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The Impact of Hypernasality on Children's Speech Development

You may worry that your child with hypernasality will suffer speech development setbacks. Or, perhaps, you are unsure of how this resonance disorder affects your child’s speech skills, in general.


These are normal concerns. As you learn more about the disorder and seek help from professionals, you will be able to help your child navigate this condition better.


We will explore the definition, causes, effects on speech development, and treatment options for children diagnosed with hypernasality.


What is Hypernasality?


Hypernasality, also referred to as velopharyngeal insufficiency (VPI) is a resonance disorder where the speech sound comes out nasally.


Resonance is the sound that is generated by the vocal cords. It provides the quality of sound and is important in making the sounds for vowels and voiced consonants. A person’s resonance is affected by the length and volume of the pharynx, the size and shape of the oral cavity, and the structure of the nasal cavity.


People produce resonance by controlling their airflow through their nose and mouth. To do this, they use a valve called the velopharyngeal sphincter (or valve). During breathing, this valve stays open. When you speak, it is closed by the soft palate (aka velum or roof of the mouth). Several structures must work together to create the opening and closing of this valve, such as the soft palate, lateral pharyngeal walls, and the posterior pharyngeal wall (the back wall of the swallowing passage).


If any of these physical structures are affected, it causes a velopharyngeal dysfunction, which can lead to communication disorders.


The velopharyngeal valve is essential in pronouncing certain consonants correctly, such as the phonemes p, b, s, and k.


In children with hypernasality, there is an abnormal flow of air and vibration during speech. The pronunciation of high vowel sounds, such as u and I, becomes difficult to make and more nasal sounding. Children with this resonance disorder may sound like they are talking through their noses.


It is important to note that some languages are more nasal than others and that people learning a second language may make more nasal sounds than others. Also, the letter sounds in this article are based on the English language. For a proper diagnosis of a child who is learning English as a second language or who speaks a different language, a speech and language pathologist can make a culturally sensitive assessment.





Symptoms of Hypernasality


The signs of hypernasality include the following according to the American Speech-Language-Hearing Association:

  • High vowels sound nasally (especially the U and I sounds)

  • Excessive nasal resonance (replacing an l or r sound with a w or y sound)

  • Nasal cognates for certain consonants (e.g. the n sound for the d sound or the m sound for the b sound)


Hypernasality is one of many resonance disorders that are characterized by irregular oral sound energy or nasal airflow errors.


Others include hyponasality (which is the lack of nasal sounds due to a blockage, cul-de-sac resonance (where sound is trapped in the nasal, oral, or pharyngeal cavity), and mixed resonance (where all or some of the other resonance disorders are present together).


Hypernasality and hyponasality are commonly mistaken for one another. The key difference is that hypernasality is when the resonance of sounds is incredibly nasal. Whereas, with hyponasality, the sounds are not nasal enough.

What Causes Hypernasality?


The main three causes of hypernasality are cleft lip or palate, physical abnormalities, or learned behaviors.


Genetic or structural anomalies in the ears, nose, and throat physiology can lead to velopharyngeal incompetence. The primary cause of this condition is having cleft palate surgery (palatoplasty), according to Dr. Joseph Haddad, Jr. and Dr. Micahel G. Stewart of New York Presbyterian.


Children with repaired cleft palates form scar tissue on the palate, causing it to not function properly. Children have difficulty with velopharyngeal closure (closing off the back of their nose) to make speech sounds. Up to 40% of patients who have previously had cleft palate surgery experience hypernasality, even after repair to the palette.


Other craniofacial abnormalities can cause hypernasal speech, including the following:

  • Cleft lip

  • Irregular adenoids

  • Adenoid atrophy

  • Enlarged tonsils

  • Post-tonsillectomy or post-adenoidectomy

  • Deep pharynx

  • Velar hypoplasia or dysplasia

  • Tissue deficit (from a tumor shrinking after radiation)

Some of these conditions will require surgery to correct the abnormality.


Genetic factors also play a role in developing hypernasality. These genetic syndromes cause structural anomalies that can increase the likelihood of your child speaking nasally:

  • DiGeorge syndrome

  • CHARGE syndrome

  • Treacher Collins syndrome

  • Nager syndrome

  • BOR syndrome

  • Turner syndrome

  • Beckwith-Wiedemann syndrome

  • Stickler syndrome

  • Kabuki syndrome,

  • Optize B/BBB syndrome

  • Jacobsen syndrome

  • Robin sequence


Besides physiological causes for hypernasality, children can have this resonance disorder due to neurogenic causes. These include traumatic brain injury, stroke, cerebral palsy, apraxia, neuromuscular disease, neurofibromatosis, Prader-Willi syndrome, myotonic dystrophy, and nemaline myopathy.


Hypernasality is also frequently a speech outcome in children who are deaf or have significant hearing loss.


Children can also develop hypernasality as a learned behavior. They may have trouble with the articulation of certain sounds and keywords. Their compensatory behavior is to produce nasal sounds instead. In these cases, there is no problem with the velopharyngeal function, rather it is a misarticulation behavior that can be corrected through behavioral speech therapy.


How Does Hypernasality Affect Speech Development?


Socially, children with hypernasality can sometimes be perceived as less intelligent and less attractive than their normal-speaking peers. This can affect a child’s friendships and self-esteem.


If a child has hypernasality into their adolescent and adult years, it can affect their social relationships.


Academically, children with hypernasality, especially due to a corrected cleft palate, may have delayed speaking. Most children begin saying a few words by 12 months of age, such as “mama” or “dada.” However, children with hypernasality may start to speak later than their peers with normal speech. Parents usually begin to notice a difference in the resonance of sounds their children are making by age 3 or 4 years old.


Children with hypernasality often have trouble with reading and writing, as well. However, this is not always the case. If your child also has a learning disorder or hearing impairment may be at a higher risk of having difficulties with these tasks.


Hypernasality in children is usually characterized by the following developmental challenges. Your child may have an inability to produce certain sounds. They also may have trouble using their tongue and lips correctly to form sounds.


Your child may also exhibit compensatory errors. For example, children may have errors using their glottis( or the part of the larynx with the vocal cords between them). Glottal stops (which are like grunts) can be used as an oral replacement for sounds your child cannot produce properly. The Glottis fricative is another compensatory error where the air is forced through the glottis to produce the h sound.


Other articulation errors include pharyngeal plosives, which are when the base of the tongue hits the back of the pharyngeal wall to substitute velar sounds (k, g). A pharyngeal fricative is when the base of the tongue tries to act as the pharyngeal wall. This results in nasal air emission escaping between the base of the tongue and the pharyngeal wall.


A posterior nasal fricative is when the back of the tongue hits against the velum and releases a loud, bubbling sound. Finally, a nasal sniff is when a child forces the sound through the nose to create the s sound.


The above-mentioned compensatory errors can make speaking very difficult for your child, especially when peers and others judge them for the ways that they speak.





Seeking Treatment


In order to treat a child with hypernasality properly, several factors have to be considered.

Your child may be treated by a combination of clinicians that may include a pediatrician, ENT (Ears, Nose, and Throat doctor), and a Speech-Language Pathologist (SLP).


You can seek out a pediatric doctor with your initial concerns. The pediatrician will informally evaluate your child’s speech and decide on whether your child’s speech is concerning or developmentally appropriate.


Then, if the doctor feels there is some form of obstruction or structural issue, they may refer your child to specialists which include a SLP or ENT.


Doctors may also use a nasometer to calculate a nasalance score. This will help measure the ratio of nasal and oral amplitudes expressed by your child. If they suspect a physiological factor, they may suggest surgery.


Pharyngeal flap or sphincter pharyngoplasty may help with velopharyngeal dysfunction. This will not completely fix the problem. Your child will still need speech therapy before and after the procedure.


In cases where the hypernasality cannot be corrected with surgery, severity metrics are determined by speech intelligibility. Usually, these determinations are made by a speech pathologist.


An SLP evaluates your child’s speech and language development. The SLP will interview your child. They need conversational speech samples to effectively diagnose your child. Single-word identification isn’t enough to determine the condition.


Once the SLP makes the diagnosis, they can create a treatment plan for your child’s speech disorder.


Many cases of hypernasality see a significant difference with speech therapy. Speech-language pathology focuses on intervening with young children to address weaknesses and increase strengths. They also create activities that help demonstrate correct speech usage. As well as give children the strategies to overcome articulation errors.


Children of at least 3 years of age tend to have better results with speech therapy, even those with severe hypernasality. As many as 43% of these children improved and were developmentally similar to their normal speech peers by the time they were 6 years of age with these interventions.


If you are looking for an affordable way to get your child speech therapy services, The California Scottish Rite Foundation can help. We offer speech, language, and learning programs for children free of charge. We are located throughout California at our 17 locations. We partner with speech and language pathologists in both private facilities and universities to ensure a large breadth of services can be offered to your child. This means your child gets the best quality of care at no cost to you.


Speech therapy can go a long way in making sure your child is able to meet their speech development goals.


Ways Speech Therapists Help Children With Hypernasality


Speech-Language Pathologists have a number of strategies they use to assist your child in developing their speech.


One example is using a mirror to show your child the path of their airflow. By doing this, they are teaching your child to be more aware of how they form speech. Understanding this lets them adjust and monitor their own airflow.


SLPs also show children how to identify the differences between oral and nasal production. Identifying these differences allows the child to control these processes more consciously.


Speech therapists can also teach your child to understand how pitch and volume change the sounds they make. Learning how to adjust their pitch and volume can reduce their nasality. It can give them more control over the sounds they make, as well.


In speech therapy, children will begin to understand how to identify speech sounds in other people, which encourages them to replicate these sounds themselves.


Speech therapy does not cure hypernasality. SLPs simply teach your child ways to better use the parts of their lips, tongue, and airflow to reduce their nasality. These strategies are less effective in children with physical obstructions or abnormalities. Yet, they do still help.


Some children will continue to have hypernasality until adulthood, while others may overcome it after a few years.


Conclusion


Although hypernasality does affect a child’s speech development, most of this can be corrected with proper treatment. This may be a combination of surgery and speech therapy OR it can involve speech therapy alone.


Continue to provide your child with plenty of speaking opportunities. Hypernasality can be treated and your child can make progress. Time and patience as well as providing support will go a long way.


Your speech-language pathologist will recommend strategies to practice at home to help your child get back on track with their speech and language development.






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