Elicitation and documentation of speech data within countries and around the world can differ in a number of ways, all influencing the result of the assessment, which jeopardizes the validity of speech outcome comparisons (Lohmander & Olsson, 2004; Sell, 2005). Minimum standards have been suggested in terms of the type of speech material to be collected when assessing cleft palate speech, but there is still a need for consideration and implementation. This is a background overview of the process throughout the years.
The Eurocleft project (1996-2000, PI Bill Shaw) were networks established to investigate clinical care, comprised standards of care including a register of services, policy statements on clinical practice with practical guidelines describing minimum recommendations, and minimum records that the teams should maintain in order to be able to measure and compare results. An early attempt to develop cross-linguistic methodology to increase sample sizes and also to understand the impact of language on speech was performed in a connected speech project (Brøndsted et al., 1994; Grunwell et al., 2000). Despite careful development of speech material using language specific sentences, it was not entirely successful, and a consensus procedure was chosen. However, networks for collaboration and calibration starting with the Eurocleft speech study were important for the continued development of methodology for speech assessment.
The Eurocran website was originally created in order to disseminate the recommendations by the Eurocleft network about ages for assessment (Shaw et al., 2000). Within the Eurocran project (2000-2004, PI Bill Shaw) the Speech project was devised for sharing information from the Scandcleft project (International multicenter randomized trial) on how to collect, record and analyse cleft palate speech across different languages (Lohmander et al., 2009). The Scandcleft project was initiated by Gunvor Semb in 1997. The methodology part of the project was one of the work packages of the Eurocran project and contained seminars, meetings, and short courses involving the eastern European countries. Furthermore, a website with good practice from the Scandcleft project were launched within the Eurocran project.
The basis for the methodology and speech material in the Scandcleft project was that all speech sounds may be influenced by the cleft condition, but only a restricted number of consonants may be similar across the languages involved. A restricted number of phonetically similar speech sounds enhances the validity of the cross-linguistic outcome data if the assessment is performed primarily on speech sounds that are highly vulnerable to the cleft condition. Furthermore, in studies of speech outcome following surgical treatment, speech outcome data based on a restricted number of different sounds are sufficient as opposed to data intended for clinical purposes, which need to be more detailed (Hutters & Henningsson, 2004).
The project driven methodology for speech assessment was adopted internationally. With the objective to achieve consistency and uniformity in reporting speech outcomes, universal parameters for reporting speech outcomes in individuals with cleft palate were suggested (Henningsson et al., 2008). The results were supposed to be available by conversion of the local team’s speech evaluation, mapping to the “universal parameters”, which then are reported, leading to difficulties with reliability (Lohmander, 2008).
With the ambition to reach international consensus, the speech part of the Eurocran website was later developed further and changed name to CLISPI, CLeft palate International SPeech Issues. The webpages are designed to provide suggestions on how to collect a good speech sample. The CLISPI website is reference for development of a speech standard set according to the International Consortium for Health Outcomes Measurement (ICHOM).
The rationale for ICHOM was to suggest a standard set that would be possible to follow also in low-income countries, containing measures that matter to the patient, and are comparable across countries, i.e., languages (Allori et al., 2017). Only by agreeing on a common standard set of outcome measures for the comprehensive appraisal of cleft care inter-center comparisons can become possible. A working group comprised 28 internationally recognised clinicians and academicians, representing 8 countries in four continents. One patient and two parents were also included. The goal was defined outcomes, particularly those that matter most to patients and their families, and standardised methods by which these outcomes can be measured. The working group was led through a structured process to reach agreement on a standard set of outcomes. The time points were selected based on typical treatment periods, stages of growth and development, and potential burden of data collection on a team.
The ICHOM standard set for assessment of speech and communication in individuals with cleft palate is based on previous knowledge and experiences and contains one measure of overall rating of velopharyngeal competence (VPC), using the scale VPC-R (Lohmander et al., 2017a), based on all available speech material. Also, it contains a measure of percentage of consonants correct (PCC) without assessment on severity of involvement (Shriberg et al., 1997). This is a measure of consonant articulation, particularly the vulnerable sounds, taking language background into account, and focusing on proficiency rather than errors. Finally, the standard set contains measures on what matters to the environment, which is Intelligibility (or acceptability), and to the patient her/him-self, that is own opinion.
The project driven methodology for speech assessment within a country/language can be exemplified by the Swedish Articulation and Nasality Test, SVANTE (Lohmander et al., 2017b), developed with inspiration from the Scandcleft project and the GOS.SP.ASS (Sell et al., 1999). It is a language specific test with a single word list for assessment of articulation (consonant inventory and phonological processes), and sentences and continous speech for assessment of nasal resonance, VPC, and intelligibility. The word list includes SVANTE mini, a restricted word list/test for cross-linguistic comparison. SVANTE contains normative data at 3-19 years. Rating of VPC has been validated (Lohmander et al., 2017a). In addition, Klintö and colleagues investigated impact of speech material on consonant production (Klintö et al., 2011) and recording medium on phonetic transcription (Klintö & Lohmander, 2017).
* Allori A, Kelley T, Meara J, Albert A, Bonanthaya K, Chapman K, Cunningham M, Daskalagiannakis J, de Gier H, Guernsey C, Heggie A, Jackson O, Jones Y, Kangesu L, Koudstaal M, Kuchhal R, Lohmander A, Long Jr R, Magee L, Monson L, Rose E, Sitzman T, Taylor J, Thornburn G, van Eeden S, Williams C, Wirthlin J, Wong K. A standard set of outcome measures for the comprehensive appraisal of cleft care. Cleft Palate-Craniofacial Journal, 2017;54:540-554.
* Brønsted K, Grunwell P, Henningsson G, Jansonius K, Karling J, Meijer M, Ording U, Sell D, Vermeij-Zieverink E, Wyatt R. (EUROCLEFT SPEECH Group). A phonetic framework for the cross-linguistic analysis of cleft palate speech. Clinical Linguistics & Phonetics, 1994;8:109-125.
* Grunwell P, Brøndsted K, Henningsson G, Jansonius K, Karling J, Meijer M, Ording U, Wyatt R, Vermeij-Zieverink E, Sell D. A six-centre international study of the outcome of treatment in patients with clefts of the lip and palate: the results of a cross-linguistic investigation of cleft palate speech. Scandinavian Journal Reconstructive Surgery and Hand Surgery, 2000;34:219-229.
* Henningsson G, Kuehn D, Sell D, Sweeney T, Trost-Cardamone J, Whitehill T. Universal parameters for reporting speech outcomes in individuals with cleft palate. Cleft Palate-Craniofacial Journal, 2008;45:1-17.
* Hutters B, Henningsson G. Speech outcome following treatment in crosslinguistic cleft palate studies: methodological implications. Cleft Palate-Craniofacial Journal, 2004;41:544-549.
* Klintö K, Lohmander A. Does the recording medium influence phonetic transcription of cleft palate speech? International Journal of Language & Communication Disorders, 2017;52:440-449.
* Klintö K, Salameh E-K, Svensson H, Lohmander A. The impact of speech material on speech judgement in children with and without cleft palate. International Journal of Language & Communication Disorders, 2011;46:348-60.
* Lohmander A. Comment on Universal parameters for reporting speech outcomes in individuals with cleft palate. Cleft Palate-Craniofacial Journal, 2008;45:452-453.
* Lohmander A, Hagberg E, Persson C, Willadsen E, Lundeborg I, Davies J, Havstam C, Boers M, Kisling-Møller M, Alaluusua S, Aukner R, Pedersen NH, Turunen L, Nyberg J. Validity of auditory perceptual assessment of velopharyngeal function and dysfunction: the VPC-Sum and the VPC-Rate. Clinical Linguistics & Phonetics, 2017a;31:589-597.
* Lohmander A, Lundeborg I, Persson C. SVANTE – the Swedish Articulation and Nasality Test – normative data and a minimum standard set for cross-linguistic comparison. Clinical Linguistics & Phonetics, 2017b; 31:137-154.
* Lohmander A, Olsson M. Perceptual assessment of speech in patients with cleft palate: a critical review. Cleft Palate-Craniofacial Journal, 2004;41:64-70.
* Lohmander A, Willadsen E, Bowden M, Henningsson G, Persson C, Hutters B. Methodology for speech assessment in the Scandcleft Project – an international randomised clinical trial on palatal surgery: experiences from a pilot study. Cleft Palate-Craniofacial Journal, 2009;46:347-362.
* Sell D. Issues in perceptual speech analysis in cleft palate and related disorders: a review. International Journal of Language & Communication Disorders, 2005;40:103-121.
* Sell D, Harding A, Grunwell PA. GOS.SP.ASS’98: An assessment for speech disorders associated with cleft palate and/or velopharyngeal dysfunction (revised). International Journal Language & Communication Disorders, 1999;34:17-33.
* Shaw WC, Semb G, Nelson P, Brattström V, Mølsted K, Prahl-Andersen B. The Eurocleft Project 1996–2000. Standards of Care for Cleft Lip and Palate in Europe. European Commission Biochemical and Health Research. Amsterdam: IOS Press; 2000.
* Shriberg LD, Austin D, Lewis BA, McSweeny JL, Wilson DL. The percentage of consonants correct (PCC) metric: Extensions and reliability data. Journal of Speech, Language, and Hearing Research, 1997;40:708-722.