Therapy Word Games
Cleft Palate Speech Training Institute
What Not to do for Cleft Palate Speech: “Nonspeech Oral Motor Exercises”
Endoscopy: Velopharyngeal Incompetence
Introduction to Cleft Palate Therapy Materials
By Chelsea L. Sommer and Catherine J. Crowley
Chelsea L. Sommer, Ph.D., CCC-SLP is a bilingual English-Spanish speech-language pathologist. Her research focuses on speech sound development in bilingual English-Spanish speakers and monolingual Spanish speakers with and without cleft palate. She enjoys collaborating with cleft palate teams throughout the world to build sustainable comprehensive cleft care.
Catherine “Cate” Crowley, J.D., Ph.D., CCC-SLP, is a Professor of Practice at Teachers College, Columbia University. Her work focuses on building capacity in the U.S. and abroad so that children with repaired cleft palates receive quality speech therapy services. An ASHA Fellow, she regularly consults on appropriate disability evaluations. Dr. Crowley is the director of the leadersproject.org website and a member of the Smile Train Global Medical Advisory Board.
The Leadersproject.org Website: Developing Global Expertise in Cleft Palate Speech Therapy by Sharing Free Video Tutorials and Assessment and Treatment Materials
The leadersproject.org website was developed to improve the quality of care provided for children in cleft palate speech therapy and in speech-language disability evaluations. What especially distinguishes leadersproject.org from most other websites is that everything on the website is free and can be downloaded, copied, and shared without additional permissions. The amount of assessment and treatment materials, online courses, videos, and resources continues to grow, as has the number of people who use the website. In March 2021 there were over 26,400 visits to the website from over 142 countries. The materials are available in over 30 languages and new languages are being added on a very regular basis.
We began to focus on international capacity-building related to cleft palate assessment and treatment in 2012. Dr. Miriam Baigorri and Dr. Crowley had finished our first five-day cleft palate speech therapy training in Guatemala. The training focused on developing cleft palate speech therapy clinical skills in the morning and then applying those skills to children with repaired cleft palates who came with their parents. In the afternoons, we realized that these parents knew their children needed help, but they would not have access to cleft-palate therapists once they returned to their homes. Compounding this shortage was that, at that time in Guatemala, even if they found a speech therapist to provide therapy, the most common approach was something called “nonspeech oral motor exercises.” These exercises include blowing on horns, sucking through straws, tongue-strengthening exercises, massaging faces, etc. These exercises tend to be ubiquitous in certain countries but they have absolutely no effect on the development of speech. The futile use of these exercises to improve speech amounts to wasted time and money when what the children need is quality services to address their cleft palate speech errors.
When we returned home, Dr. Baigorri and I could not forget those parents and how desperate they were to give their children what they needed to have clear speech. We wanted to share our cleft palate speech skills broadly so that parents who did not have access to cleft palate speech therapists could acquire some of the skills themselves, and, of course, so speech therapists could learn the particular skills needed to be a cleft palate speech therapist.
We came up with a plan to make short instructional videos for parents, in Spanish, that we put on flash drives and also made available on YouTube for anyone to access. We thought the best way to make these videos for the parents was to have individual videos based on a certain target sound with speech sound placement and shaping strategies to acquire that sound.
At the same time, Dr. Crowley was involved in a several-year-long consulting project with a number of school districts focused on improving the quality and accuracy of speech-language disability evaluations. These evaluations identify children/students with language disorders and the common approaches were to determine whether a child/student had a language disorder needing special education support. Most evaluators were using standardized language tests that mostly tested whether the child/student had acquired Standard American English rather than the particular variety of English that the child/student had been exposed to in their homes and communities. This practice led to many documented inaccurate disability identifications, especially of children/students from homes and communities where Standard American English was not commonly used.
To address this issue, we created culturally and linguistically responsive assessment materials in a number of languages. These materials and related online courses and resources are a main part of the contents at leadersproject.org. These language elicitation materials also are important in the conversation stage of the cleft palate speech therapy hierarchy as they provide opportunities to practice the targeted sounds in spontaneous speech so the corrected sounds become part of the child/student’s natural conversational speech. This will be discussed further below.
The Relationship with Smile Train
Our contact with Smile Train began when we shared the parent education videos and made them available on the leadersproject website. The Smile Train connection was quite synergistic for us. First, Smile Train was born with the goal of building local capacity in countries which was in stark contrast to the historically more common ‘mission-based” approach. In the mission-based approach, a surgeon or surgical team arrives in a country for a short period of time and performs a number of surgeries, and then returns home. Smile Train’s approach is “teach a (wo)man to fish, rather than give the (wo)man fish”. That capacity-building approach is quite similar to ours, that is to share our knowledge and skills with clinicians, professionals, and parents so that they have the skills to address a child’s specific needs. Additionally, Smile Train’s founder, Charles Wang, brought high-level technical expertise that shaped Smile Train’s online quality assurance and capacity-building professional development for surgeons. This was also similar to the online cleft palate speech assessment and treatment resources and the online courses that we had developed.
Over time we, the authors, developed strong relationships with Smile Train. We began providing these five-day in-person trainings to build capacity in English, Spanish, and French. We gave lectures and interactive learning in the mornings, then clinical application in the afternoons with patients under the supervision of experienced cleft Speech-Language Pathologists (SLPs). As of now, there have been over 30 of these cleft palate speech therapy trainings in 15 low- and middle-income countries. We have not done all of these trainings ourselves, as many are done by people who we may have trained and who use our materials.
Train-the-Trainer Cleft Palate Speech Therapy Materials
To ensure sustainability and more widespread dissemination of the knowledge and skills, we developed a train-the-trainer course with all the materials needed to offer live training including PowerPoints, videos, small group activities to build skills, role-playing scenarios, daily quizzes, pre- and post-tests, and course evaluations. That train-the-trainer cleft palate speech therapy course is itself available for free download at leadersproject.org in Spanish and English, and soon in French. Anyone wishing to do training can simply download the materials and do the training. We are also available for any questions as the more people who acquire foundational skills in how to do cleft palate speech therapy, the more children will receive effective services.
Online Cleft Palate Speech Therapy Course
Over time we learned that we wanted the clinicians to complete the online cleft palate course (Crowley, Baigorri, & Sommer, 2017). This foundational tutorial series needed to be completed before the in-person training because the level of understanding and skills that people brought to the training was so varied, either some would be behind their peers or others would already have this foundational level of knowledge and they would not be learning new information. Thus, this tutorial series (Crowley et al., 2017) provides clinicians with a basis and understanding of cleft palate assessment and treatment, while the in-person training provides additional information in addition to hands-on experience and knowledge.
This course provides a foundation for anatomy and physiology, surgery, assessment, and treatment of speech errors. After viewing the videos, there is a 57-question assessment, consisting of 40 multiple-choice questions and 17 audio-visual questions. These audio-visual questions were intended to help build the acquisition of perceptual skills and therapy strategies. With a score of 80% correct or more, the person receives a certificate that they can upload to a course or to a partner surgeon, or to whichever organization or university is sponsoring the training.
For those who do not speak English, Spanish, or French, or who would be more comfortable in another language, we typed the English subtitles verbatim on YouTube, so participants can have a quality translation into one of the 140 languages available on YouTube subtitle captions. We found that by slowing the play time to .75 speed, those who are using the subtitles can read them and then have time to watch what is being taught. The test is available in English, Spanish, French, and Bahasa, the lingua franca of Indonesia.
We have been delighted to find that many universities require this course of their graduate students here in the United States and in many countries around the world. The certificate is easily uploaded into a course learning system such as Blackboard, Moodle, or Canvas showing that the student passed the course and that the assignment was completed.
Developing Assessment Screeners in Local Languages
For each in-person training, we work with the participants to develop an articulation screener in the languages spoken by the participants. For example, during the training in Zimbabwe in 2019 for clinicians from Southern Africa, we created articulation screeners in Shona, Chichewa, Nyanja, and Ndebele, in addition to the English screener that would be appropriate in some cases. This did not mean that we had a screener for every child the clinicians were likely to see in Zimbabwe, Zambia, and Malawi, but all were uploaded to leadersproject.org and can be accessed by anyone who knows about the website. Additionally, these clinicians and trainees had experience creating articulation screeners for cleft palate assessment so they know how to do it for other languages.
Currently, there are assessment screeners in 11 different languages available at leadersproject.org.
Materials for the Cleft Palate Speech Therapy Hierarchy
The cleft palate speech therapy hierarchy has six steps: discrimination, single sounds, syllables, words, phrases and sentences, and conversation. We have treatment materials and videos for all these levels and in a number of different languages.
For discrimination, we have a downloadable illustration of a clown. In this phase, the clinician can make the correct and incorrect productions and ask the child where the sound is coming from so that the child can understand the differences in the place of production. In this first step of discrimination, the child does not speak but rather shows on the clown illustration where the sound is being made by the clinician, the mouth or the throat (glottis), or the mouth or through the nose.
Once the child understands the task and is able to discriminate where the place of articulation is located, the child can then make their own productions, and then they can tell the clinician where they think their production of the target sound was located. Both the cleft palate hierarchy video and the cleft palate course show how to use the clown or a hand-drawn clown to ensure the child can discriminate between a compensatory error and the correct articulatory placement for a sound.
Single Sounds and Syllables
Several of the videos in the online course and the hierarchy video show examples of the many different possible strategies to attain the correct placement and production of certain sounds. Once the child can produce the target phoneme with those shaping and placement techniques, the clinician should begin to target the sound in different syllable combinations depending on the syllable structure of their patient’s language(s). Typically, we start with consonant-vowel (CV) combinations and move on to VC, then VCV, and lastly CVCV. However, the clinician should assess which position the child has the highest accuracy with and start there.
Although there are some clinicians who choose to use nonspeech oral motor exercises (NSOME) to improve speech production in children with cleft palate, we have videos and handouts stressing that nonspeech oral motor exercises do not work for cleft palate speech therapy. Thus, tongue strengthening, massaging, warming up the mouth, horn blowing, straw sucking, etc., is inappropriate to use and does not lead to the development of speech sounds (Ruscello & Vallino, 2020).
Word games are available in 15 different languages. Each word game focuses on one of the high-pressure sounds that children with cleft palate often have difficulty producing such as the /p, b, t, d, k, g, s, sh, f/, and all other sounds are vowels, low-pressure /r, l, y, w/ or nasal sounds /n, m, ng/, which are usually not as impacted in children with cleft palate. There are videos showing how to play these word games in person. Additionally, these word games can be used via telepractice and there are videos showing how to use these virtually.
Phrase and Sentence Level
Once a child has the sound with 100% accuracy at the word level, the cleft palate books provide controlled practice or certain cognate sounds in phrases and sentences. Each book focuses on two sounds that are voiced and voiceless pairs, such as p/b, t/d, k/g, s/z, etc. As with the word games, all the other sounds are nasals, vowels, and low-pressure sounds. There are also instructional videos on how to use the books. There are two beautiful books in Hindi by Visaka Serres, and many books in English.
The Story of the Cuckoo Bird (A K/G Cleft Palate Practice Book). Written and Illustrated by Visaka Serres, M.S., CCC-SLP
Often the most difficult stage in the hierarchy to complete is using the new sound in conversation. To create opportunities for in-depth natural conversations, clinicians can use School-age Language Assessment Measures (SLAM) materials.
The Crayons. School-age Language Assessment Measures
The SLAM materials are used throughout the United States as evidence-based ways to elicit and analyze language to determine whether a child has a language disorder. The questions for the SLAM materials become more complex and analyze temporal and referential cohesion; social/pragmatic language in taking perspectives, theory of mind, and false beliefs; and causal cohesion as in inferencing, problem-solving, and making meaningful predictions. For example, questions for The Crayons include “What happened?”, “Why is the red crayon pointing to the blue crayon?”, “What would you say if you were the blue crayon?”, “What do you think is going to happen next?”, and “Have you ever been blamed for something you didn’t do? What happened?” These questions elicit those dialect-neutral indices of language and narratives.
The SLAM materials are appropriate for use by children ages four and above. “The Subway” and “The Crayons” can be used with children from four, and perhaps as young as three, through secondary school. “Dog Comes Home” and “Bunny Goes to School” are for children four through about ten years old. “Lost Cellphone”, “The Ball Mystery”, and “Baseball Troubles” are for children older than ten. The “Guidelines for Analysis” for each SLAM measure help the clinician to analyze the language the child/student produces. The SLAM elicitation is expository and persuasive, and the SLAM analysis is based on the Burns et al (2012) dialect-neutral indices and sentence structures. Of course, these are all available for free download at leadersproject.org. They are translated into many languages, including Hindi.
During the time of COVID, the SLAM materials were made available for teletherapy using the SLAM BOOM! Boom learning cards, which are located in the Leaders Project library. This allows clinicians to use word games and books on tablets, phones, and laptops when the families live a long distance from the clinician or when public health issues preclude travel.
Building capacity in language elicitation and analysis
In addition to the cleft palate speech therapy materials, Leaders Project has many resources to build capacity in language elicitation and analysis. SLPs struggle to elicit and analyze language according to evidence-based practice (EBP) (Fulcher-Rood, et al, 2020). Thus, we built out three different online courses, Grammar Fundamentals for a Pluralistic Society, Advanced Grammar Fundamentals for a Pluralistic Society, and EBP in Disability Evaluations. Similar to the online cleft tutorials, speech therapy students and clinicians watch these modules and then take an online assessment. Our goal was to build skills in identifying different kinds of sentences, e.g., simple, compound, complex (adverbial time/causation; noun clauses, and relative clauses), etc. These three courses develop skills in how to use that information to analyze a student’s cognitive comprehension expression and social/emotional language skills. We also offer a number of other free courses focused on disability evaluations.
An open invitation to our Indian colleagues and friends
In March 2021, Leadersproject.org had 169 users in India and 26,400 worldwide. Hopefully, this will continue to build, especially with our friends and colleagues in India. Anyone who would like to create materials for leadersproject.org, please contact firstname.lastname@example.org or email@example.com
Follow us on @Leadersproj for both Twitter and Instagram. “Like” the Bilingual Extension Institute Facebook page. Subscribe to LEADERSproject YouTube channel and the Boom learning SLAM BOOM cards at the Leaders Project library.
Hierarchy of cleft palate speech therapy:
How to use word games:
How to use the word games via teletherapy: https://www.leadersproject.org/2020/09/14/slam-boom-cards/
How to use the books:
Boom learning teletherapy:
Baigorri, M., Crowley, C., & Sommer, C. (2020). Addressing the gap in education for cleft palate: a module training series for craniofacial assessment and treatment. Perspectives of the ASHA Special Interest Groups, 5(3), 662-668.
Crowley, C., Baigorri, M., & Sommer, C. (2017, March 23). Cleft Palate Speech and Feeding Video Tutorials. Retrieved from https://www.leadersproject.org/2017/03/23/english-cleft-palate-speech-therapy-evaluation-treatment-playlist/
Fulcher-Rood, K., Castilla-Earls, A., & Higginbotham, J. (2020). What does evidence-based practice mean to you? A follow-up study examining school-based speech language pathologists’ perspectives on evidence based practice. American Journal of Speech-Language Pathology, 29, 688-704.
Kummer, A. W. (2018). Cleft Palate and Craniofacial Conditions: A Comprehensive Guide to Clinical Management: A Comprehensive Guide to Clinical Management. Jones & Bartlett Learning.
Peterson-Falzone, S. J., Hardin-Jones, M. A., Karnell, M. P., & McWilliams, B. J. (2001). Cleft palate speech. St. Louis: Mosby.
Ruscello, D. M., & Vallino, L. D. (2020). The Use of Nonspeech Oral Motor Exercises in the Treatment of Children With Cleft Palate: A Re-Examination of Available Evidence. American Journal of Speech-Language Pathology, 29(4), 1811-1820.