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The purpose of the present investigation was to examine the impact of early intervention on speech and lexical measures for toddlers with cleft palate.
Speech measures of ten 27-month-old toddlers with cleft palate who had been referred for therapy at 17 months of age were compared to those of 10 toddlers with cleft palate who had been referred but...
Context in source publication
Citations
... (Ha, 2015;Hardin-Jones & Chapman, 2008;Kaiser, Scherer, Frey, & Roberts, 2017;Lohmander-Agerskov, Soderpalm, Friede, & Lilija, 1990;Scherer, D'Antonio, & McGahey, 2008;Scherer et al., 2020Scherer et al., , 2022 (Gilkerson et al., 2018;Ha, Kim, & Lee, 2022;Wang, Williams, Dilley, & Houston, 2020 (Elmquist, Finestack, Kriese, Lease, & McConnell, 2021;Gilkerson, Richards, & Topping, 2017;Wang et al., 2017;Well & Middleton, 2010 (Ha, 2015;Hardin-Jones & Chapman, 2008;Kaiser et al., 2017;Lohmander-Agerskov et al., 1990;Scherer et al., 2008; ...
... (Ha, 2015;Hardin-Jones & Chapman, 2008;Kaiser, Scherer, Frey, & Roberts, 2017;Lohmander-Agerskov, Soderpalm, Friede, & Lilija, 1990;Scherer, D'Antonio, & McGahey, 2008;Scherer et al., 2020Scherer et al., , 2022 (Gilkerson et al., 2018;Ha, Kim, & Lee, 2022;Wang, Williams, Dilley, & Houston, 2020 (Elmquist, Finestack, Kriese, Lease, & McConnell, 2021;Gilkerson, Richards, & Topping, 2017;Wang et al., 2017;Well & Middleton, 2010 (Ha, 2015;Hardin-Jones & Chapman, 2008;Kaiser et al., 2017;Lohmander-Agerskov et al., 1990;Scherer et al., 2008; ...
Objectives: This study aimed to verify the effectiveness of early intervention for children with cleft palate using the Language ENvironment Analysis (LENA), and to investigate whether LENA’s automated measures reflect the effects of early intervention.Methods: Thirteen children with cleft palate (CP) and their parents participated in all sessions of an early intervention program. Twelve children with CP and their parents were involved as a control group, participating only in pre- and post-intervention assessments. The intervention included five direct training sessions and interventions implemented by parents at home for 3 months. As part of the training, parents were instructed to record a one-day LENA recording before and after the assessments and during each session of direct training. During these sessions, parents reviewed their language stimulation and interaction skills, analyzing the results of automated LENA measures reflecting the language environment.Results: Children in the intervention group demonstrated a significantly greater change in expressive vocabulary size and consonant inventory after the intervention. Parents who received training exhibited significantly increased contingent utterances, such as imitation, expansion, and recast, in response to their children’s communication acts compared to those who did not receive the training. Children who received early intervention exhibited a significant improvement in conversation turn counts and child vocalization counts, as measured by automated LENA measures.Conclusion: The results support that using LENA technology can improve early intervention for children with CP. LENA measures can monitor positive changes in children’s speech-language development and parents’ use of communication strategies.
... Perceptual speech assessment is the gold standard, 28 and it is reported that specialist SLTs can reliably identify CSCs as early as age 18 months. 29 In the UK, services offer early assessment, with routine reviews at 12 and 18-24 months and at 3 and 5 years of age. Reviews continue into adulthood, but a primary audit goal is for children to achieve 'normal' speech ratings across all parameters (resonance, nasal airflow, and CSCs) by school entry at age five. ...
This paper describes the impact of cleft lip and palate on speech. It provides an overview for the dental clinician of the key issues affecting speech development and clarity. The paper summarises the complex speech mechanism and cleft-related factors that affect speech, including palatal, dental and occlusal anomalies. It outlines the framework for speech assessment throughout the cleft pathway and provides a description of cleft speech disorder, as well as describing treatment approaches for cleft speech and velopharyngeal dysfunction.This is followed by a spotlight on speech prosthetics for treating nasal speech, with an emphasis on joint management by the Speech and Language Therapist and Consultant in Restorative Dentistry. This includes the core multidisciplinary approach, clinician and patient-reported outcome measures, and brief discussion of national developments in this area.The importance of multidisciplinary cleft care is highlighted and, within this, the essential interaction between speech and dental clinicians in providing routine care, as well as in delivering a highly specialist speech prosthetics service.
... It has been proposed that, additional supports, such as visual biofeedback using electropalatography (Gibbon et al., 2001) or nasoendoscopy (Ysunza et al., 1997), might provide more rapid progress than articulation-based approaches alone. Motor-based treatments have been directly compared with phonological approaches, and the results indicated that, while phonological approaches can result in more rapid progress (e.g., M. C. Pamplona et al., 1999), motor-based approaches are effective as well (Hardin-Jones & Chapman, 2008). With positive results occurring from both approaches, it is likely that no single approach is best with this population, and treatment should be based on patient-specific factors (Alighieri et al., 2021). ...
Purpose:
Cleft palate is one of the most common birth defects in the United States. Most of these children receive speech therapy by preschool and school-based clinicians. The purpose of this article is to provide a comprehensive tutorial for speech-language pathology assistants (SLPAs) regarding treatment techniques and principles for children with cleft palate.
Method:
It has been reported that 68% of preschoolers with repaired cleft palate received speech therapy. Preschool and school-based speech-language pathologists (SLPs) have reported a strong desire for practical professional development and continuing education resources regarding treatment of children with cleft palate. Thus, it seems likely that SLPAs may feel similarly unequipped to provide effective treatment for children with cleft palate. Obligatory and learned speech errors commonly found in children with cleft palate are described. Elicitation strategies for compensatory articulations are detailed. The implementation of evidence-based articulation and phonological treatment approaches is described in a step-by-step manner. "Red flags" that may arise during treatment and require input from the supervising SLP are highlighted.
Results:
SLPAs will learn elicitation techniques for compensatory articulations and implement evidence-based treatment approaches to improve the speech accuracy of children with cleft palate.
Conclusion:
It is important for all school-based clinicians to be familiar with speech therapy for individuals with cleft palate.
... Although this type of intervention has been used for over 40 years in children with a CP±L, only 7 studies investigated the effectiveness of motor-phonetic articulation therapy in this population (Van Demark, 1974;Van Demark & Hardin, 1986;Ma et al., 1990;Chen et al., 1996;Pamplona et al., 1999;Yang et al., 2003;Hardin-Jones & Chapman, 2008). Despite that these studies support the use of the motor-phonetic articulation approach, several limitations prevent us to make valid conclusions on the effectiveness of this approach. ...
... Seven studies investigated the use of this motor-phonetic approach in children with CP±L (Van Demark, 1974;Van Demark & Hardin, 1986;Ma et al., 1990;Chen et al., 1996;Pamplona et al., 1999;Yang et al., 2003;Hardin-Jones & Chapman, 2008). Unfortunately, most of these studies are outdated and lacked a detailed description of the methods hindering an in-depth comparison of the results. ...
... specific lip and tongue movement training) in their treatment programs. Hardin- Jones and Chapman (2008) investigated the impact of early intervention provided by community SLPs on speech and lexical development in toddlers with a CP±L. Their findings revealed no treatment benefits of early intervention. ...
The presence of compensatory speech errors severely impacts speech understandability and speech acceptability in children with a cleft palate with or without a cleft lip (CP±L) (Harding & Grunwell, 1998). To eliminate these compensatory speech errors, speech therapy is required (American Cleft Palate-Craniofacial Association, 2016). Almost two decades ago, the World Health Organization (WHO) stressed the need for effectiveness studies within the field of CP±L (Mossey & Catilla, 2003). Unfortunately, a systematic literature review revealed that there is still little evidence to support any specific speech therapy approach or any specific intervention dosage (Bessell et al., 2013). Moreover, evidence-based practice (EBP) goes beyond the application of intervention approaches for which evidence exists (Steglitz et al., 2015). EBP involves integration and harmonization of (1) the clinicians’ perspective, (2) the patients’ and parents’ perspective, and (3) the best available research evidence (Steglitz et al., 2015). This doctoral thesis focused on these three cornerstones of EBP.
The clinicians’ perspective: this thesis investigated the practice patterns of Flemish community speech-language pathologists (SLPs) when treating children with a CP±L. Additionally, it explored how SLPs perceive and experience the provision of speech therapy to children with a CP±L. They report a lack of available information on speech therapy-related cleft care. Most SLPs use a hybrid treatment model including a variety of intervention techniques not always in line with available scientific evidence. Scientific findings do not always reach community SLPs. This thesis revealed the existence of a research-practice gap that may have an adverse effect on the quality of provided cleft speech therapy services.
The parents’ perspective: to tailor a specific intervention approach or intervention dosage to a specific patient and his/her family, it is crucial to have insight into their perceptions on and experiences with the CP±L and the provided therapy. This doctoral thesis revealed that the most prominent expectation of parents is that they want to see their children progress during speech therapy. This highlights the need for EBP in this field. Parents consider speech therapy burdensome, mainly because of the treatment dosage that is generally applied in Flanders (i.e. two 30-minute speech sessions per week for several months or years). This doctoral thesis improved our understanding of how parents of children with a CP±L experience the current speech therapy delivery models. Perhaps, the current delivery models need to be reconsidered to decrease the experienced burden.
The best available research evidence: given the current lack of research, this doctoral thesis investigated the effect of different speech therapy approaches (content) and different speech therapy intensities (dosage) to eliminate compensatory speech errors in children with a CP±L.
Content. Speech errors in children with a CP±L are traditionally conceptualized as phonetic (articulation) disorders (Morley, 1945). Phonetic errors refer to difficulties with the correct motor production of a sound, even in an isolated production or in syllables. Different authors suggested that cleft palate speech errors can also be conceptualized as phonological errors (Chapman, 1993; Morris & Ozanne, 2003; Willadsen et al., 2018). Phonological errors refer to difficulties in using sounds in meaningful words. Therefore, this doctoral thesis compared the effect of two different speech therapy approaches (i.e. a traditional motor-phonetic approach and a linguistic-phonological approach) on speech and health-related quality of life (HRQoL) in Flemish and Ugandan patients with a CP±L. Both in Flanders and Uganda, a linguistic-phonological approach was found to be more effective in terms of improving speech outcomes. Speech therapy, irrespective of the used approach, improves the children’s HRQoL (based on children’s self-reports and parent proxy reports).
Dosage. To date, the optimal speech therapy dosage in children with a CP±L is unknown (Bessell et al., 2013). The decision for selecting a particular intervention dosage is usually dependent on the countries’ health regulations and insurance providers (Howard & Lohmander, 2011; Bessell et al., 2013). This thesis compared the short- and long-term effects of speech therapy provided with a high intensity (10 one-hour sessions for 2 weeks) and speech therapy provided with a low intensity (10 one-hour sessions for 10 weeks) on speech and HRQoL in Flemish children with a CP±L. Children who received high intensity speech intervention made significantly more progress in 2 weeks of therapy compared to children who received low intensity speech intervention. High intensity speech intervention is a promising strategy to improve speech outcomes and HRQoL in a shorter period.
This doctoral thesis is an important first step towards evidence-based practice in cleft palate speech therapy services. This thesis does not only provide evidence-based speech therapy approaches and dosages, but it also results in a deeper understanding of the perspectives and perceptions of important stakeholders in cleft palate speech therapy. In the future, the search for the most effective speech therapy approach and speech therapy dosage to eliminate compensatory speech errors in children with a CP±L will need to continue. Studies including larger sample sizes based on power analyses are highly needed.
... We certainly agree with calls for more rigorous and standardized methods for studying changes in speech behavior (Allori et al., 2017;Sell, 2005). However, we also believe that the unclear literature stems from how interventions have been evaluated on a fundamental level and that intervention outcomes mostly have been evaluated based on statistical significance (e.g., Alighieri et al., 2020;Hardin-Jones & Chapman, 2008;Pamplona et al., 2005Pamplona et al., , 2014, rather than clinical relevance. ...
Purpose
Cleft lip and/or palate (CLP) is a common birth defect, and after reconstructive surgery, about 50% of children at 5 years of age have speech deviations and are referred to speech-language therapy (SLT). The peer-reviewed evidence for the benefit of SLT has been uncertain. Our objective was to systematically review and meta-analytically summarize the benefit of SLT for individuals born with CLP.
Method
A systematic search was conducted (last search on February 19, 2021) on studies evaluating SLT with pre and post measures on speech production, language ability, intelligibility, and/or patient-reported outcomes. We sought individual participant data (IPD) and evaluated on an individual level if the outcome measure had improved to a clinically relevant degree during SLT and if the outcome measure was on a level with peers or not after SLT. Meta-analyses and meta-regressions were applied to synthesize IPD across studies.
Results
Thirty-four eligible studies were found. Nineteen studies provided IPD ( n = 343) for the main analysis on speech production. The synthesized information suggests that, during SLT, speech production improved to a clinically relevant degree for many individuals (95% CI [61%, 87%]) and that speech production was on a level with peers for some individuals after SLT (95% CI [10%, 34%]).
Conclusions
The main strength of this meta-analysis is that we evaluated on an individual level pre- and post-intervention data based on considerations of clinical relevance. This approach allowed us to conclude that many individuals benefit from SLT and that further work on evaluating SLT in this patient group is meaningful.
Supplemental Material
https://doi.org/10.23641/asha.17700992
... There was variation in the quality of the studies, with three studies demonstrating a moderate to high level of quality on the PEDro-P and SCED tools, scoring positively on at least six of the 10 questions (Kaiser et al., 2017, Scherer et al., 2008, Scherer, 1999. A further three papers were rated as fair quality with scores of 4 or 5 on the PEDro-P scale (Ha, 2015;Hardin-Jones & Chapman, 2008;Westberg et al., 2017). The study by Lohmander-Agerskov et al. (1990) was rated as poor quality, scoring 3 on the PEDro-P scale. ...
... In terms of study design, there was one randomized controlled trial (evidence level I: Kaiser et al., 2017), one nonrandomized controlled trial (Evidence level II: Scherer et al., 2008), four cohort studies (evidence level II: Ha, 2015;Hardin-Jones & Chapman, 2008;Westberg et al., 2017;Lohmander-Agerskov et al., 1990) and one case series (evidence level IV: Scherer, 1999). Four studies were undertaken in the United States (Hardin-Jones & Chapman, 2008;Kaiser et al., 2017;Scherer, 1999, Scherer et al., 2008, two in Sweden (Lohmander-Agerskov et al., 1990;Westberg et al., 2017) and one in Korea (Ha, 2015). ...
... In terms of study design, there was one randomized controlled trial (evidence level I: Kaiser et al., 2017), one nonrandomized controlled trial (Evidence level II: Scherer et al., 2008), four cohort studies (evidence level II: Ha, 2015;Hardin-Jones & Chapman, 2008;Westberg et al., 2017;Lohmander-Agerskov et al., 1990) and one case series (evidence level IV: Scherer, 1999). Four studies were undertaken in the United States (Hardin-Jones & Chapman, 2008;Kaiser et al., 2017;Scherer, 1999, Scherer et al., 2008, two in Sweden (Lohmander-Agerskov et al., 1990;Westberg et al., 2017) and one in Korea (Ha, 2015). Three of the studies were conducted after 2010 (Ha, 2015;Kaiser et al., 2017;Westberg et al., 2017), two took place between 2000 and 2010 (Hardin-Jones & Chapman, 2008, Scherer et al., 2008, and two were conducted between 1990 and 2000 (Lohmander-Agerskov et al., 1990;Scherer, 1999). ...
Background
Children with cleft palate with or without cleft lip (CP±L) are at high risk of problems with early speech sound production, and these difficulties can persist into later childhood. Early intervention could help to reduce the number of children whose problems become persistent. However, much research in the field to date has focused on older children. There is a need to determine if providing intervention during the phase of early typical speech development leads to better outcomes.
Aims
To review the evidence for the effectiveness of interventions targeting speech, delivered in the first 3 years of life for children with CP±L, and discuss factors such as intervention type, facilitator, dosage, outcome measures and the age of the child.
Methods & Procedures
The systematic review was registered with PROSPERO (CRD42019121964). Eight bibliographic databases including CINAHL and MEDLINE were searched in August 2018. Studies were included if participants received speech and language interventions before 37 months and if they reported outcomes for speech. Two reviewers independently completed inclusion reviews, quality analysis and data extraction.
Outcome & Results
The review included seven papers: one pilot randomized controlled trial, one controlled trial, four cohort studies and one case series report. Interventions largely took a naturalistic approach, namely focused stimulation and milieu teaching. The findings provide preliminary support for naturalistic interventions and suggest that these interventions can be delivered by parents with suitable training. Studies included in the review provided low-strength evidence with variation in both the type of intervention, the manner of delivery and in the risk of bias in the designs used.
Conclusions & Implications
The papers included in this review suggest that early naturalistic interventions can have positive impacts on the speech development of children with CP±L. However, the reported methodological quality of the publications overall was weak, and the current evidence lacks clarity and specificity in terms of therapy technique, delivery and optimum age of delivery. Future research should use more robust methodological designs to determine whether early speech interventions are beneficial for children born with CP±L.
What this paper adds
What is already known on the subject
• Children with CP±L show difficulties with early speech development and often have restricted speech sound inventories. They may reach the canonical babbling stage later than children without CP±L and studies have shown that 20% of children with CP±L have speech which is considered unintelligible or barely intelligible at age 5. It has been proposed that early intervention can lessen the impact of CP±L on speech development. However, currently, the evidence for early interventions for children with CP±L is limited, with the majority of studies focusing on children aged 3 years and older.
What this paper adds to existing knowledge
• This paper reviews the evidence for different types of early interventions for speech provided to children born with CP±L and whether these interventions are effective in supporting speech sound development. In this review, early intervention is defined as intervention provided to children in the first 3 years of life. This review describes intervention approaches and how they are delivered for this population.
What are the potential or actual clinical implications of this work?
• In the UK, children born with CP±L and their families are supported by National Health Service (NHS) services over a 20-year period and speech and language therapy sessions may take place over many weeks and months. If providing early intervention in the first 3 years of life is effective, there is the potential for improved speech outcomes in early childhood and a reduced burden of care on children, families and services. This review considers the evidence for early speech intervention for children with CP±L in the first 3 years of life and identifies areas for future research.
... This moment will mark the way forward in each case [22]. If the results are satisfactory in terms of anatomy and function, it is common for babies to begin producing high-pressure phonemes 2-3 months after the palate closure [23]. ...
Background
Due to the lockdown and quarantines caused by the COVID-19 pandemic, the need to study and use telepractice for providing speech pathology interventions for children with cleft palate has arisen.
Objective
To carry out a systematic review of the use of telepractice during the COVID-19 pandemic for providing speech pathology interventions for Spanish-speaking children with cleft palate.
Methods
In July and August 2020, the authors searched the electronic databases Medline, LILACS, SciELO, and the Cochrane Library using the following keywords in English (MeSH): Cleft palate combined with Early intervention, Speech therapy, Rehabilitation of speech and language disorders, Speech production measurement, Speech articulation tests and Telemedicine. Original articles were selected and analyzed, complemented by an analysis of flowcharts and recommendations by the GES Clinical Guide of Cleft Lip and Palate of Chile's Government and the authors’ expert opinions.
Results
A total of 2680 articles were retrieved, of which 23 were critically analyzed and used to adapt the early stimulation, evaluation, and treatment of children with CP to speech therapy telepractice at the Gantz Foundation, a Hospital in Santiago de Chile. Limitations: Only three researchers carried out a quick review, which limited the depth of individual analysis of the studies included. Also, the suggestions and material presented should be evaluated in future investigations.
Conclusion
This systematic review provides useful guidelines for providing speech pathology interventions through telepractice for children with cleft palate. Audiovisual materials seem to be extremely useful for families receiving the interventions. The use of interactive videos for Spanish-speaking children and educational videos for parents is manifest.
... The SLP models the correct production of the sound, and the child is given sufficient time to listen to their speech and to identify the error. Seven studies investigated the use of this motor-phonetic approach in children with CP ± L (Chen et al., 1996;Hardin-Jones & Chapman, 2008;Ma et al., 1990;Pamplona et al., 1999;Van Demark, 1974;Van Demark & Hardin, 1986;Yang et al., 2003). Unfortunately, most of these studies are outdated and lacked a detailed description of the methods hindering an in-depth comparison of the results. ...
... Ma et al. (1990) and Chen et al. (1996), for example, included oral motor exercises (i.e., specific lip and tongue movement training) in their treatment programs. Hardin-Jones and Chapman (2008) investigated the impact of early intervention provided by community SLPs on speech and lexical development in toddlers with a CP ± L. Their findings revealed no treatment benefits of early intervention. Interestingly, oral motor therapy was being utilized by some of the SLPs, which might have accounted for the reported results. ...
Purpose. The purpose of this study was to compare the effect of two different speech
therapy approaches, a traditional motor-phonetic approach and a linguistic-phonological approach, on the speech and health-related quality of life in Dutch-speaking children with a cleft palate with or without a cleft lip (CP±L) between 4 and 12
years old.
Methods. A blocked-randomized sham-controlled design was used. Fourteen children
with a CP±L (mean age: 7.71 years) were divided into two groups using blocked
randomization stratified by age and gender: one receiving motor-phonetic intervention
(MPI) (n=7) and one receiving linguistic-phonological intervention (LPI) (n=7).
Each group received 10 hours of speech therapy divided over two weeks. Perceptual
speech assessments were performed on several baseline and post-treatment data
points. The psychosocial effects of the intervention were assessed using the patient-reported VELO questionnaire. Both groups were compared over time using
(generalized) linear mixed models. Within-group effects of time were determined using
pairwise comparisons with post-hoc Bonferroni correction.
Results. Significant time-by-group interactions with large effect sizes were revealed in
terms of consonant proficiency, indicating significant differences in evolution over time
among the two groups. Only in the group receiving LPI, percentage correctly produced
consonants and places significantly improved after the treatment. Total VELO scores of
the parents significantly improved in both groups after the intervention.
Conclusion. Both motor-phonetic and linguistic-phonological speech interventions can
have a positive impact on the occurrence of cleft speech characteristics and consonant
proficiency in children with a CP±L. A linguistic-phonological approach, however, was
observed to be more effective in terms of improving these speech outcomes compared
with a motor-phonetic approach. Speech intervention, irrespective of the used
approach, significantly improved the participant’s health-related quality of life.
... To date, the effectiveness of motor-phonetic and linguistic-phonological approaches has been barely demonstrated. A systematic review by Bessell et al. [4] identified seven studies [3,[12][13][14][15][16][17] investigating the effectiveness of motor-phonetic approaches and three studies [16,18,19] investigating the effectiveness of linguistic-phonological approaches when treating children with CP ± L. Unfortunately, a lack of evidence to support any approach was found since most studies were dated, used differentoutcome measures, and lacked detailed description concerning treatment provider,setting, and included patients [4]. As a result, the selection of particular approaches is often based on general opinions, clinical experience, or strategies described in papers [4]. ...
... In general, the literature suggests that traditional motor-phonetic (i.e. articulation) treatment results in overall improvement of speech [3,[12][13][14][15][16][17]. Detailed description of the treatment approach often lacked and the specific nature of the change was seldomly reported [4]. ...
Introduction: At present, there is growing interest in combined phonetic-phonological approaches to treat active speech errors
in children with a cleft (lip and) palate (CP±L). Unfortunately, evidence
for these type of speech interventions in this population is lacking.
Therefore, the present study investigated the effectiveness of speech
intervention in Ugandan patients with CP±L. Moreover, a comparison was made between a motor-phonetic and a phonetic-phonological speech intervention.
Methods: Eight patients (median age: 11.26y) with an isolated CP±L were assigned into a group receiving motor-phonetic treatment (n=4) or a group receiving combined phonetic-phonological treatment (n=4). The participants received 6 hours of individual speech therapy. In both
groups, perceptual and instrumental speech evaluations were performed to evaluate the patients' speech before and after intervention.
Results: Speech therapy (irrespective of the used approach) was found to be effective in increasing consonant proficiency and in decreasing the occurrence of non-oral and passive CSCs. No statistically significant differences in outcome variables were found when comparing the two groups pre- and post-treatment. The descriptive results, however, revealed a larger increase in % correctly produced consonants, places and manners after the intervention in the group receiving a combined phonetic-phonological treatment compared to the group receiving a motor-phonetic treatment.
Conclusion: This study took a first step in providing evidence
concerning the effectiveness of different speech therapy approaches in children with CP±L. The present study holds some important implications for clinical practice suggesting that an additional phonological approach may be beneficial for the patients with CP±L. Further research including randomized controlled trials with larger sample sizes is necessary to provide further evidence.
... Following surgery, despite the fact that the child's ability for producing the plosive sounds or other speech patterns in a more typical manner has been adequately enhanced, the child persists in producing the compensatory articulation patterns because they have been integrated into the phonological rules. At this point in time, what once was a phonetic compensation becomes a phonological disorder [6,15]. As a productive rule, the articulatory production would not change until the rule is changed, despite that the mechanical and structural abilities to produce the sound adequately have been enhanced. ...
