Age of diagnosis and evaluation of consequences of submucous cleft palate.

OBJECTIVES: To evaluate the frequency of submucous cleft palate (SMCP) in a group of children with clefts. The reason for suspecting submucous cleft, age of diagnosis, effect of age on speech development, problems in speech, hearing and swallowing were compared with previous literature. METHODS: Retrospective chart review: Out of 33 patients with SMCP, registered by the Groninger cleft team over approximately 20 years (1990 until July 2012), 28 non-syndromic patients with a proven diagnosis of SMCP were included: 17 males and 11 females. Speech and hearing were examined and the number of patients with SMCP and age at time of diagnosis were evaluated. The percentages of problems in resonance, articulation and hearing, present at time of diagnosis, were compared with the percentages of problems found after surgery. RESULTS: Out of 800 patients with clefts, 28 patients (3,5%) were diagnosed with SMCP at a mean age of 3;9 years. All patients presented one or more symptomatic complaints at time of diagnosis: hypernasality (65%), problems in articulation (46%), conductive hearing loss (39%) and/or swallowing problems (32%). A bifid uvula was found in 92%. Following surgery, hypernasal speech and swallowing problems were no longer observed. The articulation problems remained after surgery. Age of diagnosis seems no predictor of articulation problems. An improvement in hearing was observed but normal hearing was not achieved. Pharyngoplasty appeared to be a successful and save treatment of hypernasality. CONCLUSIONS: SMCP is a rare cleft palate which is, despite the presence of a bifid uvula and symptoms of velopharyngeal insufficiency, often diagnosed late. In children with a bifid uvula and mild problems in speech, hearing and swallowing, it is important to be alert to SMCP because SMCP may account for these persistent mild complaints. Therefore, early detecting of SMCP can yield profits.

Nasometry cooperation in children 4-6 years of age.

OBJECTIVE: Hypernasality is a common problem in cleft care. It should be treated before the age of six, because of the impact it can have on speech sound development in young children. An objective method of nasalance evaluation is nasometry. Cooperation of young children, by nature, differs over time and situations. First aim of this study is to indicate a minimum age for cooperation with the nasometer. Second aim is to compare the cooperation of children in the most used research setting (school) with the cooperation of children in the most used setting in daily practice (ENT outpatient clinic). METHOD: Children from four to six years of age were recruited from schools. Outpatient clinic children were recruited from the Groningen ENT clinic. Both groups were tested with the nasometer. The cooperation with installation and repetition of speech stimuli were noted. RESULTS: 118 school children and 41 outpatient clinic children were recruited. Six years old children cooperated significantly better than the five years old. The five years old cooperated better than the four years old. Moreover, school children cooperated significantly better than the outpatient children. CONCLUSION: Most children of 6 years of age and older, will show good cooperation with nasometry. In children aged 5, cooperation depends on the situation in which the nasometer is used. In a school setting the cooperation is better than in an outpatient clinic setting. In the 4 years old children the cooperation with the nasometer often is insufficient, probably due to normal, unpredictable cooperative behavior belonging to this age.

Phonetic and phonemic acquisition: normative data in English and Dutch speech sound development.

OBJECTIVE: Comparison of normative data in English and Dutch speech sound development in young children. Research questions were: Which normative data are present concerning speech sound development in children between two and six years of age? In which way are the speech sounds examined? What are the differences and similarities between the development of speech sounds in different languages? METHODS: A literature study on the subject was performed to be able to answer the research questions. RESULTS: The presented normative English data showed that all vowels are present at three years of age, and most consonants (singletons) already at four years of age, except for/ʃ, ɹ, θ, ð/. Consonant clusters develop between 4.5 and 5.5 years of age. The phonological error patterns gliding can be present until six years of age. According to information regarding the Dutch speech sound system, the same ages are found for vowels and single consonants. The age of acquisition of most consonant clusters is present at about six years of age, but the development goes on until ten years of age. CONCLUSION: The data from the development of the English and Dutch speech sound system show many similar tendencies. Vowels are mastered by the age of three, most consonants by the age of four and most consonant clusters between 5 and 6-8 years of age. Perhaps, there is a universal trend in speech sound development like there is in language development.

Nasometry normative data for young Dutch children.

OBJECTIVE: Hypernasality is a common problem in cleft care. It should be treated before the age of six, because of the impact it can have on speech sound development in young children. An objective method of nasalance evaluation is nasometry. To decide whether a nasometer test result is normal or abnormal, normative data and cut off points are needed. Normative data for children are not available for every language and age. For Dutch children two sets of Dutch speech stimuli, the Van Zundert sentences or the Moolenaar-Bijl, sentences, are often used in the diagnostic process for hypernasality. Primary goal of this study is to determine normative data and cut off points for two sets of Dutch speech stimuli for Dutch children from four to six years of age. Secondary is to compare those two sets of oral sentences. METHOD: Children without clefts were recruited from schools. According to their teachers their speech was normal. They were tested with the nasometer with the two sets of speech stimuli. The set from Van Zundert has oral and oronasal sentences, the Moolenaar-Bijl set only has oral sentences. RESULTS: 118 children were recruited. Out of these children, 55 produced recording samples which were suitable for analysis. There were no significant differences between age groups or gender. The two different sets of speech stimuli used were significantly different, but the confidence intervals overlapped. CONCLUSIONS: Normal nasalance scores of the tested sentences are between 3 and 19% for oral sentences and between 17 and 37% for oronasal sentences. The Moolenaar-Bijl speech sentences are preferred to evaluate hypernasality in young Dutch children, because of the shortness and intelligibility. Normative nasalance scores are applicable to the whole group of children from four to six years of age.

Behavioural problems in young children with language problems.

OBJECTIVE: Analysis of behavioural problems in young children with language problems. MATERIALS AND METHODS: From 38 children diagnosed with a language problem, the opinion of the parents about the behaviour of their child, scored by the Child Behaviour Checklist 1.5-5 was compared with the behavioural problems in the Dutch population with the Chi-square test. T-tests and Mc Nemar tests were used to compare the opinion of the fathers about the behavioural problems with the opinion of the mothers and to compare the scores on internalizing problems with scores on externalizing problems. Plots display the measurement of the mean behavioural problems of the parents against the discrepancy between the parents and of the total behavioural problems against the discrepancy between internalizing and externalizing problems. The relation between the behavioural problems, the language score and the non-verbal intelligence score was also compared and is presented in a bar chart. RESULTS: All children had an inadequate language production (GDS). Twenty-seven children had an adequate and 11 children had an inadequate Language Comprehension Quotient (LCQ). Twenty-eight children had an adequate and 10 children had an inadequate non-verbal IQ (SON-IQ). In the clinical population mothers report more internalizing behavioural problems than in Dutch peers. The fathers also experience differences, but these are not significant. There is agreement between the parents in how they experience problems on the internalizing, externalizing and total problem scale. And there are no significant differences between the internalizing and externalizing problem scales, between boys and girls, and in behavioural problems in children with both adequate LCQ and SON-IQ and with inadequate LCQ and/or SON-IQ. CONCLUSION: Compared to their peers in the Dutch population, young children with language problems show more internalizing problems according to their mothers. The fathers also experience differences, but these are not significant. Fathers and mothers agree on the behaviour analysis of their child and there are no differences between the occurrences of internalizing or externalizing problems and between boys and girls. There is also no relation between the behavioural problems and the severity of the language problem or the level of non-verbal functioning.

Problems in speech sound production in young children. An inventory study of the opinions of speech therapists.

OBJECTIVE: Analysis of examination procedure and diagnosis of articulation problems by speech therapists. STUDY DESIGN: Survey study. MATERIALS AND METHODS: Eighty-five Dutch speech therapists (23% response), working in private practises or involved in language screening procedures in Youth Health Care, were questioned regarding the incidence of articulation problems in their practices, the manner of examination, the normative data used, and the importance attached to identifying articulation problems. RESULTS: According to the speech therapists, articulation problems are present in the majority of children (90%) in their practices. In children between 2 and 5 years of age, 45%; in children between 5 and 8 years of age, 36%; above age 8, about 14% of the children still have articulation problems. Despite their opinion that articulation problems often form a separate aspect of language development, all respondents indicated that they always investigate the speech sound development as part of a total speech and language examination. Frequently, more than one instrument is used. However, none of these instruments are standardised. The speech therapists prefer to examine the children at about 4 years of age, despite their opinion that the speech sounds develop until about 6 years of age. For them, this raises the problem to distinguish between articulation in development and articulation problems. They have the opinion that early treatment is important because of assumed relations with social-emotional development and reading and writing abilities later on. CONCLUSION: The speech therapists taking part in this study have a good view of the speech sound development of young children. However, due to their concern about communication, social-emotional development, and reading and writing abilities later on, they prefer to identify and treat articulation problems at an early age. More detailed research into the variations in speech sound development, in relation to language development, is needed in order to arrive at effective normative data.

Effect of different treatments in young children with language problems.

OBJECTIVE: Analysis of the relationship between treatment and improvement on language scores in children with language problems. DESIGN: Observational longitudinal study. MATERIALS AND METHODS: 123 children between 2 and 5 years of age, diagnosed as having a language problem were followed for 1 year. By means of monthly questionnaires, the form of intervention received was recorded. Language abilities were measured at baseline and after 1 year. Mixed model analysis was used to determine the relationship between improvement and language scores. RESULTS: During the year 119 parents returned the monthly questionnaires and four treatment groups were subsequently able to be categorized: language treatment (n=21, 18%), surgical hearing improvement (n=16, 13%), language treatment and surgical hearing improvement (n=42, 35%) and a three-combination group (language treatment, surgical hearing improvement and developmental guidance, n=40, 34%). For the four treatment groups there were no significant differences at baseline for the Language Comprehension Quotient (LCQ) (p=0.07) and Sentence Development Quotient (SDQ) (p=0.09). In all treatment groups the mean Sentence Development Quotient improved significantly (p=0.001). The mean Language Comprehension Quotient did not improve in the surgical hearing improvement group (p=0.42), but improved significantly in the language treatment group, in the language treatment and surgical hearing improvement group and in the three-combination group (p=0.002, 0.040, 0.001). From all included children 38 children (32%) moved from an inadequate to an adequate language score. CONCLUSION: All distinguished forms of treatment were effective. However, only for a proportion of the children this meant a clinical relevant improvement. For the improvement of language comprehension targeted language therapy seems essential, as children without this (children receiving surgical hearing impairment) did not improve their LCQ.

Speech and language development in toddlers with and without cleft palate.

OBJECTIVE: The effect of early palate closure on speech and language development in children with cleft palate. DESIGN: Comparative study. SETTING: University Medical Center Groningen, Cleft Palate Team (The Netherlands). MATERIALS AND METHODS: Forty-three toddlers with cleft palate and thirty-two toddlers without cleft palate were analyzed with standardized tests for language comprehension and language production. Moreover articulation and hyper nasality were examined by trained speech therapists. RESULTS: For language comprehension, language production and articulation there were no significant differences between the children with and without cleft lip and/or palate. This is despite the high percentage of conductive hearing loss (55%) in children with clefts. Significant difference was found for hyper nasality (mean: 35% vs. 0%, p=0.001). In both groups articulation problems raise to a higher percentage than language production problems (63-20%; 24-4%). CONCLUSIONS: Early surgical treatment is effective for a part of the communicative development, i.e. language development and articulation. Besides conductive hearing loss hyper nasality remains a serious problem in 30-50% of the children with cleft palate. Therefore, speech therapy and pharyngoplasty also are part of the treatment procedure. Because of the high amount articulation problems in all children, standards for articulation development are perhaps too strict. Future research should be carried out after normal variations in articulation development.

Satisfaction with treatment outcome in bilateral cleft lip and palate patients.

The aim of this case-controlled study was to assess satisfaction with facial appearance and function, and health-related quality of life (HRQL) in bilateral cleft lip and palate patients (BCLP). The study sample was composed of adult BCLP subjects and controls matched for age, gender and socioeconomic status. Outcome measures included a self-administered questionnaire evaluating satisfaction with facial appearance, function and HRQL. Bivariate statistics were computed to analyse the association between BCLP status and outcome measures. Forty-three treated adult BCLP patients (mean age 28.2 years, SD 7.8) were compared to 43 controls without clefts (mean age 28.5 years, SD 8.0). Quantitative and qualitative assessment revealed that BCLP patients were significantly less satisfied with the appearance of the upper lip, the nose and nasal breathing. Additionally, satisfaction with facial appearance correlated positively with HRQL. For speech, hearing and drinking, quantitative scores did not differ between BCLP and controls, while qualitative assessment revealed that BCLP patients had considerable problems and concerns with these functions. This study underlines the importance of qualitative assessment of patient satisfaction with treatment outcome to identify individual problems and concerns not revealed by quantitative measures alone.

Children with language problems in a speech and hearing clinic: background variables and extent of language problems.

OBJECTIVE: Analysis of a clinical population referred for language analysis in terms of background variables and extent of language problems. DESIGN: Descriptive study. MATERIALS AND METHODS: Children referred to a speech and hearing clinic because of assumed language problems were analyzed with standardized tests for language comprehension (Dutch version of the Reynell Developmental Comprehension Scale) and language production (Schlichting test for sentence development). A language problem was defined when the language quotient score differed 1.3S.D. from the mean (quotient scores< or =80). Furthermore, potential risk factors for language problems were compiled (gender, prematurity, birth weight, family composition, familial aggregation, parental education and daycare/home care). RESULTS: Two hundred forty children, aged between 2 and 5 years of age were included in the study. A reliable language comprehension quotient (LCQ) was obtained in 204 children (85%) and a reliable sentence development quotient (SDQ) in 206 children (85%). In 35% of the children who were assumed to have language problems, adequate language development was found. The children with language problems differed from the children without language problems with regard to language problems in the family (more family aggregation). Also the former more frequently had parents with a low level of education and more often did not attend daycare. The total referred group differed from the Dutch population with regard to gender (more boys), more instances of low birth weight, more parents with middle and high educational level, more two-parent households, fewer siblings, and more frequent attendance at daycare. CONCLUSION: Parents with a low level of education more frequently have children with language problems. However, parents with a middle and high level of education are more often concerned about the language development of their child. As a consequence, the overestimation of language problems is a real issue in clinical practice. Normal variations in language development often are not considered. The analysis of compiled background variables indicates that language problems are genetically influenced (gender and family aggregation). Language input also is of importance (interactions with a language-competent parent or caregiver and peers): children with language problems less often attended daycare.

Specific language impairments and behavioural problems.

The behavioural functioning of 56 children with a specific language impairment (SLI), aged 8, 10, and 12 years, was examined by using the Child Behaviour Checklist. Parents as well as teachers filled in the questionnaire. The data shows that 48% of the children with SLI were considered to have behavioural problems either at home or in school. The problems differ significantly from the norm group on internalizing behaviour and total behaviour. The children do not demonstrate more externalizing behaviour than children in the norm group. It is hypothesized that the absence of aggressive behaviour might be a characteristic of children with SLI.

[Communication disorders in children; experiences with a multidisciplinary outpatient diagnosis]. / Communicatieve stoornissen bij kinderen; ervaringen met multidisciplinaire poliklinische diagnostiek.

Communication disorders in children can be caused by impaired hearing. However, also other factors can adversely influence speech and language development, such as mental retardation, lack of language stimulation and anatomical defects of speech organs. Speech and language development can be regarded as a symptom; therefore a multidisciplinary diagnostic procedure is essential to the planning of an adequate therapy programme. In the Netherlands a great variety in diagnosis and treatment exists. A child with a communication disorder is usually seen by five specialists, and the interval between recognition of the communication problem by the parents and the final diagnosis, after which therapy starts, sometimes lasts almost three years. Besides that, in a majority of cases speech and language therapy is offered. In order to change this process for the better a prospective research programme was started in the Academic Hospital Groningen, the Netherlands, with a protocolled multidisciplinary diagnostic approach. The first findings are encouraging: 89% of 209 children with supposed communication disorders were diagnosed after one visit to the outpatient clinic.

Specificity of specific language impairment.

In children with specific language impairment (SLI) their problems are supposed to be specifically restricted to language. However, both on theoretical basis as well as on a practical basis it is often difficult to make a sharp distinction between specific and non-specific language disorders. In a three-step study we found in the first place that in a group of children with supposed SLI (n = 319), after multidisciplinary examination, only in 25% of the cases the diagnosis SLI was correct. Secondly we found that after a period of time children with correctly diagnosed SLI showed problems with attention, motor functioning and school achievement. Thirdly we found that the learning difficulties of the children were related to their previous language problems. We hypothesize that SLI is less specific than is generally assumed. It could be a part of a neuropsychological 'syndrome' in which neurological maturation is jeopardized.

Lack of effect of clonidine on stuttering in children.

OBJECTIVE: The authors studied the effects of the alpha 2-receptor agonist clonidine on stuttering in children. METHOD: Using a double-blind crossover study, they gave placebo or 4 micrograms/kg body weight per day to 25 stuttering children who were 6-13 years old. Stuttering was measured by counting the occurrences of four elementary speech difficulties and by asking parents and teachers to give an overall impression of the amount of stuttering, as well as their impression of how troublesome the stuttering was to the children. RESULTS: Clonidine did not improve stuttering. CONCLUSIONS: Clonidine cannot be recommended as a useful drug for treating children who stutter.

[Children with a presumably isolated speech-language disorder often have medical or cognitive problems as well]. / Bij kinderen met een vermoedelijk geïsoleerde spraak-taalstoornis vaak tevens medische of cognitieve problemen.

OBJECTIVE: To assess the language problems of children who otherwise appear to develop normally. DESIGN: A clinical inventory. SETTING: University Hospital Groningen. METHOD: The children (n = 319) were examined according to a standard protocol consisting of: ENT examination, audiologic examination, paedogogic observation and logopaedic examination. Further psychological examination was carried out when needed according to the paedagogic observation. RESULTS: 25 per cent of the children had isolated language problems. For these children logopaedic therapy was indicated. In 75 per cent, a clear associated medical factor, or a retarded cognitive and (or) motor development, was found. Forty per cent of these children received medical treatment and 35 per cent specific paedagogic guidance. In some cases additional logopaedic therapy was given. CONCLUSION: It appears advisable to give children with language problems logopaedic therapy only after a diagnostic examination has been carried out according to a standard protocol as described.

Cleft palate repair: Furlow versus von Langenbeck.

The Furlow cleft palate repair using a double opposing Z-plasty appears to be very promising. In order to detect advantages and disadvantages concerning the technique as well as speech- and hearing results, the Furlow palatoplasty was compared with the classical von Langenbeck technique. Data analysis from 10 children in both groups revealed that the Furlow technique proved to be superior to the von Langenbeck technique as far as speech sound is concerned: at a mean age of 3.5 years, nasality and nasal escape were absent in almost all cases. However, there were no significant differences between the techniques in respect of articulatory skills, language comprehension, language production as well as hearing. Technically, the Furlow technique is more difficult to perform, particularly in wide clefts.

[Voice rehabilitation following larynx extirpation using the Groningen button]. / Stemrevalidatie na larynxextirpatie met behulp van de Groninger button.

The long term results of implantation of the 'Groningen button' after total laryngectomy were determined retrospectively in the ENT Department of the University Hospital Groningen, after follow-up periods of 6 months to 5 years. The study group consisted of 86 patients who received a Groningen button between 1981 and 1985, 79 men and 7 women with an average age of 60.5 years at the time of the total laryngectomy. The Groningen button is a silicon valve, which is introduced into a tracheo-oesophageal shunt, thus preventing aspiration of oesophageal contents and keeping the shunt open. The valve can be placed primarily during the laryngectomy or secondarily after the laryngectomy. The results of the voice restoration with the Groningen button were better than the results achieved with the injection oesophageal speech only. The results of a primarily constructed shunt with placement of the button were better than those of a button placed secondarily more than one year after the laryngectomy. The average lifetime of a button was about 3 months. The buttons of one-third of all patients were removed permanently after some time. In our study the complications were few. In our opinion a Groningen button can be placed during a laryngectomy to achieve a better voice restoration.

[Disordered speech and language development as a pedagogic problem. Reaction of parents to child speech problems]. / Gestörte Sprech- und Sprachentwicklung als pädagogisches Problem. Die Reaktion der Eltern auf kindliche Sprachprobleme.

Since children live with their parents and meet other children, we looked into the possible effects of language disorders in children on their interactions with the social surroundings. Language disorders are woven into the fabric of communication between parents and child and are not attributes of the child alone. Language-disturbed children are not more difficult in their behavior than normal-speaking children at the same age. However, the parental emotions about the language problem lead to the perception of more difficult behavior. Parents of language-disturbed children try to stimulate the language development of their child. In this they get disappointed by the reactions of the child and become less stimulating. It seems as if in the interactions between parents and child, the child partly creates his own--negative--surroundings.