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108]
Original Article
Effectiveness of early intervention on
awareness and communication behaviors of
mothers of toddlers with repaired cleft lip and
palate
M. Pushpavathi, Kavya Vijayan, Akshatha Vishwanath
ABSTRACT
Objective: The present study is aimed to provide an
insight on the causative factors on expressive language
delay in toddlers with repaired cleft lip and palate
(RCLP). Participants: The present study considered
mothers of ten toddlers with RCLP with a mean age
of 2.8 years who underwent surgery within 1.5 years.
Method / Interventions: The mother-child dyads were
enrolled for Early Language Intervention Program
(ELIP). The mothers were assessed for the awareness
about CLP through a questionnaire and home training
was assessed through Mohite’s Inventory. Speech and
non-speech behaviors of the mothers were assessed
using a check list based on an interactional video. These
three measures were done before initiating speech and
language therapy. Post-therapy measurement was
done after 20 sessions. Main Outcome Measures -
Pretest post-test design was used to compare the
differences in measures for the pre-therapy and post-
therapy conditions. Results: Mothers showed greater
awareness regarding causes, assessment, treatment,
associated problems and issues related to speech
therapy in CLP post-orientation (p≤ 0.05). Results also
indicated improved home-training abilities of parents
on parameters such as language stimulation, physical
environment, variety of stimulation and maternal
attitude (p≤ 0.05). A statistically significant difference
was also noted for speech and non-speech behaviors
of the mother (p≤ 0.05). Conclusions: Extensive
counseling and orientation helped mothers to gain
effective knowledge about cleft lip and palate and
focused stimulation approach enabled them to deliver
the intervention reliably.
Key words: Awareness, cleft palate, early
intervention, home training
Department of Speech‑Language Pathology, All India Institute of
Speech and Hearing, Mysuru, Karnataka, India
Address for correspondence:
Dr. M. Pushpavathi,
Department of Speech‑Language Pathology, All India Institute of Speech
and Hearing, Manasagangothri, Mysuru ‑ 570 006, Karnataka, India.
E‑mail: shivanna.pushpa@gmail.com
S88 © 2017 Journal of Cleft Lip Palate and Craniofacial Anomalies | Published by Wolters Kluwer ‑ Medknow
Access this article online
Website:
www.jclpca.org
DOI:
10.4103/jclpca.jclpca_68_17
Quick Response Code:
INTRODUCTION
Cleft of lip and palate (CLP) is one of the most common
congenital anomalies which occurs due to multifactorial
condition resulting in various associated problems.[1]
Several studies have reported that before 3 years of age
toddlers with repaired cleft of lip and palate (RCLP)
demonstrate various language deficits such as delayed
onset, limited vocabulary, restricted sound inventories,
and compensatory articulation.[2,3] Expressive language
delay (ELD) is one of the most common conditions in
children with RCLP, wherein a severe delay is observed
in the expressive language, whereas the receptive
language skills and cognitive abilities are reported to
be age appropriate.[4]
The various language issues in children with RCLP
could be attributed to the lack of extensive counseling
and orientation regarding the issues related to speech
and language rehabilitation which would result in
inadequate knowledge about CLP.[5] The other reasons
can be attributed to less positive mother–child
interaction and stimulation patterns in the home
environment. Due to the limitations in the child’s
oromotor structures, they may not respond adequately
to the mother’s effort to communicate. This would
in turn affect the mother’s responsiveness as well as
the type and amount of linguistic input. Other factors
such as extended hospital stays, hearing loss related to
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Cite this article as: Pushpavathi M, Vijayan K, Vishwanath A. Effectiveness
of early intervention on awareness and communication behaviors of mothers
of toddlers with repaired cleft lip and palate. J Cleft Lip Palate Craniofac
Anomal 2017;4:S88-93.
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Pushpavathi, et al.: Effect of intervention on mothers of toddlers with RCLP
middle‑ear infections, and repeated exposure to surgical
pain may interfere with the readiness to learn, and thus
may cause a delay in expressive language.[4,6]
The necessity for early language intervention soon after
surgery for children with CLP has been documented
in some studies, and it has been established that early
language intervention programs (ELIP) are successful
in facilitating speech and language output.[3,7] The
role of maternal speech stimulation and the inclusion
of a parent‑implemented schedule in such early
intervention programs have been intensively studied.[3,8]
It has been seen that mothers who were enrolled in a
parent‑implemented program were able to improve their
abilities in providing speech and language stimulation
to their children after the scheduled series of training
sessions.[3,9] The American Cleft Palate Association also
encourages “ensuring that the family/caregiver and
patient have opportunities to play an active role in the
treatment process.”[10]
Although the incidence of CLP has been on the rise
in the Indian context,[11] the health‑care facilities and
benefits provided have not been utilized solely due to
the lack of awareness among the parents or the various
health‑care providers themselves. Research over the
past decade has indicated that parents of children with
disabilities including orofacial clefts have been seen
to demonstrate various psychosocial concerns such as
depression, anxiety, and stress which in turn affects the
growing parent‑child relationship.[12,13] Thus, the family
environment is an important factor in the rehabilitation
of a child with a facial/orofacial cleft. The attitudes,
expectations, and degree of support shown by parents
are likely to have an enormous influence on a child’s
perception of their cleft impairment.[14,15]
A survey on parents of children with CLP showed
that the rehabilitation program should also help
with issues such as financial management of having
a child with a birth defect, recreation for the child
and child care, along with counseling options for
the family members.[16] It is also advocated that the
professionals should provide adequate information
to the parents early in the course of treatment and in
multiple sessions which in turn increases parental
retention of information and promotes the process
of coping. [17,18] The parental attitudes toward the
treatment of their child’s cleft palate was evaluated
and it was found that 36% of parents wished for more
participation in their children’s treatment decisions
and a large percentage (65%) thought that their
help was insignificant or ineffective.[19] This clearly
Journal of Cleft Lip Palate and Craniofacial Anomalies Volume 4 / Supplement 1 / November 2017
indicates the lack of awareness among parents about
the extent of their involvement in the rehabilitative
process of their child during the early years. Due to
the transcultural factors in India such as ignorance,
transportation problems, difficulties in meeting the
expenses, neglect of the child, and gender bias often
the medical and nonmedical treatments get delayed.[20]
A recent Indian study highlighted that the mothers of
children with RCLP showed a belief in some myths with
respect to causes and treatment although they had some
awareness regarding the associated problems of CLP.[5]
Over the years, various inventories have been developed
in the Indian context to measure the effects of home and
family environment on the child’s speech and language
development. Mohite Home Environment Inventory is
one such inventory which measures the effect of home
and family environment on the child’s development.[21]
Research conducted in India by making use of this
inventory have highlighted that the home environments
which provide less linguistic and cognitive stimulation
to the child resulted in the children demonstrating a
language delay.[22]
The incidence of CLP is on the rise in the recent
years which calls for a thorough investigation into the
contributing factors leading to linguistic deficits in this
population as studies related to the same are limited.
Thus, there is a need to carry out an explorative study
to assess the knowledge and attitudes of Indian parents
about the issues related to CLP, which could also throw
light on the factors which could be involved in causing
ELD in toddlers with CLP. The objectives of the present
study are as follows:
1. To study the influence of orientation and counseling
on the parental awareness levels and the quality of
home training
2. To examine the changes if any, in the speech and
nonspeech behaviors of mothers before and after
the intervention program.
METHODS
Participants
Ten toddlers in the age range of 1–4 years who were
diagnosed to have ELD secondary to RCLP, along
with their mothers, served as participants for the
study and is provided in Table 1. The mothers were
in the age range of 20–35 years, had passed atleast
12th grade, were in the middle‑to‑high socioeconomic
status and had Kannada as their native language. The
language evaluation of the toddlers was carried out
by a qualified Speech Language Pathologist (SLP)
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Pushpavathi, et al.: Effect of intervention on mothers of toddlers with RCLP

Table 1: Detailed description of participants of the study

Participants Type of cleft Age of surgery Age of enrollment Language age
for therapy (year) (months)
RLA ELA
1 Complete cleft of primary palate 1 year (palate) 1.6 16-18 9-10
2 Unilateral complete cleft of lip 5 months (lip) and 1 year (palate) 3 33-36 20-22
and palate
3 Unilateral complete cleft of lip 7 months (lip) and 1.1 years (palate) 2 22-24 18-20
and palate
4 Cleft of soft palate 1 year (palate) 2 22-24 12-14
5 Unilateral complete cleft of lip 4 months (lip) and 11 months (palate) 1.8 16-18 12-14
and palate
6 Bilateral complete cleft of hard 1.8 years (palate) 2.4 27-30 12-14
and soft palate
7 Cleft of soft palate 1.6 years (palate) 2.6 27-30 16-18
8 Unilateral complete cleft of lip 7 months (lip) and 3 years (palate) 3.9 36-40 18-20
and palate
9 Bilateral complete cleft of lip 7 months (lip) and 1.6 years (palate) 3 33-36 22-24
and palate
10 Incomplete cleft of soft palate 11 months (palate) 2.2 24-27 20-22
RLA: Receptive language age, ELA: Expressive language age

using Receptive‑Expressive Emergent Language Scale
(REELS).[23] Children aged below 4 years and diagnosed
as ELD secondary to RCLP were enrolled for the ELIP
at our institute. The participants had not received any
speech and language therapy before enrollment. The
other inclusionary criteria included normal hearing
and cognitive abilities. Any history of neurological
or psychological illness was ruled out. An informed
consent (approved by the Ethical Committee) was
obtained from the parents before their participation in
the study.
Materials
Three different materials were used for the purpose of
investigating the factors contributing to ELD in the CLP
population. They have been mentioned below.
1. Questionnaire on Awareness of parents on Issues
Related to CLP – The questionnaire contained
eight domains such as attitude of parents,
causative factors, associated problems, treatment
(general and surgical), speech therapy, and general
nature of CLP. Each domain had ten statements
which consisted of five myths and five facts. Thus,
there were a total of 80 statements. The response
for each of the question was close‑ended and binary
choice of response was provided[5]
2. Mohite Home Environment Inventory – This
inventory was developed to assess home environment
for speech and language stimulation. It consists
of five domains such as “language stimulation,”
“physical environment,” “encouragement of social
maturity,” “variety of stimulation,” and “maternal
attitude and disciplining.” It consists of a total of 24
statements. The response for each of the question
was close‑ended and binary choice of response was
provided[21]
3. Checklist to assess speech and nonspeech behavior
of the mother – A checklist was prepared after
conducting a thorough review of literature with
respect to the behaviors adopted by a mother
while providing speech stimulation to her child.
The checklist consists of a total of 37 statements
segregated under three domains. The three
domains are “speech behaviors” which assesses
the quality of speech stimulation provided by the
mother, “nonspeech behaviors” which assesses the
pragmatic skills of the mother while giving therapy
and “other behaviors” which assesses the activeness
of the mother during the session. The aspects of
each domain were arrived at by observing and
noting down the speech and nonspeech behaviors
of mothers in various videos which were recorded
during free play and interaction between mothers
and toddlers with RCLP. During analysis, the
appropriate behaviors were marked off by the SLP,
by observing the interaction session between the
mother and child with CLP.
Procedure
In the preliminary stage, the mothers were enrolled for
the ELIP program and following this, their awareness
about CLP was assessed through the parental awareness
questionnaire and each item was scored. This was
followed by a detailed pretherapeutic evaluation
which was conducted to establish the baseline of the
children and mother’s speech and language behaviors.
The quality of home training was assessed through
Mohite’s Inventory. Subsequently, the speech and

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Pushpavathi, et al.: Effect of intervention on mothers of toddlers with RCLP

nonspeech behaviors of the mothers were assessed
using the developed checklist and scored. The scores
of Mohite inventory and behavior checklist were based
on mother‑child interactional video of 45‑min duration.
A detailed counseling and orientation session was
provided to the mothers regarding the classification,
causes, team approach, evaluation, and various
management issues in children with CLP. Speech and
language therapy was initiated for toddlers soon after
orientation. After 20 sessions of intensive therapy by
the SLP, wherein mother was also an active participant,
the questionnaire and checklists were readministered
to find out the disparity in scores between the pre‑ and
post-test measurements. The 20 therapy sessions were
carried out over a period of 2 months. Audio‑video
recording was carried out for each child during the
initial sessions and after 20 sessions of therapy to
ascertain the amount of stimulation provided by the
mother before and after therapy.
analysis. The results obtained are discussed under
different heads below.
Awareness of parents on issues related to cleft
of lip and palate
The awareness levels present in mothers before
attending therapy and after the intervention was
assessed, and the mean values obtained under each
domain are presented in the table below.
Table 2 clearly depicts the fact that mothers showed
a lesser amount of awareness regarding causes,
assessment, treatment, associated problems, and issues
related to speech therapy in CLP before orientation.
During the posttherapy condition, it was observed that
the mothers showed a greater level of awareness in all
the eight domains. To statistically analyze the data,
Wilcoxon Signed Rank test was administered which
revealed a significant difference (*P ≤ 0.05) between
the pre‑test and post‑test scores under each domain.

Focused stimulation approach was used which was Quality of home training
also shown to the mother during therapeutic sessions. The quality of home training was assessed using the
A multisensory approach was used to increase the Mohite Home Environment Inventory. The results
oromotor movements. A corpus of vocabulary was exemplify that the home training provided by the parents
prepared in the master lesson plan which contained of children with RCLP was poor. The maternal attitude
the most commonly used functional words by toddlers. and disciplining were observed to be poor during the
The positive behaviors of the child were reinforced pretest. Furthermore, the amount of language stimulation
appropriately. The mother was told to carry out a similar
training program at home in the absence of direct Table 2: The mean scores and P value of the mother’s
supervision of the SLP. response for parental awareness questionnaire under
different domains during pre‑ and post‑test conditions
Analysis Domains Mean SD P
The scores obtained under different domains in the Pre Post Pre Post
questionnaire, inventory, and checklist were tabulated General 59.00 95.00 21.32 8.50 0.01*
and subjected to statistical analysis. The data from the Attitude 77.00 95.00 15.67 7.07 0.02*
Causes 64.00 98.00 17.76 4.22 0.01*
participants were analyzed using  SPSS software (Statistical
Associated problems 79.00 95.00 11.97 10.80 0.01*
Package for the Social Sciences) was acquired by IBM Corp. Assessment 64.00 93.00 20.66 8.23 0.01*
in 2009 (version 21). Results of Kolmogorov–Smirnov test Treatment 62.00 96.00 19.32 5.16 0.01*
and Shapiro–Wilk test revealed that the data did not follow Surgery 68.00 94.00 11.35 8.43 0.01*
normal distribution. Thus, nonparametric measures were Speech therapy 82.00 96.00 12.29 6.99 0.03*
employed in the study. Wilcoxon signed rank test was *P≤0.05. SD: Standard deviation

administered to check the statistical significance between

pre‑test and post‑test scores. Table 3: The mean scores and P values for Mohite home
environment inventory under different domains during
RESULTS pre‑and post‑test conditions
Domains Mean SD P
The present study serves as a prefatory endeavor to Pre Post Pre Post
highlight the factors which may be responsible for the Language stimulation 80.93 95.47 19.49 9.95 0.04*
delay in speech and language stimulation in toddlers Physical environment 100.00 100.00 0.00 0.00 1.00
Variety of stimulation 82.50 97.50 26.48 7.91 0.06
with RCLP. The mean scores obtained under different
Maternal attitude and 72.00 98.00 25.30 6.32 0.01*
domains in the questionnaire, inventory, and behavioral disciplining
checklist were tabulated and subjected to statistical *P≤0.05. SD: Standard deviation

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Pushpavathi, et al.: Effect of intervention on mothers of toddlers with RCLP
Table 4: The mean scores and P values for mother’s
behavioral checklist under different domains during
pre‑ and post‑test conditions
Domains Mean
Pre Post Pre
Speech stimulation 56.36 82.03 16.36
Nonspeech behaviors 60.98 85.50 24.63
Other behaviors 68.75 91.25 28.41
*P≤0.05. SD: Standard deviation
and the variety of stimulation were found to be reduced.
Posttherapy and with counseling a significant difference
was seen in language stimulation and in the variety of
stimulation provided. Maternal attitude and disciplining
also showed an improvement as depicted in Table 3
below.
Checklist to assess speech and nonspeech
behaviors of the mother
The speech and nonspeech behaviors of the mother
were assessed using a checklist. The results depict
that during pretest the scores for speech behaviors of
the mothers during speech stimulation were poorer
than that of nonspeech and other behaviors. However
posttherapy, an enhancement was observed for speech
behaviors, nonspeech, and other behaviors which are
illustrated in the table below.
Table 4 illustrates the mean scores and P values
obtained under the different domains of the checklist,
both pre‑ and post‑therapy. Statistical analysis using
Wilcoxon signed rank test showed a significant
difference (*P  ≤  0.05) between the pre‑test and
post‑test scores under speech, nonspeech, and other
behavioral domains.
DISCUSSION
The results of the present study clearly portray that
there was a remarkable increase in the awareness
and home training of the mothers from the baseline
to posttherapy. Although, it was noticed that before
therapy, the mothers had better knowledge regarding
problems associated with CLP and the importance of
speech therapy, the awareness regarding the treatment
for associated problems of CLP was poor. However,
postorientation, the mothers showed an increased
awareness regarding overall causes, assessment, and
treatment of CLP.
The results of the present study are in consonance
with the previous studies which directs a greater need
for the parents to know the facts on various domains
of CLP.[5,16‑19,24‑26] Thus, the post-test results showed
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a greater improvement on all domains after detailed
counseling. The significant difference in language
stimulation and maternal attitude indicated a progress
SD P which has enabled them to deliver a qualitative
Post intervention. The findings of the present study support
14.13 0.01* the previous findings which reported that mothers who
12.91 0.01* received training program for a sustained duration were
8.44 0.02* significantly better in providing stimulation to their
children.[27] These emphasizes the role played by the
family members, especially the mothers in shaping the
linguistic development of children with CLP.
With respect to speech and nonspeech behaviors,
it was seen that the mothers demonstrated positive
patterns of interaction during post-test. The above
changes were observed as mothers had become more
accepting of the cleft condition because of orientation
and extensive counseling provided regarding
issues related to management of CLP. Furthermore,
the demonstration of focused stimulation helped
the mothers in organizing the environment and
activities that suit the child’s needs. This study
is also in consonance with the earlier findings
which revealed that mothers who participated
in a parent‑implemented program were able to
provide better speech and language stimulation to
their children after the scheduled series of training
sessions.[3,27]
The changes in the behaviors, attitudes, and knowledge
of mothers would also evidently reflect changes in the
child’s speech and language performance. The findings
of the present study corroborate the findings of the
previous studies which have highlighted that mothers
of children with RCLP who attend regular and intensive
language intervention programs showed a tendency to
use better patterns of interaction wherein they learnt to
adapt and use nonverbal modes, gestures, and actions
to help their children communicate in a better way.[28]
These changes in the mother’s communication patterns
would enhance the toddler’s speech and language
abilities in terms of increased phonetic inventory,
greater vocabulary and better oromotor skills. Studies
taken up in future along these lines would depict the
positive effects of the mothers communicative patterns
on the child’s speech and language abilities.
CONCLUSIONS
The present study emphasizes that extensive counseling
and orientation helps mothers to gain effective
knowledge about issues related to the management
of a child with cleft lip and palate. It also highlights
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Pushpavathi, et al.: Effect of intervention on mothers of toddlers with RCLP
that ELIP enabled the parents to deliver the language
intervention reliably. This study also provided an
insight toward the changes in language stimulation and
maternal attitude after the demonstration of focused
stimulation approach.
Acknowledgment
This is a part of the ongoing research on “Efficacy of
Early Language Intervention Program for Children
with Repaired Cleft lip and Palate”, funded by the
Department of Science and Technology (DST - No. SB/
SO/HS/02/2014), Government of India. The authors
would like to thank DST for funding the project. The
authors would also like to thank Dr. S. R. Savithri,
Director, All India Institute of Speech and Hearing,
Mysuru, for providing the infrastructure to carry out
the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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