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 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 132-138

Total immersion speech camps for patients with cleft palate

1 Department of Speech and Language Pathology, Hablarte e Integrarte, A. C., Mexico City; Cleft Palate Clinic is the Department at Hospital Gea Gonzalez, Mexico City, Mexico
2 Ian Jackson Craniofacial and Cleft Palate Clinic is the Department at Beaumont Hospital, Royal Oak, Michigan, United States of America

Date of Web Publication21-Nov-2017

Correspondence Address:
María Del Carmen Pamplona
Department of Speech and Language Pathology, Hablarte e Integrarte, A. C., Mexico City
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_53_17

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Background: Children with cleft palate (CCP) frequently shows language and/or speech disorders. However, a significant number of children cannot receive speech pathology treatment on a regular basis. For these children, new modalities of intervention have to be developed for stimulating speech and language. Objective: The purpose of this paper is to study and compare the two modalities of speech intervention in CCP: a conventional approach providing speech therapy in 1 h sessions, once a week, and a total immersion speech camp in which CCP received therapy within a naturalistic environment 10 h/day for a period of 5 days. Materials and Methods: Twenty-three children were studied. A matched control group was assembled. Children included in the experimental group attended a total immersion speech camp for 5 days. Matched control children received speech therapy once per week in 1 h sessions. Results: When comparing the advances of the CCP participating in total immersion speech camps to CCP assisting to speech therapy 1 day a week, significant similar advances (P > 0.05) in articulation were demonstrated. Moreover, significant improvements (P < 0.05) were found when articulation deficits were compared before and after the speech treatment periods. Conclusion: Total immersion speech camps seem to be a valid and reliable option for speech intervention in CCP.

Keywords: Cleft palate, language, speech, treatment

How to cite this article:
Pamplona MD, Ysunza PA. Total immersion speech camps for patients with cleft palate. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:132-8

How to cite this URL:
Pamplona MD, Ysunza PA. Total immersion speech camps for patients with cleft palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:132-8. Available from: https://www.jclpca.org/text.asp?2017/4/3/132/218874

  Introduction Top

Speech outcome in children with cleft palate (CCP) depends on articulation and nasal resonance. These children may be at risk for articulation disorders. Certain articulation deficits are generally regarded as compensatory behaviors secondary to velopharyngeal insufficiency (VPI). These faulty articulation patterns are known as compensatory articulation disorder (CAD). CAD has been considered as a phonologic disorder[1],[2] because it involves higher organizational levels of language processing.[3],[4]

The relationship between articulation deficits and the child's language system has been extensively studied.[1],[2],[3],[4] Pamplona et al.[2] described that children exhibiting CAD differ in their overall development of language from children with repaired cleft palate without articulation patterns characteristic of CAD. Hence, it was proposed that an intervention aimed to correct CAD should include a simultaneous approach for enhancing the linguistic organization.

Unfortunately, there are several factors affecting the delivery of complete and regular speech pathology treatment for CCP including lack of clinics in all communities, traveling difficulties, and other social and economic issues. Persistence of unintelligible and/or low-quality speech can significantly interfere with school performance and hinder the integration of the individual into society.

Since the 1960s, research has begun to address the influence of immersion for enhancing linguistic abilities – mainly in second language learning. Results have shown that immersion opportunities positively affect language development.[5] Freed[6] evaluated the differences between language learning at home/class versus language learning through immersion experiences. In this study, significant differences were found between students who receive instruction in another Language at school in conventional classrooms or at home and those who experience a foreign language immersion program. Immersion is an educational technique in which two Languages are used for instruction in a variety of topics not only as a specific and separate subject. Participants that went into an immersion program were more able to use language on a regular basis and were more committed to subsequent language study.[6],[7]

Savage and Hughes[5] combined a quantitative assessment with a qualitative evaluation to study how short-term Language immersion programs stimulate the Language acquisition process. One hundred and forty United States Air Force cadets participated in a Chinese summer Language immersion program. Participants were interviewed, completed a program questionnaire, created a photo journal, and took the pre- and post-test assessments in reading and listening. Their study revealed that Language immersion participants experienced a significant improvement in both listening and reading scores after completing a short course using immersion techniques.

The purpose of this paper is to study two different modalities of speech intervention for CCP exhibiting CAD. The first modality is a total immersion speech camp where CCP received full day stimulation for 5 days. The second modality is a conventional approach providing speech therapy in 1 h sessions once a week for 8 months. The objective is to study whether a short-term speech camp in which total immersion techniques were used could be as effective as the conventional long-term approach for delivering speech pathology treatment aimed to correct articulation deficits, specifically CAD in CCP.

  Materials and Methods Top

This study was carried out in Mexico City. The Bioethics Committee and Internal Review Board of the Association “Hablarte e Integrarte, A. C” approved the protocol, and the study had been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki's and its later amendments. Before the inclusion of each patient into the study group, the parents or legal guardians were carefully explained about the procedures and the methodology of the protocol. All elderly patients or parents of CCP included in the study group agreed to participate and gave their informed consent before the inclusion of the study.

Sample size was calculated at an Alfa of 95% confidence interval and a beta power of 80% for a comparative study of two groups. The distribution of the severity of CAD across CCP during the last 2 years was considered for defining the sample size. The aim was to detect a difference of at least 20% between categories. According to these calculations, a minimum of 19 children classified in each group should be included in the study.

To qualify for the study group, the children had to meet the following inclusion criteria:

  1. Repaired unilateral, complete cleft of primary and secondary palate (UCLP)[8]
  2. VPI after palatal repair as demonstrated by clinical assessment and videonasopharyngoscopy
  3. CAD in association with VPI as demonstrated by a complete speech pathology evaluation including standardized assessments of placement and manner of articulation
  4. Chronological age between 3 and 8 years of age at the time of selection for the study group.

Exclusion factors:

  1. Children with neurological disorders were excluded
  2. CCP associated with a diagnosed congenital syndrome were excluded
  3. Children with hearing loss as demonstrated by behavioral pure-tone audiometry were excluded.


The subjects of this study were patients with repaired cleft palates who exhibited CAD as demonstrated by a complete speech pathology evaluation including standardized assessments of placement and manner of articulation. Subjects were between the ages of 3 and 8 years at the time of evaluation.

The experimental group included 23 children with repaired cleft palate who exhibited CAD. They were between 3 and 8 years of age at the time when they were recruited for the study. Children included in the experimental group participated in a total immersion speech camp.

A control group of 23 children matched by gender, with similar family social and income levels and similar educational level of the parents was assembled. All children included in the control group presented with repaired cleft palate at a similar age as children of the experimental group. In addition, all children of the control group exhibited CAD. The age of the children included in both groups was kept as similar as possible. The same inclusion criteria and exclusion factors were considered for including the patients in both groups.

To determine if the groups were equivalent, Student's t-tests were run for the following variables: chronological age (mean age = 72.73 months for the experimental group; mean age = 70.34 months for the control group), age of repair of the secondary palate (minimal incision palatopharyngoplasty; mean age = 9.50 months for the experimental group; mean age = 9.10 months for the control group). In addition, Wilcoxon signed-ranked test was run for the ordinal variables: educational level and social-economic status.

Results indicated that no significant group differences were found for any of these variables.


All children underwent a complete speech pathology evaluation. The principles of the Whole Language Model[9] were considered. Special attention was focused on articulation and the presence of CAD. For this purpose, the children were videotaped interacting with a trained speech pathologist during storytelling for 30 min. A 20-min segment was selected where a high level of verbal interaction occurred. The 20 min of interaction were transcribed verbatim for analyzing the phonologic rules present in each patient's sample. The transcribed samples were randomly assigned to an examiner. Each transcription was then checked against the videotape by a researcher that had not done the original transcription along with a second examiner for accuracy. A Cohen's Kappa test demonstrated excellent inter- rater reliability between the two independent examiners (0.90).

All speech and language pathologists (SLPs) participating in this study had been performing transcriptions of cleft palate children for at least 3 years. For assessing the reliability of the speech evaluation, a blind procedure was utilized, whereby all analysis was independently conducted by two trained SLPs. Whenever there was a disagreement, each case was discussed until a consensus was reached.

A Goldman–Fristoe test (Spanish version) test of articulation was used for demonstrating adequate placement and manner. In addition, for measuring advances in articulation the severity of the CAD was measured according to a previously validated and reported scale.[10] This scale allows determining the specific moment of the process of correcting CAD for each child. This is the degree of severity of CAD in each child. The categories of the scale can be briefly described as follows:

  • Appropriate articulation (Level 6): The child can produce adequate placement and manner of articulation during spontaneous speech, including nonpresent situations
  • Inconsistent articulation (Level 5): The child exhibits compensatory articulation errors inconsistently during spontaneous speech. Intelligibility of speech is mostly adequate
  • Articulation within context (Level 4): The child can self-correct articulation placement when using speech within a specific context. For example, during telling a story from a storybook which the patient already knows well. Nonetheless frequent compensatory errors during are produced during spontaneous speech
  • Articulation in sentences (Level 3): The child can achieve correct articulation placement repeating selected short phrases as the clinician models correct articulation placement
  • Articulation in words (Level 2): The child can achieve articulation placement correctly only during the production of selected short words when the clinician uses specific phonologic strategies
  • Articulation of isolated phonemes (Level 1): The child can correct articulation placement only in isolated phonemes through direct instruction
  • Constant CAD (Level 0): The child is not able to correct articulation not even in isolated phonemes and despite direct instruction.

To determine if there were differences in the articulation between children from both groups, complete articulation evaluations were performed at the onset and at the end of the intervention period.

The children included in the control group were followed for 8 months. These children were evaluated before the onset of speech therapy and after the follow-up period.

The children included in the experimental group, attending the total immersion speech camp were evaluated before and after the total immersion camp.


The children included in the experimental group attended a total immersion speech camp for 5 days. These children received full-days speech intervention. During the day, several activities were planned for practicing articulation including cooking, games, storybook reading, writing stories, painting or coloring figures, pasting, and sharing experiences. All activities were designed to maximize opportunities for articulation in a naturalistic environment. A linguistic context was always kept during all activities. In addition, general phonological principles[1] and the whole language model philosophy[2],[3],[4] were considered. Whole language philosophy considers language as a whole and not a sum of parts that can be treated separately.[11] Following that assumption, the activities were designed around one topic as a topical unit.[12] Topical units are larger themes that allow for an extended exploration of a general concept. An example of a general theme – topical unit – can be “The beach.”

The intention is to create a natural environment for language learning. The activities are carefully designed to be consistent with whole language principles of learning where language is an integral part of every activity. There were no separate teaching times that focused exclusively on articulation. Rather, a single meaningful reading activity integrated all of the working areas as the children explore, talk, read, write about, or illustrate a topic. The lessons were organized to help children make sense of complex information while they acquire and use oral language and articulation. This allows person-centered planning to focus on speech and language learning while they do interesting and fun activities.[12],[13]

For most of the total immersion camp activities, children were divided into groups depending on age, language, and cognitive level. This allows interaction and working on specific needs. In each group, language and articulation were addressed.

Our main strategy is to expose children to a wide variety of books along the camp, some which include a repeatable and predictable text, others that have great and explicit drawings, and finally, others which challenge listening and critical thinking abilities because of their more complex and abstract story and/or content. It is described that storybooks are great for stimulating cognitive and language development in children.[14] Storybooks have all the elements of the narrative and discourse structure, including the relationships that provide order and structure such as temporality, causality, or perspective. In addition, they provide stability for seeing those relationships and/or working on specific language needs such as articulation patterns of words and/or sounds. Other activities that promote working with speech and language are art, cooking, music, and experiences such as visits or symbolic play [Table 1].
Table 1: Examples of activities realized during the total immersion speech camps

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[Table 1] offers some examples for planning activities that could promote working with language and articulation. Any activity might work, clinician just has to focus on linguistic needs and target sounds. In this way, the target for all activities was to address speech and the correct articulation through meaningful and fun experiences.

These situations gave the context for working all the language areas in a parallel manner. Oral language, articulation, reading, and writing were presented in natural context from whole-to-part.

The children included in the control group received speech therapy aimed to correct CAD. These children received therapy once per week in 1 h sessions. Phonological principles and the whole-language model philosophy were also used for the speech intervention as reported previously.[15] Children were placed in small groups in order to provide opportunities for interaction and socialization. Activities were similar to the ones presented in [Table 1].

  Results Top

At the onset of the total immersion speech camp or the speech therapy sessions, according with the inclusion criteria, all the children included in the two study groups (experimental and control groups) exhibited compensatory articulation errors. In other words, none of the children was classified as normal in the CAD scale used for this paper. Three (13%) of the children included in the experimental group (attending the total immersion speech camp) were in the lowest level of the scale–level 0. Six children (26%) were able to achieve adequate articulation placement only in isolated phonemes – Level 1 - Eleven children (48%) were articulating within words – Level 2, and finally, 3 children (13%) were able to articulate correctly in sentences. None of the children were on the higher levels of the scale [Table 2].
Table 2: Severity of compensatory articulation disorder at the onset and at the end of the total immersion speech camp in experimental group

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The children included in the control group showed similar results. Three children (13%) were not able to articulate even in isolated phonemes – Level 0 - Seven children (30%) articulated in level 1. Twelve children (52%) articulated within words, and one child was able to articulate in sentences correctly (5%) [Table 3].
Table 3: Severity of compensatory articulation disorder at the onset and at the end of the intervention period (8 months) in the control group

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A Mann–Whitney test demonstrated that there was a nonsignificant difference (P > 0.05) between the distributions of the severity of CAD in both groups of children.

After the total immersion speech camp, none of the children was in the lowest level of the scale – Level 0 and only six children were in the other 2 severe levels – 1 y 2-where can articulate correctly only in isolated words (26%). Nine children (39%) were articulating within sentences, and seven used adequate articulation placement in context (31%). Finally, one child was able to use the correct articulation placement inconsistently during spontaneous connected speech (4%) – Level 5 [Table 2].

After 8 months of speech therapy in the control group, one child (4%) was in the lowest level of the scale – Level 0. One was in Level 1 articulation in isolated phonemes (4%). Five children (22%) articulated correctly by repeating words as modeled by the clinician. Thirteen children (57%) were articulating in sentences, and 3 were able to use adequate articulation in context (13%). None of the children of the control group were in the highest levels of the scale – Levels 5–6 [Table 3].

A Mann–Whitney test showed no significant difference in the severity of CAD at the end of the therapy period between groups. That is, both groups showed similar levels of severity after the study [Table 4].
Table 4: Severity of compensatory articulation disorder at the end of the study

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Both groups showed a significant difference when comparing the level of severity at the onset and at the end of the speech intervention period, demonstrating that both groups had a significant improvement after the speech intervention (P > 0.05) [Table 5].
Table 5: Levels of advance in articulation scale in both groups

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  Discussion Top

The purpose of this paper was to study whether total immersion speech camps could become an effective option for correcting articulation in CCP. It was hypothesized that CCP and CAD can reduce the severity of articulation at least in the same degree than CCP-receiving speech pathology treatment in a conventional setting. The results of this study supported this hypothesis. Children participating in total immersion speech camps improved their articulation. Furthermore, children in the experimental group obtained similar levels of advance that those obtained in the control group. It is promising that in a shorter period, the severity of the CAD was significantly decreased. This is attractive especially for families that are not able to attend regularly to intervention sessions.

It has been reported that total immersion projects such as study abroad have positive results for language and second-language learning. Usually, children use to advance more in this context than the children, which received regular classes.[6]

Other approaches for providing intensive therapy in CCP have been studied like a speech summer camp. The objective of the camp is to provide intensive speech therapy in meaningful communicative contexts, for a period of 3–4 weeks. In a summer camp setting as well as in the total immersion camp setting, interventions are designed to address all linguistic areas including, phonology (articulation), syntax, pragmatics, morphology, discourse organization, and cognitive-linguistic aspects. In addition, activities are planned for enhancing language and speech. The results have been significantly positive for both language and articulation.[13],[16]

  Conclusions Top

In this study, the total immersion speech camp offered a teaching/learning context for working language and articulation with CCP. The children were highly motivated with the experience. At the speech campsite, the children participated in different activities during 5 days. This allowed planning attractive and fun activities for addressing language and articulation as a whole in a naturalistic environment. In addition to the advances in speech, positive results were observed in social aspects. The children were able to interact better with their peers; they increased their sense of belonging and they were able to work their independence. The challenge will be to sensitize parents to continue the work at home and/or during conventional speech pathology treatment.


Total Immersion Speech Camps have been funded with donations from “Smile Train.” The author and the patients who participated in this project would like to acknowledge “Smile Train” generous support and to manifest their most sincere and profound gratitude.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Chapman KL. Phonologic processes in children with cleft palate. Cleft Palate Craniofac J 1993;30:64-72.  Back to cited text no. 1
Ysunza PA, Repetto GM, Pamplona MC, Calderon JF, Shaheen K, Chaiyasate K, et al. Current controversies in diagnosis and management of cleft palate and velopharyngeal insufficiency. Biomed Res Int 2015;2015:196240.  Back to cited text no. 2
Hoffman P. Clinical forum: Phonological assessment and treatment. Synergistic development of phonetic skill. Lang Speech Hear Serv Sch 1992;23:254-60.  Back to cited text no. 3
Norris J, Hoffman P. Language intervention within naturalistic environments. Lang Speech Hear Serv Sch 1990;21:72-84.  Back to cited text no. 4
Savage B, Hughes H. How does short-term foreign language immersion stimulate language learning? Front Int J Study Abroad 2014;XXIV:103-20.  Back to cited text no. 5
Freed BF. An overview of issues and research in language learning in a study abroad setting. Front Int J Study Abroad 1998;4:31-60.  Back to cited text no. 6
Dwyer MM. More is better: The impact of study abroad program duration. Front Int J Study Abroad 2004;10:151-64.  Back to cited text no. 7
Kernahan DA, Stark RB. A new classification for cleft lip and cleft palate. Plast Reconstr Surg Transplant Bull 1958;22:435-41.  Back to cited text no. 8
Norris J, Hoffman P. Whole Language Intervention for School-Age Children. San Diego, CA: Singular Publishing Group; 1993. p. 29-105.  Back to cited text no. 9
Pamplona C, Ysunza A, Patiño C, Ramírez E, Drucker M, Mazón JJ, et al. Speech summer camp for treating articulation disorders in cleft palate patients. Int J Pediatr Otorhinolaryngol 2005;69:351-9.  Back to cited text no. 10
Pamplona MC, Ysunza A, Ramírez P. Naturalistic intervention in cleft palate children. Int J Pediatr Otorhinolaryngol 2004;68:75-81.  Back to cited text no. 11
Norris J, Hoffman P. Storybook-Centered Themes: An Inclusive Whole Language Approach. Tucson, AZ: Communication Skill Builders; 1995.  Back to cited text no. 12
Pamplona M, Ysunza A, Patiño C, Ramírez E, Drucker M, Mazón J. Speech summer camp for treating articulation disorders in cleft palate patients. Int J Pediatr Otorhynolaryngol 2005;69:351.  Back to cited text no. 13
Norris J. From frog to prince: Using written language as a context for language learning. Top Lang Disord 1991;12:66-81.  Back to cited text no. 14
Norris J, Damico J. Whole language in theory and practice: Implication for language intervention. Lang Speech Hear Serv Sch 1990;21:212-20.  Back to cited text no. 15
Pamplona Mdel C, Ysunza A, Pérez G, Vergara S. Summer school speech therapy for children with cleft palate and language disorder. Gac Med Mex 2009;145:475-9.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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