Sunteți pe pagina 1din 6

International Journal of Pediatric Otorhinolaryngology

49 (1999) 21 26

A comparative trial of two modalities of speech intervention for

compensatory articulation in cleft palate children, phonologic
approach versus articulatory approach

Ma.Carmen Pamplona, Antonio Ysunza *, Jannette Espinosa

Hospital Gea Gonzalez, 4800 Calzada de Tlalpan, Mexico D.F. 14000, Mexico

Received 29 September 1998; received in revised form 19 February 1999; accepted 20 February 1999


To compare two modalities of speech intervention (SI) in cleft palate children with compensatory articulation
disorder (CAD). The first modality was a phonologic based intervention, the second modality was an articulatory or
phonetic intervention. The main purpose is to study whether a phonologic intervention may reduce the total time of
speech therapy necessary for correcting CAD in cleft palate children as compared to an articulatory intervention. A
prospective, comparative, and randomized trial was carried out. Cleft palate children with velopharyngeal insuffi-
ciency and CAD were included in the study group. Only patients with an age ranging from 3 to 7 years were included.
A total of 29 patients were selected and were divided randomly into two groups. Fifteen patients were included in the
first group (control) and received articulatory SI. Forteen patients were included in the second group (active) and
received phonologic SI. The speech pathologist in charge of the SI was the same in all cases. A blind procedure was
utilized whereby each patient was evaluated independently by two speech pathologist every three months until both
examiners were convinced that CAD had been completely corrected. The mean total time of SI required for the
normalization of speech in the two groups of patients was compared. Median age in the control group was 54 months,
and 55.50 months in the active group (P \0.05). The mean total time of SI in the control group was 30.07, and 14.50
in the active group. A Students t-test demonstrated that the total time of SI was significantly reduced (P B 0.001)
when a phonological intervention was utilized. Phonologic based SI significantly reduced the time necessary for
correcting CAD in cleft palate children. 1999 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Cleft palate; Speech; Therapy

1. Introduction

Articulation disorders in children may be either

* Corresponding Author. Fax. + 52-5-568-50-86. phonetic or phonologic in nature. Phonetic disor-

0165-5876/99/$ - see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 0 4 0 - 3
22 M.C. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) 2126

ders are related to inaccurate learning principles underlying traditional approaches for
oranatomic, physiologic and/or motor deficits. In articulation disorders. In contrast, articulation
contrast, phonologic disorders are considered to must be recognized as a critical aspect of speech
be linguistically based and reflect difficulty in the sound development under any theory. Conse-
childs organization and representation of the quently, phonological principles should be consid-
sound system of the language [3,6,14]. ered as adding new dimensions and a new
Several authors have described that cleft palate perspective to an old problem, not simply as
patients are at risk for phonetic based problems refuting established principles [3].
due to the structural deviations associated with The purpose of this paper is to study and
clefting [1,11,18]. However, cleft palate children compare two different approaches for speech in-
may be also at risk for phonologic disorders [2]. tervention in cleft palate children with compensa-
Speech disorders in cleft palate patients, such as tory articulation disorder, a phonetic approach,
compensatory articulation disorder, may initially and a phonologic approach.
occur as a consequence of the cleft, producing a
phonetic based disorder. However, over time,
these errors become incorporated into the childs 2. Materials and methods
developing rule system producing a phonologic
disorder [2]. Sample size was calculated at an a 95% confi-
Phonology is a much broader concept than dence interval, and a b power of 80% for a
articulation, and refers to the language compo- comparative study of two groups. The frequency
nent that governs the manner in which speech of compensatory articulation disorder in cleft
sounds are patterned. It involves the repertoire of palate children, and the mean period of time of
phonemes that are found in any language; in speech therapy necessary for correcting this disor-
other words, those sounds that function in the der were considered. According to these data, at
language to signal a change in meaning. It also least 14 patients should be included in each group.
involves the alternations that phonemes undergo All cleft palate patients attending the cleft
when they occur in different phonetic contexts palate clinic of the Hospital Gea Gonzalez in
and the combination of sounds that may occur in Mexico city from June of 1993 to December of
language [3]. 1994 were evaluated. To qualify for the study
Speech intervention in cleft palate children with group for this paper, the patients had to meet the
a phonetic approach considers articulation learn- following criteria:
ing as a specific time of motor learning. More- 1. unilateral, complete cleft of primary, and sec-
over, errors in articulation must be seen as ondary palate [8]. The patients had to be
disruptions at some level of the relatively periphe- normal in all respects otherwise;
real articulatory processes. Consequently, some 2. cleft palate width had to be grades I or II
therapy procedures are based almost exclusively [13];
on the notion that articulation errors are due to 3. palatal repair of the UCLP had to be per-
faulty control of the articulators [7,3]. In contrast, formed according to the surgical routine of
in a phonologic approach the children must learn the Cleft Palate Clinic. This routine includes:
-more than just a set of complex articulatory surgical repair of the lip and primary palate
patterns associated with words. They must learn a between 13 months, and surgical repair of
complete phonology. Furthermore, several au- the secondary palate between 1218 months
thors have proposed that some central, cognitive- with a minimal incision palatopharingoplasty
phonological processing must be included in any [13];
description of phonological acquisition [6,14]. 4. velopharyngeal insufficiency (VPI) after
The phonological approach for treating com- palatal repair had to be demonstrated by
pensatory articulation disorder in cleft palate pa- phoniatric assessment, videonasopharyn-
tients does not necessarily rejects well established goscopy, and multi-view videofluoroscopy [4];
M.C. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) 2126 23

5. compensatory articulation disorder in associ- tory intervention [10,19], where errors in

ation with VPI had to be demonstrated by articulation were treated in a phoneme-by-
phoniatric assessment during isolated and phoneme basis (e.g. discrimination and produc-
connected speech; tion of /p/, first, isolated, then in words, later in
6. absence of postoperative fistulae; sentences).
7. chronological age had to be between 3 7 The second group received therapy with a
years of age at the time of selection for the phonologic approach including the following as-
study; pects: (a) the treatment goals were set depending
8. normal hearing demonstrated had to be on the phonological rules that are active in the
demonstrated by conventional pure-tone childs system [5], (b) the intervention program
audiometry; was focused on the modification of groups of
9. language development had to be within nor- sounds that seemed to be treated by the child in a
mal limits as demonstrated by a battery of similar fashion. In other words, errors were at-
age appropriate standardized language tests tacked at the rule level, rather than at the pho-
[16]; netic level (e.g. all plosives substituted by glottal
10. patients with other neurological deficits other stops), and (c) emphasis was placed on the estab-
than the speech disorders were excluded; lishment of previously neutralized phonological
11. parents had to agree to participate in the contrasts. For example, the child who replaced all
study, and attend to the speech therapy ses- fricatives with stops could receive a positive re-
sions, twice per week for as long as necessary. sponse from the clinician when any fricative was
Twenty-nine children met the criteria men- used, even if place of articulation or voice errors
tioned herein and participated in the study. The persisted.
children were randomly divided into two groups. The goal can be conceived as establishing and
The two groups were assessed at the beginning maintaining new contrasts. With such goal in
and at the end of the study to determine their mind, correct production is not essential. There is
level in language development and to identify the much greater emphasis on the use of speech
phonological rules present in the phonological sounds for communicative purposes, rather than
system of each child with special attention in on the correct production of sounds as a goal in
compensatory articulation patterns. For this pur- itself [3].
pose, the children were videotaped interacting Children were placed in small groups (of similar
with a trained speech pathologist during free play age and speech characteristics) to provide oppor-
for 30 min. A 10-min segment was selected where tunities for peer interaction and socialization.
a high level of verbal interaction occurred. The 10 Only two to three children were placed in one
min of interaction were transcribed verbatim to group to maximize individual opportunities for
analyze the childs phonological system and the adult modeling and other intervention prompts.
presence of compensatory articulation. Intervention consisted of 1-h sessions, twice per
A blind procedure was utilized, whereby all week. All patients were followed until both exam-
analysis were independently conducted by two iners had coincided that compensatory articula-
speech pathologists who were trained in the pro- tion disorder (CAD) was completely eliminated.
cedures. Both speech pathologists participating in The following variables from both groups were
this study had been performing phonological tran- compared: age at the onset of speech therapy, and
scriptions of cleft palate children for the last 8 total time of speech therapy.
years. Total time of speech therapy was considered as
Both groups received speech therapy aimed to the time from the onset of speech therapy until
correct compensatory articulation. The speech the complete normalization of articulation as as-
pathologist providing therapy was the same for all sessed in a phonological analysis from a free
patients from both groups.The first group re- speech sample (videotape). Once articulation was
ceived therapy according to a traditional articula- corrected, all the patients underwent additional
24 M.C. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) 2126

nasopharyngoscopy and multi-view Table 2 shows total time of speech therapy

videofluoroscopy for pre-operative surgical from both groups. The total time necessary for
planning. correcting compensatory articulation disorder in
Two-hundred and seventy-eight cleft palate the patients from group 1 (articulatory approach)
children were revised. A total of 29 patients met ranged from 14 to 46 months (mean = 30.07
the inclusion criteria and were included in the months). In the patients included in group 2
study group. Fifteen patients were randomly se- (phonologic approach), the total time of speech
lected and were included in the first group. Four- therapy ranged from 6 to 22 months (mean=
teen patients were included in the second group. 14.50 months). A Students t-test demonstrated
The first group underwent an articulatory inter- that the patients that received speech therapy with
vention program of speech therapy. The 14 pa- a phonologic approach required a significantly
tients included in the second group started a shorter time of speech therapy for correcting
phonological intervention speech therapy CAD.
A blind procedure was utilized whereby all
4. Discussion
analysis of child utterances were independently
conducted by two speech pathologists who were
It is evident that the total time of speech inter-
trained in the procedures. Language performance
vention necessary for correcting children compen-
and the phonological rules (compensatory articu-
satory articulation disorder (CAD) associated
lation) present in each childs system were
with cleft palate, was critically reduced when a
classified before and after the follow-up period
phonological approach was used. In a phonologi-
and a concordance value was obtained.
cal approach, errors are considered to be linguisti-
cally based and are attacked at the rule level,
rather than at the phonetic level.
3. Results Table 1
Age at the onset of speech therapy (months)a
Results showed a 94% agreement at pre-test,
and a 95% level of agreement at post-test. In the Patient number Group 1 (articula- Group 2 (phono-
tory approach) logic approach)
small percentage of cases in which there were
disagreements, the observations were discussed 1 85 46
until a consensus was reached. 2 54 57
Age ranged from 37 to 113 months. Mean age 3 38 85
in group 1 (articulatory approach) was 55.33 4 46 77
5 68 78
months, and mean age in group 2 (phonologic
6 63 54
approach) was 57.64 months. A Mann Whitney 7 78 53
rank sum test revealed a non significant difference 8 61 72
in the age at the onset of speech therapy between 9 41 37
both groups (Table 1). 10 44 38
11 65 67
At the onset of the speech therapy period, all
12 65 40
patients included in both groups demonstrated 13 39 45
glottal stops and pharyngeal fricatives. In addi- 14 43 58
tion, other types of compensatory articulation 15 40
patterns (i.e. pharyngeal stops, mid-dorsal con- n =15; X =55.33, n =14, X = 57.64,
median =55.50, median =55.50,
tacts, posterior nasal fricatives) were found in less
S.D. =15.14 S.D. =15.90
than 10% of the patients. The distribution of the
types of compensatory articulation patterns across a
MannWhitney rank sum test (median) T=0.284, P =
the two groups of patients was similar. 0.0776.
M.C. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) 2126 25

Table 2 Traditionally, the treatment for compensatory

Total time of speech therapy (months)a
articulation disorder in cleft palate patients has
Patient number Group 1 (articula- Group 2 (Phono- been at a phonetic level [1,11,18]. However, higher
tory approach) logic approach) organizational levels of language have not been
considered. A phonologic approach considers
1 18 13 speech sound production as an integral compo-
2 42 20
nent of higher levels of language organization
3 42 6
4 18 13 such as pragmatic, syntactic, and semantic knowl-
5 26 22 edge. Also, phonological treatments acknowledge
6 38 18 that speech sounds function as phonemes that
7 25 10 signify differences in word meaning, and have
8 14 16
become more cognitive and meaning-based than
9 32 12
10 18 18 traditional treatments which practice execution of
11 46 17 gestures in meaningless syllables [6].
12 39 11 The final goal of both modalities of interven-
13 28 14 tion is to improve intelligibility of speech; the
14 29 13
difference is in the methods for achieving this
15 36
n = 15, X=30.07, n= 14, X= 14.50, objective.
median= 29, median =13.50, It should be pointed out that the small number
S.D.=10.22 S.D.= 4.27 of patients and the homogeneity of the sample
[17] included in this study does not allow definite
Students t-test, PB0.001. conclusions, but the results obtained are
Several authors have described the phonetic It will be necessary to use the phonologic ap-
disorders in cleft palate patients [12], and most of proach in a larger number of patients including
them reported that these patients have articula- different conditions, i.e. different kinds of cleft,
tion abilities below age expectations [1,18]. Only a and different levels of linguistic development, in
few studies have focused on the phonologic dis- order to further assess its efficiency for correcting
abilities of these children [5,9,15]. These data sug- CAD associated with cleft palate.
gest that some of the speech sound problems
present in cleft palate children are phonologic in References
nature [5]. Chapman in 1993, studied the phono-
logic processes in children with cleft palate and [1] K. R. Bzoch, Articulation proficiency and error patterns
found that children with cleft palate exhibit early of preschool cleft palate and normal children, Cleft Palate
delays in phonologic development. This finding J. 2 (1965) 340 349.
[2] K. Chapman, Phonologic processes in children with cleft
has implications for the assessment and manage-
palate, Cleft Palate J. 30 (1993) 64 71.
ment of children with cleft palate, including anal- [3] M. Fey, Clinical Forum: Phonological Assessment and
ysis of phonologic processes in addition to Treatment. Articulation and Phonology: An Introduction.
phonetic analysis. It also implies that during Language, Speech and Hearing Services in Schools, 23,
speech intervention, remediation strategies based 1992, pp. 224 232.
[4] K. Golding-Kushner, A. Ysunza, et al., Standarization
on phonological principles should be employed.
for the reporting of videonasopharyngoscopy and multi-
Moreover, these strategies should emphasize cog- view fluoroscopy. A report from an interanational work-
nitive-linguistic activities [2]. ing group, Cleft Palate J. 27 (1990) 337 347.
The reduction in the total time of speech inter- [5] B. Hodson, E. Paden, Targeting Intelligible Speech, Col-
vention necessary for complete correction of CAD lege Hill Press, San Diego, CA, 1983.
[6] P. Hoffman, Clinical Forum: Phonological Assessment
using the phonological approach with cleft palate and Treatment. Synergistic Development of Phonetic
patients, suggests that the study of the phonologic Skill. Language, Speech and Hearing Services in Schools
system in these patients is of great importance. 23, 1992, pp. 254 260.
26 M.C. Pamplona et al. / Int. J. Pediatr. Otorhinolaryngol. 49 (1999) 2126

[7] P. Hoffman, R. Daniloff, Evolving Views of Childrens plasty, Scand. J Plastic. Reconstr. Hans Surg. 28 (1994)
Disordered Speech Sound Production from Motoric to 199 205.
Phonological, JSLPA/ROA 14 (1990) 1322. [14] J Norris, J. Damico, Whole language in theory and
[8] D.A. Kernahan, R.B. Stark, A new classification for practice: implication for language intervention, Lan-
cleft lip and palate, Plast. Reconst. Surg. 22 (1958) guage Speech Hearing Services School 21 (1990) 212
435 443. 220.
[9] J. Lynch, D. Fox, et al., Phonological proficiency of [15] G. Powers, et al., Speech analysis of four children with
repaired cleft palate, J. Speech Hearing Disord 55
two cleft palate toddlers with school age follow up, J.
(1990) 542 550.
Speech Hearing Disord. 48 (1983) 274285.
[16] E. Rangel, et al., Batera de Evaluacion de la Lengua
[10] E.T. McDonald, Articulation Testing and Treatment: A
Espanola (BELE) para ninos mexicanos de 3 a 11 anos
sensory-motor approach, PA: Stanwix-House, Pitts-
SEP-DGEE, Mexico, 1988, pp. 1 383.
burgh, 1964. [17] R.J. Shprintzen, Fallibility of clinical research, Cleft
[11] B. McWilliams, R. Musgrave, Diagnosis of speech Palate-Craniofacial J. 28 (1991) 136 140.
problems in patients with cleft palate, Brit. J Com. Dis. [18] D. Van Demark, et al., Patterns of articulation abilities
Spring 26 (1977) 241274. in speakers with cleft palate, Cleft Palate J. 16 (1979)
[12] B. McWilliams, et al., Diagnosis of speech problems in 230 239.
patients with cleft palate, 2, BC Decker, Philadelphia, [19] Van Riper, C. (1963) Speech Correction: Principles and
1990, pp. 5 19. methods (4th ed.). Prentice Hall, Englewood Cliffs, NJ,
[13] M. Mendoza, et al., Minimal incision palatopharyngo- pp. 1 74.