Collaborating with Your Local Cleft Team

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Collaborating with Your Local Cleft Team

• Cynthia Solot, MA, CCC/SLP
• The Childrens Hospital of Philadelphia
• Marilyn Cohen, BA LSLP
• Cooper University Hospital

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Purpose

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

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ASHA Code of Ethics

• Individuals should provide services competently
• Individuals shall use every resource including
  referralto ensure high quality service
• Recognize professional limitations
• Seek consultation and referral when a clients
  care exceeds an SLPs competence beyond training
  and experience

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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

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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

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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

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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

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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

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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

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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

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Evaluations Continued

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

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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

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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

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Mechanisms for Collaboration

• Written reports outlining treatment goals and
  progress
• Therapist to team
• Team to therapist
• Phone reports and consultations
• Direct observation

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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

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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

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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

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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

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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

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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.

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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 patients progress to
  team
• Especially regarding consonant production

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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

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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.
• SLPs share techniques
• 2. 6 month reevaluation to assess progress and
  need for visualization studies

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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

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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

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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