Chapter 16: Speech and Language

What is the difference between speech and language?

Speech consists of the individual sounds that make up words e.g. the word "dog" is made up of the sounds 'd' , 'o' and 'g'. Children learn the speech sounds in a number of stages i.e.

• 2years - m, n, h, b
• 2.5years - p, ng, w, d, g
• 3years - y, k, f, sh
• 3.5years - t, ch, j
• 4years - l, s
• 5years - r, z
• 7years + - v, th

The time taken to progress through these stages varies from child to child.

Language consists of the words we use to communicate. As children, we gradually learn to combine words to form phrases, then sentences, and then more complex forms such as stories. Speech Pathologists often call spoken language "expressive language" as we use it to express ourselves. For example, when a 2 year old requests "more drink", they are expressing themselves. Language also involves understanding what others say. Speech pathologists often call understanding language "receptive language".

The development of normal speech and language skills depends on a number of factors:

• Normal structures of the mouth including tongue, lips, a hard palate and a soft palate that moves well enough to close the nose off from the mouth during talking, eating and drinking.
• Adequate hearing
• Adequate intellectual ability
• Lots of talking, reading bookes and playing games with parents, family and caregivers.

Normal Speech and Language

Speech starts with the birth cry and develops steadily to the age of 6-9 months. At this time babies begin to babble. This is when babies repeat short syllables, for example 'mumum' or 'bababa'.

Usually children speak their first real words between 12 and 14 months with a rapid increase in the number of words used during the next year. By 2 years of age, children should be using about fifty single words and at the same time beginning to combine them into two-word phrases such as 'daddy home', 'more drink', 'mummy gone'.

By 3 years of age, most children can ask simple questions and conduct a simple conversation.

The use of complex sentences such as "you can't have that because I said", occurs by 4 years of age, although mistakes may still be present.

Most children have developed sufficient speech and language by 3 to 32 years of age, so that what they say can be understood by unfamiliar people. While there are exceptions, girls seem to develop speech and language a little earlier than boys.

There are a number of factors which may cause a delay in the development of language (understanding and expression abilities), articulation (production of each consonant and vowel sound) and voice. One of these reasons could be a degree of hearing impairment, which is more common in children with cleft palates (see Section 14 and Section 15 on Ear, Nose and Throat problems and Audiology). It is, therefore, important to have your child's hearing checked regularly, especially after middle ear infections.

16.2 Soft palate during speech.

Speech Difficulties

It is difficult to predict what a young child's speech and language will be like. This is true regardless of whether a child has a cleft palate or not. Approximately 5-10 per cent of children in the normal population present with speech difficulties quite apart from those related specifically to the cleft. But it is important to remember that approximately 75-80% of children who have undergone repair of a cleft palate have a normal quality of speech tone, that is, speech that is not nasal.

What causes 'nasal' speech?

The movement of the soft palate is important in speech because it moves upwards and backwards when we speak and separates the nose from the mouth (see figure 16.1). If your child has a cleft of the palate there is an opening between the oral and the nasal passages. This means that air and the speech carried with it enters the nasal cavity and results in the speech sounding 'nasal'.

This speech going through the nose is what the Speech Pathologist will call 'hypernasal speech' as there is too much air going through the nose during talking. If this is severe, children may even get food coming through the nose during eating and drinking.

If there is not enough air going through the nose, the Speech Pathologist will say that the child sounds 'hyponasal' as there is too little air going through the nose during talking. This is the sound that we hear when someone has a cold or blocked nose.

Children with hyponasal speech often snore due to a degree of nasal obstruction. If the snoring or general situation becomes severe, the child would need to see their local doctor and perhaps the ENT Surgeon.

If a baby with a cleft palate starts to talk before their palate operation, their 'baby words' will, therefore, sound a little more nasal, for instance, 'ta-ta' may sound more like 'na-na', 'bub bub' like 'mum mum' and 'daddy' like 'nanny'. After your baby's palate has been repaired, he or she will have an excellent chance to gradually learn to make the correct speech sounds. He or she cannot learn these sounds, or learn to join them together in words, overnight, any more than a child without a cleft palate can.

Speech Therapy

The speech pathologist will begin speaking with you on a regular basis during your visits to the Cleft Palate Clinic. These sessions are to discuss the development of general speech and language, as well as to suggest activities to encourage good speech habits, even before your child actually begins to speak.

Children born with an isolated cleft lip (i.e. palate intact) are generally not at risk of speech problems related to the cleft.

It is, however, common for children with a cleft palate to require speech therapy. At least a third of these children need to see a Speech Pathologist at some stage in their development.

Some examples of common speech problems in children with cleft palate are:

• Using back sounds like "k" and "g" for the more front sounds of "t" and "d" e.g: daddy said as "gaggy"
• Saying their long sounds, such as the "s", "z" and "sh" sounds through the nose or with incorrect tongue position.

With early intervention these problems can be overcome and the vast majority of cleft palate children eventually have normal speech. The therapy for sound errors follows the same principles for all children with speech problems. Initially the child is taught to make the sound accurately by itself, and then by progressive steps to use it in words and sentences. As is the case with all habits, change is not always rapid and any change will require constant practice, motivation and family support.

Should 'nasal' speech problems continue, the Speech Pathologist and Surgeons may suggest that further investigation of soft palate function is needed. This is either done via:

• Nasendoscopy (direct visual examination)

In this procedure the nasendoscope (a thin camera shaped like a flexible rod, 2-4 millimetres in diameter) is passed through the nostril into the nasal cavity. The soft palate and throat movements are viewed directly during speech and may be recorded onto videotape. This procedure generally does not hurt because the nose has been anaesthetized with local anaesthetic beforehand. However, it may cause some slight discomfort.

• Videofluoroscopy (motion picture x-rays)

Videofluoroscopy is a way of looking at the function of the soft palate during speech using x-rays. The procedure is not done until the child is at least 3 years of age and is talking. It is a painless procedure, but may cause some discomfort due to the fact that some barium liquid needs to be squirted into the nose. This is to help make the soft palate more visible under x-ray. Some preschool aged children may find the large x-ray equipment frightening and in these cases the procedure may be delayed until a later date.

These procedures allow the Speech Pathologist and Surgeons to see whether the soft palate is too short or doesn't move well during speech.

16.3 Child having videofluoroscopy of the soft palate.

Speech Therapy and Surgery

The information obtained in the above procedures assists the Surgeons with decisions about surgical options to help improve speech. Surgery generally takes the form of pharyngeal flap surgery and/or palate lengthening surgery, (see Section 9).

Whilst the surgery is usually successful, a further period of speech therapy is often needed to teach correct speech habits. If you are at all worried about the development of your child's speech then contact your Speech Pathologist no matter how young your child is or how trivial the problem may seem.

Further Information

To obtain further information on "Cleft Lip and Palate: A Parent's Guide", please contact Belinda Liston:

Belina Liston
Cleft Palate Clinic Coordinator
The Cleft Palate Clinic
The Children's Hospital at Westmead
Locked Bag 4001
WESTMEAD NSW 2145
AUSTRALIA
T: + 61 2 9845 2079
F: + 61 2 9845 2078
E: BelindaS4@chw.edu.au