JCPSLP Vol 22 No 2 2020

Table 2. Causes for concern in the early speech of toddlers with CP±L

Area of development

Causes for concern

Speech*

Backing to velar (e.g., /t/ → [k]) Double articulation (e.g., /t/ → [ ͡ t k]) Glottal stop substitution (e.g., /t/ → [ ʔ ]) Pharyngeal fricatives (e.g., /s/ → [ ħ ]) Active nasal fricatives (e.g., /s/ → [ m̥͌ n̥͌ ŋ̥͌ ]) Non-pulmonic sound substitution (e.g., clicks) Reduced phonemic inventory (i.e., only /m, n, ŋ , h, w, j, l, ɹ /) Nasal substitutions (e.g., /b/ → [m]) Other: gliding of fricatives (e.g., /s/ → [j]) Vowel errors Errors on nasals (e.g., /n/ → [m])

Velopharyngeal function

Increased nasal resonance on vowels and voiced consonants (hypernasality) (e.g., /b/ → [b̃]) Weak or reduced pressure consonants (e.g., /d/ → [dV]) Nasal realisation (e.g., /b/ → [m]) Passive nasal fricatives (e.g., /s/ → [(s) ͡ n̥ ]) Nasal emission or nasal turbulence on oral pressure sounds (e.g., /t/ → [ t ͋ ])

Language

Delayed receptive or expressive language

Overall development

Regression/loss of skills Delays in fine motor, gross motor or play development

Feeding

Oral aversion Picky eating Nasal regurgitation

*Adapted from Harding and Grunwell (1998), Hardin-Jones, Chapman, and Scherer (2015)

Goal-setting and intervention The importance of choosing functional goals, family-centred practice, and listening to children and families were key findings from the Toddlers With Cleft Palate Study (Cronin et al., 2020b). Given the complexities of the speech of young children with CP±L and the potential for there to be many possible targets for therapy (such as participation in the community, speech production, intelligibility, language, feeding, surgery), listening to families’ priorities can provide a helpful starting point for therapy, and increase families’ engagement. A recent survey of SLPs working in cleft teams regarding speech management for young children with CP±L found no agreement among experts for targets for intervention (Hardin-Jones, Jones, & Dolezal, 2020), indicating that a range of potential goals is possible. Further resources on assessment and intervention can be found on the ASHA Practice Portal on CLP (https://www.asha.org/ Practice-Portal/Clinical-Topics/Cleft-Lip-and-Palate/) and the ASHA site on Person-Centered Focus on Function CLP (https://www.asha.org/uploadedFiles/ICF-Cleft-Palate.pdf). Partnerships with families and educators The Toddlers with Cleft Palate Study provides support for SLPs working with young children with CP±L by synthesising understandings from several perspectives: specialist SLPs, families, and educators. Families There is an emerging recognition of the need to focus on patient-centred outcomes in health care, and more recently, family-centred care, to privilege and consider the voices of individuals with CP±L themselves and their families (e.g., Pfeifauf et al., 2020). There has also been recognition by

Development Inventories; Fenson et al., 2007; Toddler Phonology Test; McIntosh & Dodd, 2012). Speech is a common area of need due to the impact of CP±L upon body structures and functions involved in speech production. All oral pressure sounds (/p, b, t, d, k, g, f, v, s, S , Z , ʧ , ʤ , θ , ð/) are probed where possible, which can reveal sounds in the children’s inventories that might not be expected. These oral pressure sounds have significance in the assessment on children with CP±L in terms of their manner and place of production for evaluating velopharyngeal function, e.g., if a child produces /m/ instead of /b/ then it could be an indication of difficulty achieving a seal between the velum and pharyngeal wall, and the possible presence of VPI, although this would need to probed further and monitored to determine whether it was nasalisation or nasal substitution. Typically, there has been a focus on the articulation of children with CP±L (e.g., Scherer, 2017); however, a phonological analysis provides a useful framework for identifying areas of difficulty, but also strengths in moving forward with intervention (e.g., the Children’s Independent and Relational Phonological Analysis, CHIRPA, Baker, 2017). The sounds and word contexts that are strengths may be incorporated into intervention or provide alternative targets to provide the children with success. Tailoring the measures used is important as toddlers with CP±L vary, with some children being intelligible (or unintelligible), with or without mild to profound VPI. Young children with CP±L are also at risk of early language delays which may be associated with the children’s reduced speech sound inventories (e.g., Hardin-Jones & Chapman, 2014; Lancaster et al., 2020), or, they may be at risk of more persistent developmental language disorder (e.g., Morris & Ozanne, 2003).

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JCPSLP Volume 22, Number 2 2020

Journal of Clinical Practice in Speech-Language Pathology