1. Parameters: Definitions & Guidelines Debbie Sell PhD, FRCSLT Head, Speech & Language Therapy Department Great Ormond Street NHS Trust Honorary Senior Lecturer University of London Judith Trost-Cardamone, PhD, FASHA Professor, California State University Northridge Department of Communication Disorders & Sciences

2. Parameters: Primary & Secondary Primary Parameters: speech parameters most directly related to the cleftpalate/velopharyngeal condition Secondary Parameters: speech parameters less directly related or not related to the cleft palate/velopharyngeal condition but which are frequently observed in speakers with cleft palate

3. Guidelines Aim of guidelines is to provide a set of definitions to accompany the parameters, to ensure their appropriate application and interpretation Section 1 (discuss in final session of the day) Section 2 System is for reporting speech outcomes based on perceptual speech analysis; they are not intended to explain the outcome

4. Primary Parameters: Speech parameters most directly related to the cleft palate/velopharyngeal condition

5. Hypernasality (HN) 0-3 rating scale  0 = WNL; does not exceed HN heard in regional speech  1 = Mild  2 = Moderate  3 = Severe

6. Hypernasality Increased or excessive nasal resonance heard on vowels and vocalic consonants of a language. Rated using a 4 point scale that reflects increasing severity from 0-3

7. Hyponasality [HypoN] Binary judgment  0 = WNL/None  1 = Present

8. Hyponasality Decreased or insufficient nasal resonance heard on nasal consonants and vocalic segments of a language. Rating based on a binary judgement of within normal limits or present. Cul-de-sac resonance is reflected in hyponasality Mixed resonance is accounted for by the combined ratings of hypernasality and hyponasality

9. Audible Nasal Air Emission and/or Turbulence Binary judgment  0 = WNL/None  1 = Present [indicate pattern] intermittent and variable nasal emission and/or turbulence phoneme specific nasal emission and/or turbulence frequent/pervasive nasal emission and/or turbulence Weighted scoring for patterns

10. Audible Nasal Air Emission and/or Turbulence def. Nasal air emission /turbulence that accompanies/is co-produced with and distorts any or all (oral) high pressure consonants in a language Rating based on a binary judgement of within normal limits or present Second rating is given to reflect severity/impact on speech acceptability/understandability based on the frequency and pattern of the nasal air emission/turbulence

11. Intermittent and variable: nasal air emission and/or turbulence heard occasionally with various oral pressure consonants with no obvious pattern of occurrence Phoneme specific: nasal emission and/or turbulence heard consistently but only with selected oral pressure consonants e.g. sibilant fricatives and/or affricates ** Frequent/pervasive: nasal emission and/or turbulence heard with most/all high pressure consonants in the inventory ** Phoneme specific: is this correctly placed here?

12. Oral Pressures Binary judgment  0 = WNL: perceptually adequate for pressure consonants  1 = Weak; perceptually inadequate for pressure consonants

13. Substitution Errors Binary judgment  0 = WNL/None  1 = Present [indicate type and frequency] Six categories Weighted scoring for frequency

14. Substitution Errors Def: maladaptive “compensatory misarticulations” of high pressure consonants as a result of the cleft palate/velopharyngeal inadequacy condition. Second rating based on type and frequency of occurrence for glottal stop, pharyngeal fricative/stop/affricate, palatal stop, palatal fricative, nasal fricative, atypical backing of targets to velar

15. Substitution Errors: glottal and pharyngeal Glottal stop Pharyngeal: fricative, stop, affricate or any combination

16. Substitution Errors: mid-dorsum palatal Mid-dorsum palatal stop Mid-dorsum palatal fricative

17. Substitution Errors: backing but targets remain oral Backing of dental, alveolar and/or palatal targets to velar

18. Substitution Errors continued Atypical backing of dental and alveolar targets. It includes a consonant target that is backed from its more anterior target place but is still made within the oral cavity.

19. Substitution Errors: nasal fricative Nasal fricative with or without turbulence ___ phoneme specific pattern** **Is this necessary, informative?

20. Substitution Errors continued Nasal fricative: def: used as a substitution/replacement for oral stops, fricatives and affricates. It is articulatory substitution that frequently takes the form of an unvoiced (bilabial, alveolar or velar) nasal

21. Secondary Parameters : Speech parameters less directly related or not related to the cleft palate/velopharyngeal condition but which are frequently observed in speakers with cleft palate. They are all speech characteristics/deviations that can be seen in speakers without cleft palate.

22. Secondary Parameters Binary judgment  0 = WNL/None  1 = Present Includes errors related to: Dentition, Occlusion, palatal vault Developmental delay, other articulation/phonological errors Voice/laryngeal disorders

23. Secondary Speech Parameters cont. Errors related to Dentition, Occlusion, Palatal Vault Configuration such as lateralized sibilants, palatalized alveolars, dentalized/linguadental alveolar fricatives and stops Inverted labiodentals, etc.

24. Secondary Speech Parameters cont. Developmental delay, other articulation/phonologic errors and voice/laryngeal disorders are self - explanatory

25. X = Missing Data Could not test (e.g. child was not cooperative, inadequate speech sample) Did not test (e.g. time constraints)

26. Discussion Time

27. Parameters: Scales & Scoring Judith Trost-Cardamone, PhD, FASHA Professor, California State University Northridge Department of Communication Disorders & Sciences Triona Sweeney, PhD Specialist Speech & Language Therapist The Children’s Hospital Temple Street, Dublin Adjunct Professor, University of Limerick

28. Hypernasality [HN] 1Mild Hypernasality Exceeds regional speech HN Assimilation nasality primarily; heard on high vowels primarily; or both; “inconsistent Socially acceptable in most circles Patient [age 10 >] or parent [age 5] mostly satisfied Would probably not recommend physical management at this time

29. Hypernasality [HN] 2 Moderate Hypernasality Pervasive and draws attention to itself and away from the message Most vowels retain identity Socially unacceptable Would probably recommend physical management after instrumental assessment

30. Hypernasality [HN] 3Severe Hypernasality Pervasive and interferes with speech understandability Many vowels lose identity Socially very unacceptable Would definitely recommend physical management after instrumental assessment

31. Audible Nasal Air Emission and/or Turbulence Binary judgment –0 = WNL/None –1 = Impaired [indicate pattern] intermittent and variable nasal emission and/or turbulence [1] phoneme specific nasal emission and/or turbulence [2] frequent/pervasive nasal emission and/or turbulence [3] Weighted scoring for patterns

32. Weighted scores intermittent and variable is nasal emission with or without turbulence that is heard occasionally with various oral pressure consonants with no obvious pattern of occurrence [1] phoneme specific is nasal emission and/or turbulence that is heard consistently but only with selected oral pressure consonants; e.g., sibilant fricatives and/or affricates [2] frequent/pervasive is nasal emission and/or turbulence that is heard with most/all high pressure consonants in the inventory [3]

33. Issues Nasal emission and/or nasal turbulence as 1 parameter!! - perceptually different nasal airflow errors BUT - similar impact in terms of speech outcome Raters ability to distinguish between nasal emission and/or nasal turbulence AND nasal fricatives

34. Substitution Errors Binary judgment  0 = WNL/None  1 = Present [indicate type and frequency] Six categories Weighted scoring for frequency

35. Substitution Errors: glottal and pharyngeal Glottal stop [1] –Frequent [3] –Infrequent [1] Pharyngeal: fricative, stop, affricate or any combination [1] –Frequent [3] –Infrequent [1]

36. Substitution Errors: mid-dorsum palatal Mid-dorsum palatal stop [1] –Frequent [2] –Infrequent [1] Mid-dorsum palatal fricative [1] –Frequent [2] –Infrequent [1]

37. Substitution Errors: backing but targets remain oral Backing of dental, alveolar and/or palatal targets to velar [1] –Frequent [2] –Infrequent [1]

38. Substitution Errors: nasal fricative Nasal fricative with or without turbulence [1] –Frequent [3] –Infrequent [1] ___ phoneme specific pattern [2]** **Is this necessary, informative?

39. Nasal Emission/Nasal Turbulence accompanies/is co-produced with and distorts any or all [oral] high pressure consonants in a language need to distinguish from Nasal Fricative which is used as a substitution/replacement for oral fricatives and affricates –Nasal fricative: frication generated in nose –Velopharyngeal fricative/posterior nasal fricative

40. Substitution Errors Frequent [2] Infrequent [1] How do we define frequency? Is it necessary to document this?

41. Discussion Time