Demystifying Cleft Palate Speech: A Primer for the New SLP and Non-SLP Members of The Craniofacial Team

Background and Purpose: Compensatory articulation errors are conventionally defined as speech errors that are made in response to velopharyngeal inadequacy (VPI) in which the articulatory constriction is below the velopharyngeal valve. It is an active strategy that the child uses to alter the place of articulation (i.e., level of the glottis and/or pharynx), while preserving the manner of articulation. Historically, glottal stops and pharyngeal stops, fricatives and affricates were considered to be clearly compensatory for VPI as the place of constriction clearly circumvents a defective velopharyngeal valve (McWilliams et al., 1984; Peterson-Falzone et al., 2010). 

Over the years, additional "compensatory" articulation patterns presumably occurring as a consequence of VPI have been reported (e.g., Trost, 1981). These include mid-dorsum palatal stops, posterior nasal fricatives, and velar fricatives. However, all of these articulations – especially the mid-dorsum palatal stop – do not circumvent the velopharyngeal valve and thus do not meet the fundamental definition of a compensatory behavior. 

In addition, recent evidence from empirical studies has led us to question whether the categorization of the mid-dorsum palatal stop and posterior nasal fricative as compensatory errors is appropriate. As noted above, the articulation or occlusion that occurs in the oral cavity during the production of these sounds does not circumvent the velopharyngeal mechanism. With respect to the mid-dorsum palatal stop, there is a growing body of research to suggest that the associated maladaptive articulation patterns may be unavoidable, in some cases, due to anterior structural defects such as collapsed or narrow maxillary arches (Zajac et al., 2012; Eshghi et al., 2013). Thus, this particular error may best be considered an obligatory oral distortion – similar to dental and/or lateral distortions of sibilants – that in some children with cleft palate may become phonemic over time. Young children without cleft palate also produce mid-dorsum palatal stops (Chapman and Hardin, 1992). As these authors have suggested, it is possible that this articulation reflects a developmental placement error, perhaps triggered by either subtle (non-clinical) palatal arch differences and/or reduced hearing. Relative to the latter, Shriberg et al. (2003) has reported evidence that children with histories of otitis media tend to back obstruent consonants. Clearly, children with cleft palate are at high, almost universal, risk of conductive hearing loss associated with otitis media. During the presentation, we will emphasize the need for studies that follow young, non-cleft children who exhibit mid-dorsum palatal stops longitudinally to elucidate the factors that may contribute to this articulation. 

In the case of the posterior nasal fricative, the child "actively" attempts articulation of the fricative by occluding the oral cavity to direct all airflow through the nose (Harding and Grunwell, 1998). We have observed both aerodynamically and spectrographically that it is this oral airflow stopping gesture that differentiates nasal fricatives from passive (obligatory) audible and turbulent nasal air escape that may indeed sound similar in children with cleft palate. We will show examples of these similar sounding but different behaviors during the presentation. There is evidence, albeit limited, to suggest that most children with cleft palate who exhibit posterior nasal fricatives do not have VPI (Peterson-Falzone and Graham, 1990; Zajac and Vallino, 2015). As with mid-dorsum palatal stops, children without palatal anomalies also produce posterior nasal fricatives. Again, there is limited research to suggest that conductive hearing loss associated with otitis media may be a contributing factor in the development of this behavior (Peterson-Falzone and Graham, 1990; Morgan and Zajac, 2016; Zajac, 2018). Zajac (2015, 2018) has hypothesized that conductive hearing loss is the triggering event in children both with and without cleft palate. The overall goal for this webinar is to introduce to the SLP and other team members to the types of resonance, nasal emission (both obligatory and learned as part of nasal fricatives), and articulation problems that are commonly encountered in the clinic. We will present a practical and evidence-based framework for describing resonance and nasal air emission characteristics and discriminating between obligatory errors and traditionally defined compensatory articulation errors.

Content: This session will include descriptions and definitions of speech problems often present in individuals with cleft palate. This includes an overview of resonance problems. Nasal air emission will be presented from a framework of obligatory versus learned. Obligatory nasal air emission and obligatory turbulence (rustle) due to velopharyngeal (VP) dysfunction will be differentiated from anterior nasal fricatives and posterior nasal fricatives, respectively, that occurs as learned articulation errors. We will illustrate the use of oral-nasal audio recordings via the Nasometer as an "off label" procedure to identify and spectrally define both types of behaviors. We will also present a practical and evidence-based framework for describing and categorizing articulation errors according to place of production primarily-within and outside the oral cavity- and type of production (obligatory vs. compensatory) secondarily. We will present evidence to show that some traditionally defined compensatory errors such as the mid-dorsum palatal stop may be better defined as an obligatory distortion in many cases. We will also discuss treatment ramifications of such a reclassification. 

Conclusion: Articulation errors in individuals with cleft palate are common. Some errors are obligatory, occurring as a direct consequence of VP dysfunction and structural conditions such as dental/occlusal defects. Other errors are learned, and in some cases may be compensatory in that the pattern of errors are made to circumvent the VP valve. Still others produce other types of errors that are unusual (e.g., posterior nasal fricatives) that do not easily fit into these categories. Based on the current evidence, a reclassification of some articulation errors traditionally considered as compensatory is suggested. Best practice is centered on the SLP's thorough understanding of these problems and causative factors. 

Continuing Education

Attendees must register, attend and evaluate each webinar to receive continuing education credit. Presenter disclosures can be found in the "Topics" tab in the speaker bio. This course will be available on-demand through July 3, 2021.

  • ACCME: ACPA designates this educational activity for a maximum of 1 AMA PRA Category 1 Credits™.  Physicians should only claim credits commensurate with the extent of their participation in the activity. The American Cleft Palate-Craniofacial Association is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • ASHA: This program is offered for 0.10 ASHA CEUs (Intermediate Level, Professional Area).

  • Nursing: This nursing continuing professional development activity was approved by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

    To receive 1.0 contact hours:

  • Learners will be awarded contact hours for only the sessions they attend.
  • Learners must attend 80% or more of each session attended.
  • Learners must complete and submit an evaluation form.

The planning committee for this webinar do not have any conflicts of interest related to the content of this activity.  Individual presenter disclosures may be found in the “Topics” tab under their name. 

Original Seminar Date: July 3, 2019

On-Demand Release Date: July 4, 2019

On-Demand Expiration Date: July 3, 2021

Seminar Objectives
  • -Discuss the differences between traditional compensatory errors related to velopharyngeal inadequacy and other learned maladaptive errors that do not fit the conventional definition of compensatory behaviors
  • -Describe the articulatory and spectrographic nature of mid-dorsum palatal stops and posterior nasal fricatives
  • -Discuss evidence-based research to explain the etiology and nature of mid-dorsum palatal stops and posterior nasal fricatives as other maladaptive articulations.
  • -Describe a reclassification construct of those articulation errors traditionally identified as compensatory.
  • Discuss diagnostic and management implications of the errors presented.
Seminar Information
Expiration Date:
June 04, 2021 11:55 PM
1 hour
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Demystifying Cleft Palate Speech: A Primer for the New SLP and Non-SLP Members of The Craniofacial Team
Speaker Information
Linda D. Vallino, PhD, CCC-SLP/A, FASHA  [ view bio ]
David J. Zajac, PhD, CCC-SLP, FASHA  [ view bio ]
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