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ORATION
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 120-124

Indocleftcon 2022 Braithwaite Oration: Early Intervention in Cleft Lip and Palate - Perspectives from a Speech Language Pathologist


Department of Audiology and Speech Language Pathology, SRM Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Chennai, Tamil Nadu, India

Date of Submission07-Jul-2022
Date of Acceptance12-Jul-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Dr. Savitha Vadakkanthara Hariharan
Department of Audiology and Speech Language Pathology, SRM Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_16_22

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How to cite this article:
Hariharan SV. Indocleftcon 2022 Braithwaite Oration: Early Intervention in Cleft Lip and Palate - Perspectives from a Speech Language Pathologist. J Cleft Lip Palate Craniofac Anomal 2022;9:120-4

How to cite this URL:
Hariharan SV. Indocleftcon 2022 Braithwaite Oration: Early Intervention in Cleft Lip and Palate - Perspectives from a Speech Language Pathologist. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Oct 2];9:120-4. Available from: https://www.jclpca.org/text.asp?2022/9/2/120/354290



I am indeed honored and humbled to deliver the Fenton Braithwaite oration in this prestigious organization the Indian Society of Cleft Lip Palate and Craniofacial Anomalies. Here is a brief note about Braithwaite, the renowned plastic surgeon in whose name this oration is bestowed upon. Fenton Braithwaite (1908–1985) was a senior consultant plastic surgeon in Newcastle and advisor in plastic surgery to the Newcastle Regional Hospital Board [Figure 1]. Born in a farming family, he gained an honors degree in mathematics and a degree in biochemistry with subsidiary anatomy and physiology before pursuing his medical education. He trained in several disciplines, including general surgery, neurosurgery, ear, nose, and throat surgery, and thoracic surgery before embarking on his career in plastic surgery. With this background, he developed a precise analytical approach to problems, and this, combined with a great depth of humanity, resulted in his being a surgeon of the very highest quality.
Figure 1: Braithwaite, Fenton. Source: https://livesonline.rcseng.ac.uk/

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I dedicate this oration to my mentors, who are two pillars and have contributed tremendously to the cause of cleft lip and palate in India [Figure 2]. I have been fortunate to learn from these two diverse personalities and imbibe their qualities, which has helped me grow as a professional. Dr. Jyotsna Murthy always instilled in me the quality of doing everything at the moment, then and there. She made me reflect upon this saying Itayi Grande “It's never too early or too late to be someone of worth or to do something about your life. As long as you're alive, it's time.” If Dr. Jyotsna emphasized on me doing everything now, Prof. Roopa Nagarajan always encouraged me to be my own critique and introspect each bit of my work and keep moving forward. She always reminded me of this saying of Winston S. Churchill, “Success is not final, failure is not fatal: It is the courage to continue that counts.” These two qualities of being in the present and reflecting upon my past activities have helped me move forward in my career.
Figure 2: My Menors, Dr. Jyotsna Murthy and Prof. Roopa Nagarajan

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Reading the documents relating to the inception of Braithwaite oration in ISCLPCA makes me realize that this oration in being bestowed on in recognition of work toward the cause of cleft lip and palate, more specifically in the research domain. Therefore, I have chosen to talk on the topic “Early Intervention in Cleft Lip and Palate: Perspectives from a Speech Language Pathologist,” primarily reflecting upon two of my following recent and ongoing research in the area of early speech and language in children with cleft:

  1. Savitha V.H. (2018). Early speech and language development in children with cleft lip and palate: A longitudinal study. Ph. D. Thesis submitted to Sri Ramachandra University, Chennai
  2. Venkatesh L., Meghana S., Savitha V.H., Subramaniyan B., and Nagarajan R. (2021). The development and evaluation of training module for caregivers on early speech-language stimulation for children with repaired cleft lip and palate. Work in progress.


Before embarking on the findings of my research, please permit me to dwell upon what inspired me to choose this topic. The important point for us to understand is “What does early intervention mean in individuals with cleft lip and palate?” While the most common and popular answer would be early surgical intervention, one has to acknowledge that for wholistic results, it would only be meaningful if this early intervention also includes other aspects such as early feeding management, early speech and language intervention, and oral hygiene. The status and definition of the term early in the context of intervention in cleft lip and palate has gone through a lot of modification throughout this century. At the beginning of this century, Raman et al.[1] analyzed the subjects in a specialty cleft clinic and revealed that the mean age of first medical consultation for children with cleft reported to be around 4 years. Nearly 30% of population with cleft had their first consultation only above 3 years of age. In this context, any intervention below 3 years of age was considered to be early intervention. India, as a country has evolved from those conditions and the median age of surgical intervention has been reducing gradually.[2] Today most the cleft lips are operated between the ages of 3 and 6 months, and palates are operated on between 12 and 18 months.[3] With reductions in the age of surgical intervention, the system has to evolve to provide early intervention of other aspects including speech and language. Most of the organizations dealing with cleft care are setting quality benchmarks in which early speech and language focus begins as early as 6 months (https://www.smiletrain.org/sites/default/files/2021-05/comprehensive-cleft-care-recommended-timeline-english. pdf). This evoked my interest in the area of early speech and language and I embarked on my Ph.D. journey to understand the early speech and language development in children with cleft lip and palate by employing a longitudinal study. I was fortunate to have a renowned linguist, Dr. R. Vaidyanathan willing to guide me for this work. For want of time, and keen to engage the multidisciplinary audience in this group, I am going to be highlighting just the below three arms of my thesis:

  1. To compare the phonetic repertoire of early vocalizations during babbling (from 8 to 9 months of age) in children with Cleft lip and palate (CLP) with that of typically developing children learning Tamil as the primary language
  2. To compare the phonetic repertoire during verbalization phase (from the onset of meaningful words till 30 months of age) in children with CLP with that of typically developing children learning Tamil as the primary language
  3. To evaluate the early language and lexical development in children with CLP and typically developing children at 30 months of age and infer the effects of cleft in such development.


The vocalization and verbalization phases were differentiated based on the presence of meaningful utterances. The vocalization phase is one in which children do not have any semantic referents or meaningful utterances in their vocalization. When the child demonstrated the usage of at least one meaningful word, it was considered as verbalization phase.

Being a longitudinal study, there were 14 subjects with cleft and 7 typically developing children who completed the study that involved follow-up of children from the age of 8 months to 30 months. Monthly video recordings of the parent–child interaction were carried out in each child's home environment (a natural environment is best suited for obtaining a representative sample of the child). At the end of the study, there was a total of 274 recordings from children with cleft and 157 recordings from the typically developing children. The herculean task here was to analyze each of these 30–45-min sample by listening to them individually and transcribing every utterance of the child. At the end of the transcription, I had a corpus of 262,891 speech sounds from children with cleft, and 217,513 speech sounds from typically developing children. All children with cleft had clefts of lip and palate, were nonsyndromic, and the palates were repaired by the ages of 10–12 months.

The transcriptions of each child were then analyzed using the program Systematic Analysis of Language Transcripts Research Version 9,[4] to probe into the speech sound acquisition patterns. The salient findings are described below:


  Finding 1 – Age at Onset of Verbalization Top


Children with cleft demonstrated usage of meaningful words at a significantly later age (Median age: 17 months) than typically developing children (Median Age: 13 months).


  Finding 2 – Changes in Vowel Patterns Top


There was a significant increase in the occurrence of nasalized vowels in children with cleft (Median = 4.23, interquartile range [IQR] =2.19–7.27) compared to their typical peers (Median = 0.46, IQR = 0.05–1.11), during vocalization, U = 2.0, p < 0.001, r = 0.76, and verbalization, U = 0, p < 0.001, r = 0.80. Children with cleft had significantly lower percentage of back vowels (0.08% during vocalisation and 5.56% during verbalisation) compared to the control group (1.45% and 11.31% during vocalisation and verbalisation respectively). Among the vowels, the back vowels like (u) are relatively more difficult to produce compared to the front vowel like (i) and mid vowel like (a).


  Finding 3 – Changes in Consonants Size Top


The size of consonant inventory indicates the number of consonants a child produces at least twice in a sample. There was no significant difference in the size of consonant inventory between children in both the groups. This was predominantly because children with cleft using glottal substitutions and a lot of gliding to compensate for their inability to produce other sounds. To understand this, the size of true consonant inventory was probed into. The true consonant inventory disregards the productions of glottal sounds and glides and only considers those consonants that are actually produced by constricting and modifying air pressure within the oral cavity. When this was considered, there was a significantly decreased number of true consonants in children with CLP compared to control group, in vocalization (U = 19.5, p = 0.028, r = 0.48) and verbalization phase (U = 22, p = 0.04, r = 0.44).


  Finding 4 – Changes in Consonants – Place of Articulation Top


Consonants can be described based on the place of articulation that specifies where exactly in the oral cavity the constriction is made for producing it. The findings demonstrated the difficulty predominantly in producing the sounds in the anterior part of the oral cavity. Children with CLP had decreased percentage of dental/alveolar sounds and increase in the percentage of palatals and glottal sounds in both phases compared to the typical group. Further, complex sounds such as retroflex emerged only in verbalization phase in both groups of children and were decreased in children with cleft compared to the control group. Comparing across vocalization and verbalization revealed that bilabials, labiodentals, and glottal decreased in both groups during verbalization compared to their vocalization phases. Dentals/alveolars and retroflex sounds increased during verbalization compared to vocalization in both groups. While there was a developmental trend noticed across phases in both the groups, the development in children with CLP was not in par with that of the typically developing children.


  Finding 5 – Changes in Consonants – Manner of Articulation Top


The manner of articulation describes consonants based on how the air pressure is modulated in the oral cavity. Comparatively, certain sounds (stops, fricatives, and affricates) require more air pressure modulation and are complex to produce than other sounds (glides). Significantly lower occurrence of fricatives was noticed in children with cleft compared to typically developing children during vocalization. Affricates, trills/flaps, and laterals were not observed at all during vocalization phase. The verbalization phase showed an emergence of a range of sounds in both groups of children, except trills/flaps in children with cleft. The percentage of stops, fricatives, trills/flaps, and laterals was still decreased in children with cleft compared to typically developing children during verbalization phase. Nasal sounds were the highest among children with cleft while stop consonants were the highest among typically developing children during vocalization. Stop consonants appeared maximally followed by nasals in both groups of children during verbalization.

The data provided sufficient evidence to state that the development of speech sounds happened in the positive direction in both children with CLP and typically developing children as they moved from the vocalization phase to verbalization phase. The summary of changes in speech sound patterns during verbalization is described in [Table 1].
Table 1: Changes in speech sounds during verbalisation phase

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  Finding 6 – Language Measures at 30 Months of Age Top


At the age of 30 months, children with cleft demonstrated significant delays in language development, with greater delay in expressive language (6 months) than receptive language (2 months), as measured through a developmental scale. However, the size of vocabulary, as reported by parents on a communication development inventory did not differ significantly between the two groups (401 in the clinical group and 433 in the control group).

The findings from this study conveyed the following:

  1. Need to redefine the assessment protocol: Include assessment of children at 12 and 16–18 months of age to check for vocalizations and commencement of verbalization
  2. Delayed development pattern is observed in children with CLP. This establishes the need for early intervention of speech and language skills in children with cleft
  3. Provides evidence-based guidelines for the development of early intervention module to facilitate speech sound production and language development. The study provides information on what sounds are to be emphasized during the early stimulation.


What feels like the end is actually a new beginning. The end of my thesis paved way for work in the direction of the development of early intervention module. A collaborative project has been undertaken with Sri Ramachandra Institute of Higher Education and Research, headed by Lakshmi Venkatesh and team in this direction. This project is a three-pronged study and is a work in progress. The three arms of this study are as follows:

  1. To identify the current trends of practice in early speech and language intervention among speech and language professionals working with children with CLP
  2. To develop and validate a caregiver training module for providing guidance on early speech and language stimulation for nonsyndromic children with repaired CLP
  3. To assess the effectiveness of the training module on caregivers' communicative behaviors toward their child with repaired CLP.


A survey was undertaken to understand the practice trends relating to early speech and language intervention in cleft among 27 speech-language pathologists from specialized cleft clinics across the country revealed variations in the assessment and intervention practice. While majority of the participants reported to provide some form of counseling relating to speech and language development and intervention to parents of children with CLP, active intervention was most often deferred to around 2 years of age. Several factors have contributed to the variation in the point of contact and the point of actual intervention in children with cleft. One of the major factors that can be attributed to this is the complex nature of intervention itself in speech and language, which is not a one-time/single visit affair and requires multiple visits. Several reasons such as time taken to travel and distance to reach centers, financial restrictions, unavailability of caregiver of the child due to work, lack of family support, wage loss when taking time from work to attend the intervention, contribute to difficulty in accessing intervention services.

The solution for this could be to move from a corrective model to preventive model. The focus should also move from a purely clinician-led model to an empowered parent-led model monitored by the clinician. Research by teams in the Western world led by experts such as Scherer, Chapman, and others have provided evidence that early intervention through involving parents in children with cleft has promising results.[5],[6],[7],[8] Scattered studies are also available in the Indian literature, led by Dr. Pushpavathi and team from the All India Institute of Speech and Hearing regarding using parent training with techniques such as facilitated communication.[9],[10],[11] Analyzing the practice patterns and based on evidence in literature, this project focused on developing a module for training parents on early stimulation. Recognizing the need for materials in local language, this study has developed the module in the regional language Tamil. A pilot study has been carried out in which it has established that this module can be delivered to parents across six sessions. The strength of this module is that parents are empowered in an interactive manner on understanding speech and language development and strategies that can be used to develop language and speech sound production to children. The third prong of the study to assess the effectiveness of this module is in the pipeline.

In summary, the key takeaway points from my research are as follows:

  1. There is evidence to state that one should focus early on speech and language development in children with cleft
  2. There is a need for systematicity while counseling parents in the early stages.
  3. The focus should be on task-shifting involving empowering parents to become effective facilitators of speech and language development for children with CLP.


“With the falling of just drops of water, the pot gradually gets filled up. So is the case with acquisition of all knowledge and all pursuits too”.

-Hitopadesha



 
  References Top

1.
Raman S, Jacob M, Jacob MS, Nagarajan R. Providing intervention services for communication deficits associated with cleft lip and/or palate - A retrospective analysis. Asia Pac Disabil Rehabil J 2004;15:122-9.  Back to cited text no. 1
    
2.
Kharbanda OP, Agrawal K, Khazanchi R, Sharma SC, Sagar S, Singhal M, et al. Clinical profile and treatment status of subjects with cleft lip and palate anomaly in India: Preliminary report of a three-center study. J Cleft Lip Palate Craniofac Anom 2014;1:26.  Back to cited text no. 2
    
3.
Batra P, Sybil D, Izhar A, Batra P, Thiruvenkatachari B. Standard of Care for Patients With Cleft Lip and Palate in India-A Questionnaire-Based Study. Cleft Palate Craniofac J 2022:10556656221074212.  Back to cited text no. 3
    
4.
Miller J, Iglesias A. Systematic Analysis of Language Transcripts (SALT), English and Spanish (Version 9). Madison, WI: Language Analysis Lab, University of Wisconsin-Madison; 2006.  Back to cited text no. 4
    
5.
Scherer NJ, D'Antonio LL, McGahey H. Early intervention for speech impairment in children with cleft palate. Cleft Palate Craniofac J 2008;45:18-31.  Back to cited text no. 5
    
6.
Scherer NJ, Kaiser AP. Early intervention for children with cleft palate. Infants Young Child 2007;20:355-66.  Back to cited text no. 6
    
7.
Hardin-Jones M, Chapman K, Scherer NJ. Early intervention in children with cleft palate. ASHA Leader 2006;11:8-32.  Back to cited text no. 7
    
8.
Scherer NJ. The speech and language status of toddlers with cleft lip and/or palate following early vocabulary intervention. Am J Speech Lang Pathol 1999;8:81-93.  Back to cited text no. 8
    
9.
Pushpavathi M, Kavya V, Akshatha V. Efficacy of focused stimulation in early language intervention program for toddlers with repaired cleft palate. Glob J Otolaryngol 2017;9:555752.  Back to cited text no. 9
    
10.
Pushpavathi M, Vijayan K, Akshatha V. Efficacy of early intervention program for children with cleft lip and palate: A case study. J Child Lang Acquis Dev 2017;5:53.  Back to cited text no. 10
    
11.
Pushpavathi M, Vijayan K, Vishwanath A. Effectiveness of early intervention on awareness and communication behaviors of mothers of toddlers with repaired cleft lip and palate. Journal of Cleft Lip Palate and Craniofacial Anomalies. 2017;4:88.  Back to cited text no. 11
    


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