Maximizing Treatment Effects with VPI and Cleft Lip and Palate

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• In this presentation you will learn to describe how craniofacial differences occur and how they negatively impact intelligibility, list underlying speech components that can be affected by VPI and …

• In this presentation you will learn to 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, and identify intervention and evaluation strategies for working with a child with craniofacial anomalies.

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  • 1. Photos courtesy of Operation Smile Maximizing Treatment Effects with VPI and Cleft Lip and PalateScott Prath, M.A., CCC-SLPKeith Lebel, M.A., CCC-SLP TSHA Annual Convention March 9th, 2012- San Antonio, Texas
  • 2. Structural Anomalies
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. What is a Cleft?• Clefts result from incomplete development of the lip and/or palate in the early weeks of pregnancy.
  • 7. 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.
  • 8. What types of cleft palates exist? • A cleft palate can be: ▫ unilateral ▫ bilateral ▫ submucousal with bifid uvula
  • 9. 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
  • 10. When does a cleft occur? 4 and 5 weeks in utero
  • 11. When does a cleft occur? 5 ½ and 6 weeks in utero
  • 12. When does a cleft occur? 7 and 8 weeks in utero
  • 13. When does a cleft occur?
  • 14. What causes a cleft?1. Gene Mutation2. Chromosomal Aberrations3. Teratogenic Agents4. Multifactoral Inheritance5. Mechanical Factors
  • 15. 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.
  • 16. What is the process for the family?
  • 17. Influences on familyeffectivenessParent Reaction to a CleftChild Reaction to a CleftParent InvolvementMother-child Bond and Feeding
  • 18. What is the process for the family?The Cleft Palate Team• Clinic Director • Pediatric Dentists and• Audiologist Prosthodontists• Craniofacial Surgeon • Pediatric Radiologists• Geneticist • Physical Therapists• Neurosurgeons • Plastic Surgeons• Nurses • Speech Language Pathologists• Occupational Therapists • Surgeon’s Assistant• Oral and Maxillofacial Surgeons• Orthodontists• ENTs• Pediatrician• Pediatric Anesthesiologists
  • 19. 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.
  • 20. 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
  • 21. The effects of CLP on the parentIntervention: ▫ 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.
  • 22. 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
  • 23. 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.
  • 24. 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.
  • 25. The Kubler-Ross Grief Cycle • Denial: Example - “She’s fine."; "This cant be happening." • Anger: Example - "Why me? Its not fair!" "NO! NO! How can you accept this!" • Bargaining: Example - "Just let him talk fine, I don’t mind the scar." • Depression: Example - "Im so sad, why bother with anything?"; “Everything that we had planned for her isn’t going to happen." • Acceptance: Example - "Its going to be OK."; "I cant fight it, I may as well prepare for it."
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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
  • 30. How is communication affected?Speech Development Articulation Voice ResonanceLanguage DevelopmentHearing Development
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. Successful Diagnostics:Using the VPI Pyramid for abottom-to-top approachUnderlying Motor AbilitiesPurposeful Use of Motor AbilitiesTypical Focus of a Standard Speech Assessment
  • 36. VPI Pyramid
  • 37. Vertical Jaw MovementA child’s ability to produce the full spectrum ofsounds 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?
  • 38. Vertical Jaw Movement
  • 39. VPI Pyramid
  • 40. Breath SupportAn 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?
  • 41. Breath Support
  • 42. VPI Pyramid
  • 43. Anterior/Lateral Lip MovementThe sound repertoire is also dependent onmanipulation of the oral chamber.• Can the child produce: ▫ u-e ▫ a-o
  • 44. Anterior/Lateral Lip Movement
  • 45. VPI Pyramid
  • 46. Tongue PlacementConsonant repertoires are dependent on tongueplacement• 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‖
  • 47. Tongue Placement
  • 48. VPI Pyramid
  • 49. 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?
  • 50. Phonation
  • 51. VPI Pyramid
  • 52. Imitation of a Movement Imitation of a MovementTherapeutic success is dependent on the child’sability to imitate movements• Does the child have experience following commands? (Simon says)• Can they imitate articulator movements? 7/10
  • 53. Imitation of a Movement Imitation of a Movement
  • 54. VPI Pyramid
  • 55. 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
  • 56. Imitation of a Vowel
  • 57. VPI Pyramid
  • 58. Imitation of a Consonant Imitation of a ConsonantConsonants 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? 7/10
  • 59. Imitation of a Consonant Imitation of a Consonant
  • 60. VPI Pyramid
  • 61. Production of Sounds andSyllables 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
  • 62. Production of Sounds and ProductionSyllables of Sounds and Syllables
  • 63. Communication goals/ Outcomesfor Structural AnomaliesIncrease Vowel RepertoireIncrease Consonant InventoriesIncrease VocabularyIncrease Oral AirflowDecrease use of Nasal and Glottal Sounds
  • 64. Increase Vowel RepertoireDate October 10th 10th November 15th 15th December 7tha 10/10e 3/10 5/10 10/10i 0/10 3/10 7/10o 10/10u 4/10 8/10 10/10a-o 0/10 4/10 6/10u-e 0/10 4/10 7/10
  • 65. Increase Vowel Repertoire
  • 66. Increase Consonant Inventories BEFORE palate repair LOW pressure words to target • Hi • Mamá • Hello • No • Hey • Mío • Mommy • Niña • More • Niño • Me • Ojos • No • En • Whoa • Mano • Wow • Wawa – agua • Honey
  • 67. Increase Consonant Inventories AFTER palate repair HIGH pressure words to target • Baby • Papá • Boy • Bebé • Pop • Boca • Pooh • Gato • Pie • Todo • Toy • Tú • Doll • Tío • Daddy • Qué • Cookie • Ten • Go
  • 68. Increase Consonant Inventories
  • 69. 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?
  • 70. 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
  • 71. Increase Vocabulary
  • 72. 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
  • 73. 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!
  • 74. Increase Oral Airflow
  • 75. 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
  • 76. 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
  • 77. Case StudyApplication to Academic Needs
  • 78. Identification of Initial Sound Words Answers 09/29/2011 01/24/2012Tobillo /t/ 0 0Zorro /s/ 1 1Humano /u/ 0 1Diamante /d/ 0 1Planta /p/ 0 1Jamon /j/ 1 1Lluvia /y/ 0 1Restaurante /r/ 0 1 TOTAL 2 7
  • 79. Identification of Final Sound Words Answers 09/29/2011 01/24/2012Entro /o/ 1 1Tribu /u/ 1 1Fotos /s/ 1 1Nueve /e/ 1 1Album /m/ 0 0Estrella /a/ 1 1Calidad /d/ 1 0Caminar /r/ 0 0 TOTAL 6 5
  • 80. Identification of Final Sound
  • 81. Union of Sounds Words Answers 09/29/2011 01/24/20121/t/ /e/ /ch/ /o/ Techo 0 0/j/ /i/ /s/ Gis 1 1/c/ /a/ /y/ /e/ Calle 1 1/y/ /e/ /m/ /a/ Yema 0 1/b/ /u/ /rr/ /o/ Burro 0 1/v/ /e/ /l/ /o/ /s/ Veloz 0 1/p/ /l/ /u/ /m/ /a/ Pluma 0 1/r/ /e/ /g/ /l/ /a/ Regla 1 0 TOTAL 3 6
  • 82. Union of Sounds
  • 83. Segmentation of Sounds Words Answers 09/29/2011 01/24/2012Ola /o/ /l/ /a/ 1 0Mesa /m/ /e/ /s/ /a/ 0 1Ella /e/ /y/ /a/ 1 1Bello /b/ /e/ /y/ /o/ 0 1Pina /p/ /i/ /ny/ /a/ 0 1Jabon /j/ /a/ /b/ /o/ /n/ 0 1Arbol /a/ /r/ /b/ /o/ /l/ 0 0Verde /v/ /e/ /r/ /d/ /e/ 0 0 TOTAL 2 5
  • 84. Segmentation of Sounds
  • 85. Omission of Initial Sound Words Omission Answers 09/29/2011 01/24/2012Les /l/ (es) 1 1Cama /k/ (ama) 0 1Rojo /r/ (ojo) 1 1Llave /y/ (ave) 1 1Marco /m/ (arco) 0 0 TOTAL 3 5
  • 86. Omission of Initial Sound
  • 87. Omission of Final Sound Words Omission Answers 09/29/2011 01/24/2012Osa /a/ (os) 1 1Solar /r/ (sola) 0 1Hacen /n/ (hace) 1 0Capaz /s/ (capa) 0 1Pared /d/ (pare) 1 1 TOTAL 3 4
  • 88. Omission of Final Sound
  • 89. Recognizing Words Words 09/29/2011 01/24/20121Luz 0 1Vive 0 1Lleva 0 0Voy 0 1Hay 0 1Tortuga 0 1Caballo 0 1Ensena 0 0Hombres 0 0Chocolate 0 0Alfombra 1 0Pequenos 1 0 TOTAL 2 6
  • 90. Recognizing Words
  • 91. VPI Pyramid
  • 92. 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
  • 93. More Great Resources onCultural and Linguistic Diversity
  • 94. 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
  • 95. A word from the parents Parents DID report positive feelings from professionals who did not ignore condition. ▫ Do not ignore the condition
  • 96. 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
  • 97. 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
  • 98. 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
  • 99. A word from the CLP team What 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.
  • 100. A word from the CLP teamWhat should professionals educate parents on?The second surgery normally occursaround 12 months so kids withclefts won’t develop speech soundson time. Let the parents know thatthey should be looking for andpracticing low pressure sounds toget the ball rolling.
  • 101. 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.
  • 102. 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.
  • 103. Thank you!