Collaborating with Your Local Cleft Team

1. Collaborating with Your Local Cleft Team Cynthia Solot, MA, CCC/SLP The Children’s Hospital of Philadelphia Marilyn Cohen, BA; LSLP Cooper University Hospital

2. Purpose • Introduction to the team approach • Provide a framework for interaction and collaboration with the local cleft team • Discuss the ethical mandates for collaboration

3. ASHA Code of Ethics • Individuals should provide services competently • Individuals shall use every resource including referral…to ensure high quality service • Recognize professional limitations • Seek consultation and referral when a client’s care exceeds an SLP’s competence beyond training and experience

4. ACPA StandardsEvaluation and Treatment Parameters (ACPA, 1993, 2000) • …For children with speech problems, reevaluations should take place as deemed necessary by members of interdisciplinary team in consultation with local care providers and • …when speech patterns are deviant, arrangements should be made for speech-language stimulation programs or remedial services

5. Why a Cleft Team? • Availability of multi-specialties to provide diagnostic information and treatment planning for a complex communication problem • Expertise of individuals dealing with the many sequelae associated with clefting • A comprehensive approach to evaluation and management

6. Sequelae of Clefts • Poor feeding ability • Otitis Media • Conductive Hearing Impairment • Deviations in vocal quality & resonance • Developmental and compensatory articulation problems • Increased incidence of language based learning disability and dyslexia

7. Sequelae Continued • Malalignment of teeth and jaws • Emotional social problems, family adaptation to the disorder and to issues related to appearance and learning delays • Palatal insufficiency due to post operative fistulae and- or decreased palatal function • Associated genetic syndromes

8. Management of SequelaeThe Team Approach • Core Team consisting of specialists from the following disciplines: • Plastic Surgery • Otolaryngology • Nursing • Pediatrics • Genetics • Speech Pathology • Audiology • Pediatric Dentistry • Orthodontics • Psychology • Social Work

9. Team Treatment & Evaluation • Surgical management • Comprehensive evaluations on a regular basis that include the following: • Physical and developmental assessments • Hearing evaluations • Speech and language assessment • Dento-facial development • Psycho-social adjustment

10. The Role of The Speech Pathologist • Assessment of speech and language across the developmental continuum • Screening of receptive and expressive language development • Articulation profile • Patterns of Articulation: conversational speech, Isolated phonemes and single words • Motor speech skills • Overall intelligibility • Stimulability

11. Evaluations Continued • Phonation • Resonation • Perceptual and Instrumentation Measures • Nasendoscopy • Videofluroscopy • Nasometer • Pressure Flow • Nasal Air Emission • Oral Peripheral Examination • Feedback to Families

12. Why Collaborative Care? • Involves the professionals and family members who provide child focused care • Collaboration provides quality, comprehensive and efficient care • Collaboration utilizes an inter-disciplinary approach to treatment and evaluation • Collaboration utilizes the expertise of the cleft team together with community based providers due to diverse geography

13. Goals of Collaboration • Patient centered care • Eliminates role confusion • Creates a team approach • Diminish hierarchy- create professional equity • Provides a continuum of care that includes the home, school, community and the cleft-craniofacial team

14. Mechanisms for Collaboration • Written reports outlining treatment goals and progress • Therapist to team • Team to therapist • Phone reports and consultations • Direct observation

15. Barriers to Collaboration • Training & experience of community providers • The generalist verses the specialist • Cultural/Environmental Differences • Medical setting verses school setting • Willingness/desire to collaborate

16. Models for CollaborationUsing the Cleft Team • Consultation for difficult diagnostic problems • An educational resource for the speech community • Provision of evaluations that can not be accomplished in a community setting • Imaging studies • Surgical-medical evaluation • Specialized speech evaluations

17. Models for Community Collaboration • Speech therapy in a community setting • Consultation with community educational services such as child study teams, teachers, school psychologist and counselors • On going determination of progress and needs in a school or community environment

18. Limitations to Services • Economics • Medical need verses educational need • Geographics • School: federal, state and educational guidelines • Hospital: 3rd party payer contracts, staff limitations and budgetary constraints • HIPPA guidelines

19. Barriers to Care • Economic: limitation of available financial resources • Parental: social, economic and emotional constraints • Parental buy in of treatment & evaluation recommendations • Physical, mental and emotional conditions of the child

20. Case Study I • 5 year old boy • Bilateral repaired cleft lip and palate • Hx. 3 years of oral-motor therapy in community setting • Speech characteristics • Consonant omissions, glottal stops & nasal substitutions • Resonance is hypernasal with visible and audible nasal emission.

21. Recommendations for Collaboration Case 1 • Evaluation or re-evaluation by a cleft palate team • VP imaging studies recommended after development of sufficient consonant repertoire • Communicate recommendations from team evaluation to both family and community based SLP • Return to community based SLP for articulation therapy to • Stimulate consonant production • Eliminate compensatory articulation • Develop a home program • Provide periodic reports of patient’s progress to team • Especially regarding consonant production

22. Case Study II • 7 year old girl in school based speech therapy. Not progressing. • Audible nasal emission • Hypernasality reported • Normal language development • No overt cleft of the palate • Referred to cleft team for further evaluation

23. Team Findings & Recommendations Case 2 • No SMCP or other palatal anomaly • Tonsils of normal size • Nasal emission on /s/ & /z/ both audible and visible • Resonance perceptually WNL = Phoneme Specific VPI Recommendations: 1. Trial school based speech therapy. SLP’s share techniques 2. 6 month reevaluation to assess progress and need for visualization studies

24. Case Study III • 3 year old boy • Late emergence of language • Unintelligible speech • Five word vocabulary & reduced phonemic repertoire • Hypernasality • History of poor feeding as an infant • Behavior & attention difficulties noted

25. Findings and Recommendations Case 3 • Mild facial dysmorphia • SMCP and VPI • Delayed receptive and expressive language on standardized testing • Genetic and medical evaluations indicate a 22q11.2 deletion syndrome Recommendations: 1. Pre-school placement 2. Collaboration with school 2. Intensive one to one speech-language therapy 3. Use of Total Communication 4. Develop speech sound repertoire and expressive vocabulary 5. Institute a home program

26. Summary • Community and team are extensions of each other • Lines of communication are open • Co-therapeutic model evolves • Goals of treatment are collaborative and realistic • Techniques are shared and serve as a gateway to both the medical model and an educational model