Collaborating with Your Local Cleft Team

Cynthia Solot, MA, CCC/SLP The Children’s Hospital of Philadelphia Marilyn Cohen, BA; LSLP Cooper University Hospital

Purpose

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

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

ACPA Standards Evaluation 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

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

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

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

Management of Sequelae The 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

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

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

Evaluations Continued

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

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

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

Mechanisms for Collaboration

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

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

Models for Collaboration Using 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

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

Limitations to Services

 Economics  Medical need verses educational need  Geographics  School: federal, state and educational guidelines  Hospital: 3 rd party payer contracts, staff limitations and budgetary constraints  HIPPA guidelines

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

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.

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

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

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

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

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

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