Title: Language and auditory processing in children with cleft palate: a description of the disorder and its relationship to speech outcomes
Funder: Health Education England

Abstract: Background Children with cleft lip and/or palate (CLP) are at significant risk of speech disorder. While outcomes in speech have improved over the last 20 years, up to 35% of children with all cleft diagnoses still present with persisting articulation problems at age 5 years. Currently all children are assessed using the same tools and treatment protocols for speech. These are based on the assumption that the underlying deficit relates to a structural problem of the palatal anatomy which affects how the child is able to articulate those sounds. However, this may not be the case for all children with cleft lip and/or palate. There is some evidence to suggest that there is a group of patients born with cleft lip and/or palate who have significant associated language and/or auditory processing problems. This may impact on speech development as well as reading skills, with negative consequences which can extend into adulthood. Aims To establish if there is a relationship between language and auditory processing skills and persistent articulation difficulties in children with CLP Research questions Do children with CLP perform poorly compared to peers on standardised tests of language (including receptive and expressive language skills and phonological awareness)? Do children with CLP perform poorly compared to peers on standardised tests of auditory processing? Do children with articulation disorder related to cleft palate have poorer language skills than those with normally developing speech? Do children with articulation disorder related to cleft palate have poorer auditory processing skills than those with normally developing speech? Hypothesis In tests of language and/or auditory processing, children with persistent articulation disorder related to cleft palate will perform poorly compared to those with age appropriate articulation. Plan of investigation An observational, cross-sectional study which will compare articulation with language and auditory processing skills in children with unilateral cleft lip and palate (UCLP); bilateral cleft lip and palate (BCLP); and cleft palate only (CPO). Participants will be recruited from regional cleft centres from across the north of the UK. Two groups will be recruited using robust data from the 5 year audit - 1) poor articulation; 2) good articulation. Children will be at least 6 years old to allow time for speech audit data to have been collected and consensus listened by trained SLTs. Following recruitment speech will be reassessed to confirm persistent articulation disorder and participants will be asked to complete tests of language and auditory processing. Results from these tests will be compared across the two groups. Potential benefits to patients and the NHS This research represents the first step in a programme of research which aims to improve the long term outcomes for children with CLP who currently do not respond to traditional intervention. The proposed study will develop our understanding of the nature of the relationship between language and auditory processing abilities in children with CLP with good or poor speech. Thus, hypotheses will be generated as to potential underlying mechanisms of speech difficulties which are resistant to conventional articulation therapy. Subsequent studies will then be possible, including a prospective cohort study to identify children at risk of persistent articulation disorder. This will allow us to direct speech therapy resources more appropriately and to better inform parents. By providing earlier intervention for children at risk of persistent speech disorder, we potentially allow them to enter their school years with a more robust baseline, increasing their readiness for school. Early intervention will potentially reduce the number of speech therapy appointments needed, making speech therapy resources more effective and efficient.

Lay abstract: Almost 1000 babies are born every year in the UK with a gap in their lip, palate or both; this is called a cleft lip, cleft palate or cleft lip and palate. This is usually repaired by surgery in the first year of life but the consequences can last for the whole of that person's life. Outcomes for these children have improved over the last 20 years. Yet every year more than 300 children with a cleft lip and/or palate will still have problems with their speech as they start school. They can have problems with air coming down their nose when they speak and with making sounds in the right way. Many of these children will also have delayed language development. These problems can affect how well they form friendships at school and how well they learn. These early experiences can affect what they achieve in life as adults. Speech and language therapy services make every effort to help children achieve good speech by the time they start school. Yet some children do not respond to the usual treatment used to teach how sounds are made. There appears to be a group of children with a cleft lip and/or palate who have specific language processing difficulties that persist after the age of five years, which can impact on their learning; specifically, the way they learn to produce accurate speech sounds. These children will need speech therapy through their school years. There is some research from Finland, Brazil and China suggesting that this may be due to how these children perceive and process sounds (auditory processing). This study aims to find out if there is a group of children with cleft lip and/or palate in the UK who also have language problems and/or auditory processing difficulties which are also affecting the way the make speech sounds. The standard language assessments routinely used by speech and language therapists in the field of cleft lip and/or palate do not pick up on these very specific problems. One hundred children with cleft lip and/or palate aged between 6 years and 7 years 11 months, will be recruited to participate following appropriate informed consent by their parents. All children will be assessed on the following: Understanding of what is said to them Understanding of vocabulary Use of vocabulary How they form sentences Use of grammatical markers, e.g. past tense Ability to manipulate sounds Processing of sounds compared to visual stimuli Hearing Parents of participants will be asked to complete a questionnaire on behaviours associated with auditory processing problems, such as difficulties remembering instructions. Results from the above tests will be linked to speech data to assess the impact on speech of any language problem and/or auditory processing. Other issues will be considered too, for example, social economic status, severity of the gap in the palate before the operation and continued problems with the movement of the palate. If children with specific auditory and/or language problems are identified early, targeted therapy can be implemented, with the aim of achieving age appropriate speech and language before they start school. This will benefit the child by increasing access to the school curriculum, e.g. through better literacy skills. Family life will be less disrupted by reducing the number of speech and language therapy appointments during their school years. It is predicted that there will be an economic benefit to the NHS because overall fewer speech and language therapy sessions will be needed.

Research activity codes: 2.1 BIOLOGICAL AND ENDOGENOUS FACTORS
Health categories: ORAL AND GASTROINTESTINAL;EAR