paper concludes with a discussion of the cultural, political and clinical problems encountered in this type of training, and highlights the special difficulties encountered in the training of counterparts in the field of speech therapy in less developed countries.

Speech results following late palatal surgery in previously unoperated Sri Lankan adolescents with cleft palate.

The speech of 18 Sinhala speaking patients over 11 years of age with previously unrepaired palatal clefts is presented preoperatively, 8 months postoperatively, and after two brief courses of speech therapy (8 and 12 months postoperatively). Speech was usually severely disordered in the unoperated patient. The postoperative results show that speech often remains disordered following surgery, but there is the potential for change in some patients when supported by intensive goal directed therapy.

Training assistants in cleft palate speech therapy in the developing world: a report.

This paper describes the training, which took place in Sri Lanka, of five speech therapy assistants in cleft palate speech therapy. The context in which this training occurred is described. The original aims of the training and the criteria drawn up for the selection of the assistants are contrasted with the modifications required to these, once the British therapists started working in Sri Lanka. Information is given on the training objectives, syllabus, curriculum, and methods of evaluation of the assistants' progress. The achievements of the assistants are described. Factors relating to the difficulties and ease with which the assistants were trained are highlighted. The paper concludes with a discussion of the cultural, political, and clinical problems encountered in this type of training, and highlights the special difficulties encountered in the training of assistants in the field of speech therapy in developing countries.

Phonological development in children with cleft lip and palate.

This paper presents preliminary results of a longitudinal investigation into the phonological development of children with repaired cleft lip and palate (CLP). The aim of the project is to investigate the extent to which the cleft palate condition affects the nature and chronology of phonological development from 0;10 to 3;6. Recordings are being made of the vocalizations and speech of CLP children at frequent intervals during the first three years of language development. The first recording at 0;10 is immediately prior to surgical repair of the palate. Recordings are then recommenced six weeks post-operatively and made at approximately six-monthly intervals up to 3;6. We report our findings from the study of two children in this paper. Profiles of their phonetic repertoires pre- and post-surgery are presented and compared with those reported for normal children at the same ages. The phonetic and phonological characteristics of their pronunciation patterns at 2;6 and 3;6 are compared with those normally expected at these ages. Also, the phonetic characteristics of their speech are compared with their pre-speech repertoires. We discuss whether the presence of a structural abnormality inhibits and/or disturbs the development of a child's phonological system.

Intelligibility in acquired dysarthria--a neuro-phonetic approach: three case studies.

A descriptive framework of phonetic parameters for the assessment of dysarthric speech is presented. The phonetic parameters examined are based on a linguistic analysis of aspects of continuous speech. The assessment thus evaluates the functional efficiency of the speech producing mechanisms in encoding the spoken medium of language. The interaction of the deviant parameters is related to the breakdown of intelligibility. Possible underlying neurological correlates are discussed. The implications for therapy using the combined phonetic and neurological information are considered. This assessment procedure is illustrated with case studies of three types of acquired dysarthria.