Enhanced milieu teaching with phonological emphasis: A pilot, telepractice study for parent training in early intervention.

PURPOSE: This pilot study evaluated enhanced milieu teaching with phonological emphasis (EMT + PE) parent training intervention delivered through telepractice and its impact on parent implementation, child speech outcomes, and child language outcomes. METHOD: A multiple baseline design across behaviours was used to assess response to parent training and child outcomes. The intervention was delivered to four parents and their young children with repaired cleft palate. Speech production, receptive language, and expressive language were assessed prior to intervention. EMT + PE strategies including matched turns, modelling and expansions, and prompting/speech recasting were taught to parents using the teach-model-coach-review model. Social validity questionnaires were administered pre- and post-intervention to assess parents' rating of competence and confidence for managing their child's early development. Reliability and procedural fidelity were conducted. RESULT: All parents increased their use of modelling and expansions, and prompting and speech recasting in response to training, as evidenced by large effect sizes. Children also responded positively to these strategies by increasing percentage of consonants correct (PCC) and target vocabulary, although PCC gains were less than observed in a prior hybrid telepractice and face-to-face intervention. Social validity measures indicated parents increased their confidence to provide intervention for their children. CONCLUSION: This pilot study indicated that effective parent training in EMT + PE strategies can be delivered through telepractice.

Speech Production Errors in Children With Cleft Palate With or Without Cleft Lip.

PURPOSE: The purpose of this study was to describe the frequency of speech production errors in children with cleft palate with or without cleft lip (CP±L) and explore characteristics related to speech production errors. METHOD: Fifty-six children with nonsyndromic CP±L between the ages of 4;0 and 7;11 (years;months) were included in this study. The children's audio-recorded production of a sentence repetition task was transcribed using narrow transcription and coded for speech error type. RESULTS: Children used, on average, 18 speech errors during the sentence repetition task that sampled 59 phoneme targets. On average, phonological errors were used most frequently, with nine errors per sample, followed by anterior oral speech errors at four errors per sample, and non-oral compensatory errors at three errors per sample. Individual-level characteristics including age and cleft type were related to frequency of phonological errors and anterior oral speech errors, respectively. One treatment-level characteristic, hypernasality, was related to use of non-oral compensatory errors and passive speech errors. CONCLUSIONS: This study identified the most frequent speech production errors as phonological errors, followed by anterior oral speech errors and non-oral compensatory errors. Individual-level and treatment-level characteristics were related to speech production errors. Future research should explore additional characteristics that may influence use of speech production errors. Clinically, this study adds information regarding speech error types that should be monitored throughout cleft care, including phonological errors that were most prevalent among this sample. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22044095.

Reading Development in Children With Nonsyndromic Cleft Palate With or Without Cleft Lip: Meta-analysis and Systematic Review.

OBJECTIVE: We conducted a meta-analysis and systematic review of literature comparing pre-reading and general reading in school-age children with nonsyndromic cleft palate with or without cleft lip (NSCP/L) to their peers without NSCP/L. METHODS: Our literature search identified 1238 possible records. After screening we identified 11 samples for inclusion for systematic review and eight for meta-analysis. We compared 292 children with NSCP/L to 311 peers for 23 pre-reading effect sizes and 17 general reading effect sizes (EFg). We conducted a random-effects metaregression using robust variance estimation. RESULTS: On average school-age children with NSCP/L scored lower on pre-reading (EFg = -0.36) and general reading measures (EFg = -0.38) compared to their peers. We conducted post-hoc analyses on phonological awareness and word decoding effect sizes; children with NSCP/L performed lower on phonological awareness (EFg = -0.22) and word decoding (EFg = -0.39) compared to their peers. There was weak evidence that hearing status and/or speech-language functioning might moderate reading development. There was limited evidence that age or socioeconomic status moderated reading development. However, samples did not consistently report several characteristics that were coded for this project. CONCLUSIONS: Our findings suggest that school-age children with NSCP/L have persistent reading problems. Further research is needed to explore reading development in children with NSCP/L, as well as the relationships among hearing, speech, language, and reading development.

Early speech and language intervention in Brazilian-Portuguese toddlers with cleft lip and/or palate.

Young children with cleft palate with or without cleft lip (CL/P) are at risk for early vocabulary and speech sound production delays. Early intervention studies have shown some promising findings to promote early speech and vocabulary development following palate repair; however, we know little about how these interventions can be used in other international contexts. This study adapted an early speech and language intervention developed in the US, Enhanced Milieu Teaching with Phonological Emphasis (EMT+PE), to the Brazilian context at the Hospital for Rehabilitation of Craniofacial Anomalies at the University of São Paulo-Bauru. The purpose of this study was to compare the speech and language performance of 24 toddlers with CL/P randomized into an EMT+PE intervention group and a business-as-usual (BAU) comparison group over three time points: prior to, immediately following, and three months after intervention. Results immediately following intervention indicate gains in multiple measures of language. Three months following intervention, participants showed gains in both language and speech measures.

Waveform Amplitude and Temporal Symmetric/Asymmetric Characteristics of Phoneme and Syllable Segments in the W-1 Spondaic Words Recorded by Four Speakers.

BACKGROUND: The amplitude and temporal asymmetry of the speech waveform are mostly associated with voiced speech utterances and are obvious in recent graphic depictions in the literature. The asymmetries are attributed to the presence and interactions of the major formants characteristic of voicing with possible contributions from the unidirectional air flow that accompanies speaking. PURPOSE: This study investigated the amplitude symmetry/asymmetry characteristics (polarity) of speech waveforms that to our knowledge have not been quantified. STUDY SAMPLE: Thirty-six spondaic words spoken by two male speakers and two female speakers were selected because they were multisyllabic words providing a reasonable sampling of speech sounds and four recordings were available that were not related to the topic under study. RESEARCH DESIGN: Collectively, the words were segmented into phonemes (vowels [130], diphthongs [77], voiced consonants [258], voiceless consonants [219]), syllables (82), and blends (6). For each segment the following were analyzed separately for the positive and negative datum points: peak amplitude, the percent of the total segment datum points, the root-mean-square (rms) amplitude, and the crest factor. DATA COLLECTION AND ANALYSES: The digitized words (44,100 samples/s; 16-bit) were parsed into 144 files (36 words × 4 speakers), edited, transcribed to numeric values (±1), and stored in a spread sheet in which all analyses were performed with in-house routines. Overall approximately 85% of each waveform was analyzed, which excluded portions of silent intervals, transitions, and diminished waveform endings. RESULTS: The vowel, diphthong, and syllable segments had durations (180-220 ms) that were about twice as long as the consonant durations (∼90 ms) and peak and rms amplitudes that were 6 to 12 dB higher than the consonant peak and rms amplitudes. Vowel, diphthong, and syllable segments had 10% more positive datum points (55%) than negative points (45%), which suggested temporal asymmetries within the segments. With voiced consonants, the distribution of positive and negative datum points dropped to 52 and 48% and essentially was equal with the voiceless consonants (50.3 and 49.6%). The mean rms amplitudes of the negative datum points were higher than the rms amplitudes for the positive points by 2 dB (vowels, diphthongs, and syllables), 1 dB (voiced consonants), and 0.1 dB (voiceless consonants). The 144 waveforms and segmentations are illustrated in the Supplementary Material along with the tabularized positive and negative segment characteristics. CONCLUSIONS: The temporal and amplitude waveform asymmetries were by far most notable in segments that had a voicing component, which included the voiced consonants. These asymmetries were characterized by larger envelopes and more energy in the negative side of the waveform segment than in the positive side. Interestingly, these segments had more positive datum points than negative points, which indicated temporal asymmetry. All aspects of the voiceless consonants were equally divided between the positive and negative domains. There were female/male differences but with these limited samples such differences should not be generalized beyond the speakers in this study. The influence of the temporal and amplitude asymmetries on monaural word-recognition performance is thought to be negligible.

Enhanced Milieu Teaching with Phonological Emphasis: A Pilot Telepractice Parent Training Study for Toddlers with Clefts.

OBJECTIVE: the purpose of this study was to evaluate the effects of training caregivers to use intervention strategies from the Enhanced Milieu Teaching with Phonological Emphasis (EMT + PE) program, delivered via telepractice, and to examine the effects on child speech and language outcomes for children with repaired cleft lip +/- palate (CL/P). DESIGN: A multiple baseline within subject design across parent behaviors was replicated across three participating dyads. A pre-post intervention comparison was provided with a non-cleft twin. PARTICIPANTS: Three mother-child dyads participated in this study. Children ranged in age from 21 to 27 months at the beginning of the study and all had a diagnosis of CL/P. A noncleft twin without CL/P was assessed pre- and post-intervention to provide a normative comparison. RESULTS: Parents demonstrated a positive intervention effect by substantially increasing their use of EMT + PE intervention strategies during telepractice intervention sessions (Tau 0.675 to 1.1333). Following the conclusion of intervention, parents were able to maintain their use of strategies once direct coaching had been discontinued. Children demonstrated increased talking rate, improved speech production and expanded expressive vocabulary measures over the course of intervention. Speech and language development of a child without cleft palate was provided as a comparison. CONCLUSIONS: Parents were trained through telepractice to effectively deliver EMT + PE speech and language facilitation strategies that resulted in increased language and speech outcomes for their children with CL/P.

Effects of a naturalistic intervention on the speech outcomes of young children with cleft palate.

Purpose: The purpose of this study was to investigate the extent to which a naturalistic communication intervention, Enhanced Milieu Teaching with Phonological Emphasis (EMT + PE) improved the speech outcomes of toddlers with cleft palate with or without cleft lip (CP ± L)Method: This study was a stratified randomised controlled trial.Setting: Treatment was delivered in a university clinic by a trained speech-language pathologist.Thirty children aged between 15 and 36 months (M = 25) with nonsyndromic CP ± CL and typical cognitive development were randomly assigned to a treatment (EMT + PE) or business as usual comparison condition.Participants in the EMT + PE treatment group received 48, 30-min sessions, over a 6-month period. Fidelity of treatment was high across participants.The primary outcome measures were percent consonants correct (PCC), consonant inventory, compensatory articulation errors, and nasal emission.Result: Regression analyses controlling for pre-intervention child characteristics were conducted for PCC and consonant inventory. Intervention was not a significant predictor of post-intervention outcome. Words per minute differentiated the children who benefitted from the intervention from those who did not. Reduction in compensatory errors and nasal emission occurred in both groups but to a greater degree in the EMT + PE group.Conclusion: EMT + PE is a promising early speech intervention for young children with CP ± L, especially for children with higher rates of word use.

Early Speech and Language Development in Children With Nonsyndromic Cleft Lip and/or Palate: A Meta-Analysis.

Objective The aim of the study was to conduct a meta-analysis of research examining the early speech and language functioning of young children, birth to age 8;11 (years;months), with nonsyndromic cleft lip and/or palate (NSCL/P) compared to their peers without NSCL/P. Method We conducted a random-effects metaregression using 241 effect sizes from 31 studies comparing 955 young children with NSCL/P to 938 typically developing peers on measures of speech and language functioning. Moderators were sample characteristics (i.e., age, cleft type, publication year, and study location) and measurement characteristics (i.e., speech sample material, language modality and domain, and assessment type). Results Young children with NSCL/P scored significantly lower on measures of speech and language compared to children without NSCL/P. Children with NSCL/P had smaller consonant inventories (standardized mean difference effect size [ESg] = -1.24), less accurate articulation (ESg = -1.13), and more speech errors (ESg = 0.93) than their peers. Additionally, children with NSCL/P had poorer expressive (ESg = -0.57) and receptive (ESg = -0.59) language skills than their peers. Age and assessment type moderated effect sizes for expressive language. As children with NSCL/P aged, their expressive language performance became more similar to their peers. Expressive language effect sizes from parent reports and observational language measures (estimated effect size = -0.74) were significantly lower than those from standardized norm-referenced tests (estimated effect size = -0.45). Conclusions These findings suggest that young children with NSCL/P experience delays relative to their peers across multiple speech and language constructs. Differences between children with NSCL/P and their typically developing peers appear to decrease with age. Supplemental Material https://doi.org/10.23641/asha.11356904.

The Influences of Child Intelligibility and Rate on Caregiver Responses to Toddlers With and Without Cleft Palate.

OBJECTIVE: The purpose of this study was to investigate the influences of child speech intelligibility and rate on caregivers' linguistic responses. DESIGN: This study compared the language use of children with cleft palate with or without cleft lip (CP±L) and their caregivers' responses. Descriptive analyses of children's language and caregivers' responses and a multilevel analysis of caregiver responsivity were conducted to determine whether there were differences in children's productive language and caregivers' responses to different types of child utterances. SETTING: Play-based caregiver-child interactions were video recorded in a clinic setting. PARTICIPANTS: Thirty-eight children (19 toddlers with nonsyndromic repaired CP±L and 19 toddlers with typical language development) between 17 and 37 months old and their primary caregivers participated. MAIN OUTCOME MEASURES: Child and caregiver measures were obtained from transcribed and coded video recordings and included the rate, total number of words, and number of different words spoken by children and their caregivers, intelligibility of child utterances, and form of caregiver responses. RESULTS: Findings from this study suggest caregivers are highly responsive to toddlers' communication attempts, regardless of the intelligibility of those utterances. However, opportunities to respond were fewer for children with CP±L. Significant differences were observed in children's intelligibility and productive language and in caregivers' use of questions in response to unintelligible utterances of children with and without CP±L. CONCLUSIONS: This study provides information about differences in children with CP±L's language use and caregivers' responses to spoken language of toddlers with and without CP±L.

Longitudinal Comparison of the Speech and Language Performance of United States-Born and Internationally Adopted Toddlers with Cleft Lip and Palate: A Pilot Study.

OBJECTIVE: This study compares the early speech and language development of children with cleft palate with or without cleft lip who were adopted internationally with children born in the United States. DESIGN: Prospective longitudinal description of early speech and language development between 18 and 36 months of age. PARTICIPANTS: This study compares four children (age range = 19 to 38 months) with cleft palate with or without cleft lip who were adopted internationally with four children (age range = 19 to 38 months) with cleft palate with or without cleft lip who were born in the United States, matched for age, gender, and cleft type across three time points over 10 to 12 months. MAIN OUTCOME MEASURES: Children's speech-language skills were analyzed using standardized tests, parent surveys, language samples, and single-word phonological assessments to determine differences between the groups. RESULTS: The mean scores for the children in the internationally adopted group were lower than the group born in the United States at all three time points for expressive language and speech sound production measures. Examination of matched pairs demonstrated observable differences for two of the four pairs. No differences were observed in cognitive performance and receptive language measures. CONCLUSIONS: The results suggest a cumulative effect of later palate repair and/or a variety of health and environmental factors associated with their early circumstances that persist to age 3 years. Early intervention to address the trajectory of speech and language is warranted. Given the findings from this small pilot study, a larger study of the long-term speech and language development of children who are internationally adopted and have cleft palate with or without cleft lip is recommended.

The Effects of Enhanced Milieu Teaching With Phonological Emphasis on the Speech and Language Skills of Young Children With Cleft Palate: A Pilot Study.

PURPOSE: The purpose of this pilot study was to investigate the extent to which a naturalistic communication intervention, enhanced milieu teaching with phonological emphasis (EMT+ PE), improved the language and speech outcomes of toddlers with cleft lip and/or palate (CL/P). METHOD: Nineteen children between 15 and 36 months (M = 25 months) with nonsyndromic CL/P and typical cognitive development were randomly assigned to a treatment (EMT+PE) or nontreatment, business-as-usual (BAU), experimental condition. Participants in the treatment group received forty-eight 30-min sessions, biweekly during a 6-month period. Treatment was delivered in a university clinic by trained speech language pathologists; fidelity of treatment was high across participants. RESULTS: Children in the treatment group had significantly better receptive language scores and a larger percentage of consonants correct than children in the BAU group at the end of intervention. Children in the treatment group made greater gains than children in the BAU group on most language measures; however, only receptive language, expressive vocabulary (per parent report), and consonants correct were significant. CONCLUSIONS: The results of this preliminary study indicate that EMT+PE is a promising early intervention for young children with CL/P. Replication with a larger sample and long-term follow-up measures are needed.

Speech therapy where there are no speech therapists: the task force for the american cleft palate-craniofacial association.

This paper describes the outcome of the 2013 American Cleft Palate-Craniofacial Association Task Force entitled "Speech Therapy Where There Are No Speech Therapists." The membership and goals of the initial task force are presented. Survey methods, communication of the members, and meeting discussion of the task force at the 12th International Congress for Craniofacial Anomalies in Orlando, Florida, in May 2013 are described. Conclusions of the task force and recommendations for the future comprised four areas: organization and communication, protocols, service delivery models, and development of training programs/modules in speech-language pathology for craniofacial conditions.

Pre-linguistic children with cleft palate: growth of gesture, vocalization, and word use.

Children with cleft lip and/or palate show early delays in speech and vocabulary development that may have an impact on later communication and social development. While delays in the complexity of babbling may put children at risk for later delays in speech and language development, there is considerable variability in development. This study focused on the rate of children's communication acts, canonical vocalizations, and word use as they made the transition from the pre-linguistic to linguistic development. The study included 15 children with non-syndromic cleft lip and/or palate who were seen at three time points between 17-34 months age. Communication rates were calculated from parent-child language samples collected during play activities. Assignment to linguistic stages was based on the children's expressive vocabulary, as reported on the MacArthur Communicative Development Inventory: Words and Sentences. From the pre-linguistic to linguistic level, the children's average rate per minute of: communicative acts overall increased significantly from 1.49 to 3.07 per minute; canonical vocalizations from 0.21 to 0.90 per minute; and word use from 0.16 to 3.61 per minute. Rates of communicative acts were associated with later word use. It appears that children with clefts rely on non-verbal communicative acts when verbal development is delayed.

Longitudinal comparison of early speech and language milestones in children with cleft palate: a comparison of US and Slovak children.

The purpose of this study was to compare early speech and language development of children with and without cleft lip and/or palate (CLP) in the US and Slovakia from 6 to 24 months of age. Thirty-two children from the US (eight with CLP and eight noncleft) and Slovakia (eight with CLP and eight noncleft) participated in this study. The children were videotaped at four time points for 30 minutes during mother-child interaction with play sets controlled for early-developing sounds in each language. Mean Babbling Level, consonant inventories, number of different words and mean length of utterance were calculated for 6- to 24-month samples. Results indicated that the US and Slovak groups showed similar performance across the ages. Cleft and noncleft groups showed significant differences in acquisition of all of the speech and language measures. High-pressure consonants, particularly alveolar place of articulation, were problematic for children with CLP.

Assessment of Single-Word Production for Children under Three Years of Age: Comparison of Children with and without Cleft Palate.

Background. This study reports comparative phonological assessment results for children with cleft lip and/or palate (CLP) to typically developing peers using an evaluation tool for early phonological skills. Methods. Children without clefts (NC = noncleft) and 24 children with CLP, ages of 18-36 months, were evaluated using the Profile of Early Expressive Phonological Skills (PEEPSs) [1]. Children interacted with toy manipulatives to elicit a representative sample of target English consonants and syllable structures that are typically acquired by children between 18 and 27 months of age. Results. Results revealed significant differences between the two groups with regard to measures of consonant inventory, place of articulation, manner of production, accuracy, and error patterns. Syllable structure did not indicate differences, with the exception of initial consonant clusters. Conclusions. findings provide support for PEEPS as a viable option for single-word assessment of children with CLP prior to 3 years of age.

Early and later vocalization skills in children with and without cleft palate.

OBJECTIVE: The purpose of this study was to describe the early vocalization skills in children with cleft lip and palate (CLP) at 6 and 12 months of age and compare these early vocalization measures to later speech and vocabulary development at 30 months of age. METHODS: The participants in the study included 13 children without cleft lip or palate (NCLP) who were typically developing and 13 children with CLP matched for age, gender and socioeconomic status. Standardized measures of cognition, language, hearing, and prelinguistic vocalization measures were administered at 6 and 12 months and speech production, and vocabulary measures were collected at 30 months of age. RESULTS: Group differences were observed in both receptive and expressive language development at 12 and 30 months of age. Group differences were observed in the frequency of babbling and Mean Babbling Level at 12 months and speech sound accuracy and vocabulary production at 30 months of age. Significant correlation coefficients were observed between babbling frequency at 6 months and consonant inventory size, vocabulary at 30 months for the children with clefts and PCC-R for noncleft children. CONCLUSIONS: This study documented that young children with clefts have persistent vocalization and vocabulary deficits well beyond palate closure. Measures of babbling frequency, Mean Babbling Level and consonant inventories provide clinically effective means of identifying these early deficits. Additionally, these measures may provide a tool for monitoring the effects of early intervention programs that promote facilitation of sound and vocabulary development.

Early intervention for speech impairment in children with cleft palate.

OBJECTIVE: This study explored the effectiveness of a parent-implemented, focused stimulation program on the speech characteristics of children younger than 3 years with cleft lip and palate. The research questions included the following: (1) Can parents be trained to deliver an early intervention (EI) program for children with cleft palate? (2) Does a parent-implemented EI program result in positive changes in speech characteristics? PARTICIPANTS: Ten mother-child pairs in which the child had cleft lip and palate (CLP) and 10 mother-child pairs in which the child did not have a cleft (NCLP). The children ranged in age from 14 to 36 months of age and were matched between the CLP and the NCLP groups for vocabulary size, age, and socioeconomic status. MAIN OUTCOME MEASURES: Group differences (CLP and the NCLP) for preintervention and postintervention language and speech measures were compared. RESULTS: The results of this study showed that the mothers could be trained to deliver the intervention reliably. Furthermore, the results indicated that the intervention resulted in increased sound inventories, increased speech accuracy, and reduced use of glottal stops for the children with clefts. CONCLUSIONS: While the intervention resulted in speech gains for the children with clefts, speech measures did not exceed those made by the children without clefts. The results of the study have implications for service delivery models where the services of speech-language pathologists are limited.