Children with cleft palate experience articulation errors and resonance issues such as hypernasality, hyponasality and nasal air emissions. The bulk of therapy for this population tends to focus on these areas of speech production.

Sally Helton, MS, CCC-SLP, teaches her young patients at Children's Mercy Hospitals and Clinics, in Kansas City, MO, about "speech helpers": the nose, lips, teeth, tongue, voice box, palate and, of course, air. Teaching children about articulators not only allows them to understand the vocabulary associated with speech production but also the concepts of using their articulators appropriately.

"I want them to know what I mean when I say, 'That's a lip sound, and you made it with your tongue.' I tailor it to each individual child and their cognitive level," Helton told ADVANCE. She has taught these valuable lessons to children as young as 2, as well as individuals with Down syndrome and other intellectual deficiencies.

She also exposes children to the parameters of sound, working on nose and mouth sounds, as well as plosives and fricatives. Examples of plosives, or "popping" sounds, are the short /t/ and /p/. Fricatives, or "blowing" sounds such as /s/, last longer.

Children also learn the difference between "noisy" sounds, which are made with vocal fold movement, and "quiet" sounds. "I've found if I don't teach the speech helpers or these different parameters of sound, I don't have a foundation underlying the whole thing," said Helton.

Making therapy fun can facilitate success. This comes easy to Helton. With a clientele that ranges in age from 3 to 7, her stack of games can prompt unmotivated or uncooperative children to quickly change their tune. "I find the game that a child enjoys, like Connect Four or something with SpongeBob. The younger kids might like a Diego or Dora game," she said, noting that the game is a means to an end. "It keeps their attention and interest."

To help children distinguish between nose, mouth and throat sounds, Helton uses visuals such as a set of laminated pictures of turtles. On each picture she places a letter representing a specific sound, like /m/ for "mom" and /p/ for "pop." When children understand where a sound is produced, they place the turtle picture and letter on the appropriate part of an image showing a person's mouth, nose and throat.

"I'll hold up my turtle sound and say, 'Say /m/.' I'll also have them put their finger alongside their nose and say, 'Did you feel it wiggle?' Even if they tell me no, which some of them do, I'll say, 'Well, mine wiggled.' Then I show them that the turtle with the /m/ goes on the picture with the nose," explained Helton. She tells younger children that her nose wiggled, points to where the picture goes, and even places the picture in the correct spot for them. "I give them the entire answer," she said. "After I do that for awhile, it builds up, and they understand it."

For the /p/ sound Helton asks a child to place a finger on the nose and say 'puh.' "I'll ask, 'Did your nose wiggle?' It might for these kids because they may still be making that sound out of their nose," she said. "I'll say, 'Mine didn't wiggle-this is a mouth sound.' Even though they can't make the sound correctly, I still require them to repeat after me as best as they can because

I want them to understand that this sound goes with this symbol."

Helton snaps her fingers once to demonstrate that a plosive is a short sound. To help children understand that a fricative is a long sound, she repeatedly snaps her fingers while moving her arm away from her body.

When teaching children the difference between noisy and quiet sounds, she has children position their fingers on the "bumpy part" of their throats, or vocal folds. She asks them if they feel the vibrations when they say certain sounds.

Children with cleft palate are prone to velopharyngeal incompetency, insufficiency and dysfunction. Typically, velopharyngeal incompetency is a neurological problem, while velopharyngeal insufficiency denotes a structural problem. "There can be a problem even after the primary palate repair," Helton pointed out. "Just because the palate has been brought together doesn't mean children will have the structure they need."

Most cases of velopharyngeal dysfunction are phoneme-specific. For example, a child may produce every sound fine except /s/ and /z/. "It's probably a dysfunction or mislearning," Helton said.

There is often overlap between the three categories. One individual might have an insufficiency and incompetency, while another might exhibit phoneme-specific and structural problems. This has an impact on therapy.

If a child has a structural problem, speech therapy can begin after palatal surgery. "We have to retrain the brain to let it know it has something to work with," Helton said. Therapy also can address phoneme-specific problems. It also can help with an incompetency, but it cannot override a neurological problem.

Using descriptive labels for sounds can help establish articulation skills. They explain in simple terms how a sound is made. "We have cutesy-sounding names in traditional articulation therapy, like calling /s/ the snake sound," Helton said. "That works to a point. But if a child has been in therapy a long time and continues making that sound through the nose, every time you say 'snake sound,' the brain thinks that sound goes through the nose."

To correct an erroneous /s/ sound she has children put their teeth together and blow when making the sound. With the /f/ sound she asks them to put their top teeth on their bottom lip and blow. She calls this the "bite and blow" and offers reminders like 'This is your quiet bite-and-blow sound" and "This is a mouth sound."

There are many aspects of speech production to focus on. Where can children put the sound? Can they do it at the beginning, middle and end of the word? Do they need the word broken down into sections? Can they say syllables? Should we just concentrate on making sounds?

This population typically uses compensatory articulations, making sounds by any means necessary. In many cases the soft palate isn't closing against the inside wall of the throat to keep the sounds out of the nose and build up the pressure that is needed to make those sounds.

"They might valve down at the vocal cords and make a lot of glottal sounds," Helton explained. "They may take their tongue all the way back to the inside wall of the throat on the pharyngeal area where we don't make any sounds in English. They might use the mid-portion of their tongue to make sounds that ought to be made at the tongue tip or on the soft palate. A whole class of sounds has been identified that is typical of people with velopharyngeal inadequacy."

If children are not making sounds with their palate and instead are making lots of glottals, it is difficult to determine where the velopharyngeal inadequacies lie, even with an endoscopy. "You could see the structure problem, but you wouldn't see function because they're not using it," she said. They must attempt to make high-pressure sounds using the palate.

The speech-language pathology department at Children's Mercy often gets referrals from community clinicians asking for endoscopies and surgery when they have trouble eliciting sounds from a child. Ideally, clinicians want to hear as many plosives and fricatives as possible, including high-pressured affricate sounds like /ch/ and /j/.

In order to begin sorting out the problem, Helton asks what sounds a child has. The therapist might say an /h/. "That is not a candidate for an endoscopy," she stated. "You're not going to have a valid study. We need them to at least be attempting some plosives and fricatives so we can see that function of the palate. We've got to see the function to know what's going on."

The surgeon needs to see the function to know what type of surgery to perform. "It's not a one-size-fits-all surgery," Helton said.

One of the most important criteria children need to meet in order to qualify for instrumental assessments is an attempt to make sounds that move the palate. They must be able to produce those sounds in connected speech. Solo words are acceptable. But if clinicians only have isolated sounds to work with, they won't be able to track movement between the sounds.

Hypernasality often is related to structure. Children with moderate to severe hypernasality are candidates for endoscopies. Those with slight hypernasality are not because it doesn't interfere with communication in most cases.

Helton often occludes the nose to test whether a child can make a sound appropriately through the mouth. "I can feel when air and sounds go in the nose," she said. She then asks the child to repeat a sound several times fast, gradually removing her fingers from the nose to see if the sound can be kept in the mouth instead of the nose.

Some children hesitate when they see a clinician's gloved hand because they associate exam gloves with negative experiences. For example, a child may have visited a doctor because of strep throat and felt pain when examined. "They think, 'Why do I want someone with a glove to approach me?' When you wear an exam glove during therapy, tell them, 'The hand with the glove is going to stay over here the whole time; it's not even going to get near you,'" she explained. "Maybe next time it's across the table, or I will touch their tummy."

Children need to cooperate for procedures like endoscopies. "We have a very good team that works well together, and we can get a lot done," Helton said. As part of the preparations, clinicians give children a coloring book to calm their anxieties and fears of the unknown. Other incentives, like toys, also are provided. "Some kids will go to the plastic surgeon, give him a hug, and shake his hand," she said. "We ask if it was that bad, and they will say 'no.' Then we ask if they were just kind of scared, and they will say 'yes.'"

Her personal philosophy is that she is working to enhance the lives of children with cleft palate. "I'm here to figure them out," she said. "They are jigsaw puzzles with every piece, and I try to figure out how they go together."

Working with this population requires "a different way to apply anatomy and physiology of the speech mechanisms," Helton said. Misconceptions exist, though. "The most common-and it's understandable-is that all problems can be chalked up to structure. Clinicians will say, 'We can't work with this child anymore because there is a structural problem, and we've got to wait for them to do another surgery.' Well, it may or may not be a structural problem."

For More Information

• Children's Mercy Hospitals and Clinics, online: www.childrensmercy.com

Jason Mosheim is a Senior Associate Editor of ADVANCE. He can be contacted at jmosheim@advanceweb.com.