........................................................................................................................................ I Acknowledgements ........................................................................................ ................................ II Tables ••..•....••...•.•............••...•.•.•.............•••.•••.............••.••.......•.••..•............................................ III Figures ........................................................................................................................................ v Chapter 1 Introduction ............................................................................................................... 1 Chapter 2 Literature Review ................................................................................................. ...... 9 Part A A review of aspects of speech associated with cleft palate ............................................. 9 I. Historical Aspects ................................................................................................................ 9 II. General Characteristics of Cleft Palate Speakers ............................................................. 13 III. Review of Speech Characteristics ................................................................................... 17 IV. A Critique of Approaches In 'Cleft Palate Speech' Research ......................................... 26 V. Structural Issues ............................................................................................................... 29 a. Velopharyngeal Function ......................................................................................... 29 b. Fistulae ..........................................•...•....................................................................... 32 VI. Speech Therapy ............................................................................................................... 34 Part B Speech In patients with unoperated palates ................................................................. 38 Chapter 3 Issues and Hypotheses ............................................................................................. 49 Chapter 4 Methodology ............................................................................................................ 55 I. Materials ............................................................................................................................ 55 II. Procedures ........................................................................................................................ 58 a. Speech •.•••••••••••••••••••••••••.•••••..••••.•.••.•.•••.•••••••••.•.•.••••.•••••••••••••••••.•..••••.•.••.•••••..•. II •••• II 58 b. Velopharyngeal Function ......................................................................................... 59 c. Intra-oral Examination .............................................................................................. 64 d. Surgical Observations ............................................................................................... 65 e. Other procedures ..................................................................................................... 66 III. Speech Therapy Courses ................................................................................................. 66 Chapter 5 Method of Speech Analysis ...................................................................................... 70 I. The Rating Scale ................................................................................................................ 70 II. Speech Patterns ................................................................................................................ 80 III. Speech Categories ........................................................................................................... 85 Chapter 6 Results ......................•.............................................•.................................................. 90 I. Overall Articulation Results ............................................................................................... 90 II. Patterns of Change In relation to Pre-operative Speech ................................................ 94 III. Surgical and Speech Therapy Intervention .................................................................... 97 IV. Age .................................................................................................................................. 99 V. Cleft Type .............................•...•.......•••••••••..•.•••..••••••••.....•...•..•.•..................................... 109 VI. Structural Issues ............................................................................................................ 116 a. Velopharyngeal Function ....................................................................................... 116 b. Fistulae .................................................................................................................... 129 c. Surgical Observations at Palate Repair .................................................................. 141 VII. Intervention: Therapy .................................................................................................. 147 VIII. Imitation of Singletons and Imitation of Trlsyllables................................................. 152 IX. Years of Education ........................................................................................................ 157 Chapter 7 Discussion ............................................................................................................... 160 I. The Research Problem ..•••••........•••...•.•.•..............•.•......••••••.•..••.•••.•.•....•••••.•••.•..•...••.....•.• 160 II. Methodological Issues...................................... .............................................................. 161 III. Critique of the Method of Measuring Speech ............................................................. 163 IV. Critique of the Method of Measuring Velopharyngeal Function ................................ 166 V. Critique of the Method of Measuring Fistulae .............................................................. 169 VI. Major Hypotheses ......................................................................................................... 170 VII. Minor Hypotheses ........................................................................................................ 183 VIII. Other Factors .............................................................................................................. 187 IX. Further Research ........................................................................................................... 190 Chapter 8 Conclusion ••••••.•.••.•.•......•.••.••.....•.•.•..•..•.•.•..•••..••••.•.....•........................................... 192 References ••••••••.•••.••..•.......•........••....•••••••..•••••..••.••••..••••••.••..••.••.........••••.....•......••••••..••..•.•••..•.... 198 Appendix I Selected photographs .......................................................................................... 210 Appendix II The Sri Lankan Cleft Palate Project: The Unoperated Cleft Lip and Palate Mars et al. (1990) ............................................................................................................... 215 Appendix 111The Language of Sinhaia .................................................................................... 216 Appendix IV The Speech Sample ............................................................................................ 226 Appendix Va Oral-Motor Assessment ..................................................................................... 228 Appendix Vb Palatal Surgery Rating Scale ............................................................................. 229 Appendix Vc Nasopharyngoscopy Speech Sample and Framework of Analysis .................... 230 Appendix Vd Psychosocial Forms ............................................................................................ 231 Appendix VI Early Results based on Quantitative Data .......................................................... 232 Appendix VIIAssociated Publications ..................................................................................... 237 Sell D. and Grunwell P. (1990) Speech results folloWing late palatal surgery In previously unoperated Sri Lankan adolescents with cleft palate. Cleft Palote J. 27:169-173. Wlrt A. Wyatt R. Sell D. Grunwell P. and Mars M. (199Oa) Training counterparts In cleft palate speech therapy In the developing world:a report. Cleft Pa/ote 1.27:169-173. W1rt A. Wyatt R. Sell D. Grunwell P. and Mars M. (1990b) Training counterparts In cleft palate speech therapy In the developing world:an extended report. Brit. I. Dis. of Commun. 25:355-367.