Craniofacial Society of Great Britain and Ireland April 14, 2011

1. Speech-language intervention for young children with cleft palate: Maximizing development from birth to 3 years Craniofacial Society of Great Britain and Ireland April 14, 2011 Nancy J. Scherer, Ph.D. Dean, Clinical & Rehabilitative Health Sciences

2. The evolution of early intervention for children with cleft lip and palate • Concept of early intervention makes logical sense for children with clefts • But in fact much of our current practice is not driven by evidence

3. Assumptions about early development • Speech and language development are intertwined during early development • Speech and language develop simultaneously • Children learn language in naturalistic environments not through drill and practice

4. Programmatic Research • My background in early assessment and intervention • Developed an early intervention program for children with clefts at a large speech and hearing center in California • Follow up of the children indicated that they had both early language and speech deficits • The literature at that time only discussed speech deficits

5. Initial Studies • First set of studies examined the assessment of early speech and language in children with clefts • Scherer & D’Antonio, 1995 (Parent questionnaire) • Scherer & D’Antonio, 1997 (Play & Language) • Snyder & Scherer, 2004 (Play & Language )

6. Findings • Retrospective studies indicated presence of both language and speech delays • Intervention goals for the children included both language and speech • Severity and prevalence of delays varied • Some children normalized by 3 years of age

7. Longitudinal Studies • A second set of studies examined longitudinal development of speech and language performance from birth to 5 years for several groups: nonsyndromic children with clefts, children with VCFS and children with Down syndrome • Scherer & D’Antonio, 1999 • Scherer, D’Antonio & Rodgers, 2001 • D’Antonio, Scherer, Kalbfliesch, Miller, Bartley, 2001 • Scherer, Williams & Proctor-Williams, 2008

8. The majority of children with clefts experience early speech-language delays despite early palate repair

9. These delays may persist for some children through the preschool period

10. Speech-language characteristics of young children with clefts • Limited complexity of babbling • Delayed onset of words and word combinations • Slow early vocabulary growth • Limited consonant inventories • Many sound substitution and omission errors • Emergence of compensatory articulation errors

11. What are the factors that could impact development? • Children attempt to communicate less? • Parents provide fewer opportunities? • Poor speech intelligibility results in less successful communication?

12. Do children with clefts communicate as much as noncleft children matched for language level?

13. Do children with clefts talk as much as noncleft children?

14. Conclusion • Children with CLP communicate as frequently as noncleft children but they do not communicate as often with words.

15. We know children with CLP use fewer words but how does that translate into clinical definitions of impairment? • Are they language impaired? • At risk for language impairment? • Secondarily affected by speech deficit?

16. Compared language development in children with clefts to noncleft children in 2 groups • Language impairment • Typical development

17. Results • When standardized language test scores were compared children with CLP were • Similar to the typically developing children • When conversational language samples collected with parents were compared, children with CLP were • Similar to children with language impairment • When parents word use was compared • Parents of children with CLP were similar to parents of language impaired children

18. Conclusion • Children with CLP show a competence-performance gap in language development. • Gap between what they know and what they use • This gap is affecting • How often they use words • How often they get feedback from adults • How often they practice speech production

19. Studies of Early Intervention Models • A third set of studies explored models of early intervention for children with clefts • Enhanced Milieu Teaching • Scherer, 1999 • Scherer & Kaiser, 2007 • Focused Stimulation • Scherer, D’Antonio & McGahey, 2008 • Enhanced Milieu Teaching with Phonological Emphasis • Scherer & Kaiser, 2010

20. Conclusions • Can simultaneously increase vocabulary and speech sounds, reduce compensatory articulation • Can train parents to increase • Exposure to new words • Opportunities for the child to communicate • Feedback to the child that will expand language complexity and increase speech accuracy

21. Current Study • Is this intervention better than • Other early interventions • No intervention • Does the intervention • Reduce the competence-performance gap? • Improve intelligibility • Reduce the habituation of compensatory errors?

22. Currently testing a hybrid naturalistic early speech and language intervention compared to current community-based intervention

23. Assumptions of the Hybrid Model: Increasing exposure and feedback • The more a child hears a word, the more likely they are to use it. • The more opportunities a child has to say the word, they better their speech accuracy becomes.

24. Enhanced Milieu Teaching with Phonological Emphasis (EMT/PE) • A set of tools to help facilitate a child’s communication growth: • Setting up an interactive context between the adult and child through play • Noticing and responding to child communication; balancing turns • Modeling and expanding play • Modeling and expanding word use • Using environmental arrangement strategies • Using prompting strategies to expand language and speech simultaneously

25. Key Components of EMT/PE • Train parents and others in the child’s environment to extend opportunities to daily routines • Train parents and clinicians to provide prompting and feedback strategies that • Increase vocabulary • Increase speech sound acquisition • Reduce or prevent compensatory articulation

26. Key Component: Parent Training • It is more than- • Giving developmental information • Observing therapy • It requires systematic training using methodology for adult learners

27. Typical training session • Review video clips of last session to discuss implementation issues • Presentation of information regarding a component of the intervention • Role play technique • Clinician demonstrate technique with child • Parent practice technique with child while clinician coaches

28. Key Component: Speech Recasting • Repeat child’s production of a target word while emphasizing a sound in the word • A type of corrective feedback • Responds to the child’s production of the word when they are most attentive

29. Preliminary Findings

30. What happens to vocabulary during the intervention?

31. Intelligibility

32. Vocabulary and intelligibility growth were highly correlated during the intervention (r=.82)

33. Compensatory Articulation

34. Reducing compensatory articulation • Child C1002 (red) was exposed to an intervention with speech recasting

35. Summary • Young children with clefts show early language and speech differences • Intervention is most efficient and effective when • both language and speech are treated simultaneously • occurs in natural environments • trains parents as intervention agents

36. Thank You