Speech therapy that is successful for children with cleft lip and palate involves collaboration among the speech-language pathologist (SLP) (e.g., school, hospital, private clinic, etc.), the cleft palate team, and parents and caregivers. Partnership within the SLP and the SLP on the cleft palate team is crucial to ensure optimal speech outcomes for an individual child’s needs (Peterson-Falzone et al., 2016). Team models range and may fluctuate over the course of treatment, based on the needs of the individual and the availability of resources (Dailey & Wilson, 2015). The SLP considers the child with a craniofacial syndrome/anomaly holistically and provides her knowledge about the disorder while considering evidence-based practices. This paper will explore the role of the SLP, as it is related to education of craniofacial anomalies, familiarity of the surgical and orthodontic timeline, the impact of oral and pharyngeal structures on speech, and the types of errors related to clefts and velopharyngeal dysfunction (VPD).

Training and Education

Students of speech-language pathology must prepare at the graduate school level as well as participate in continuing education and training opportunities to possess adequate knowledge and skills necessary to treat children with craniofacial anomalies (Bedwinek, Kummer, Rice, & Grames, 2010). An essential function of the SLP is to remain informed of research involving cleft lip and palate and to help advance the knowledge base related to the nature and treatment of these disorders. According to a survey that looked at the opinions of school-based SLPs, all of whom had experience working with students with craniofacial anomalies, they reported that information in several areas would be helpful in their profession. These areas included knowledge about: 1) specific speech treatment techniques, 2) assessment and treatment of articulation disorders related to VPD, 3) treatment of resonance disorders, and 4) language problems of children with cleft lip and palate (Bedwinek et al., 2010). The SLPs surveyed emphasized the importance of gaining the knowledge to adequately serve this population of students in the school setting. According to the American Speech-Language-Hearing Association’s (ASHA) Code of Ethics, SLPs who serve this population should be specifically educated and appropriately trained to do so. This is of utmost importance for those serving on a cleft palate-craniofacial team, where decisions regarding surgical intervention require significant SLP input (ASHA, 2016a). Therefore, first and foremost the SLP’s role in the treatment of individuals with craniofacial syndromes/anomalies is a solid foundation of knowledge about the disorders. This requires the SLP to educate himself or herself on the disorders with continuing education and training beyond the graduate school level.

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A well-informed SLP can educate patients, parents, teachers, other SLPs, and other craniofacial team members on the assessment and treatment of individuals with craniofacial syndromes/anomalies. The SLP is also familiar with the surgical and orthodontic timeline that takes place in the treatment of specific cases of cleft lips and palates. While their role does not include diagnosis of clefts, the SLP may educate others about the rough timeline of surgery for these conditions. Surgery for cleft lips typically takes place within the first three months of age, while surgery for cleft palates takes place by the child’s first birthday (Zajac & Vallino, 2017). Prior to these surgical repairs, the SLP may inform parents and others about pre-surgical orthopedics such as lip adhesion, lip taping, and nonalveolar molding (NAM) appliances that help to align the oral and nasal cavities (Zajac & Vallino, 2017). As the child grows older and begins to speak, they may be referred to an SLP for any noted speech differences/difficulties. The patient may require additional surgery if the SLP notes resonance disorders, pervasive nasal air emission, or other obligatory errors that may be related to dental malocclusions. These deviations may be noted by the SLP during an oral mechanism evaluation or other evaluations of the oral and nasal cavities.

Roles and Responsibilities

Once adequate training is established via the ASHA Code of Ethics, the SLP’s role in care for the child with craniofacial syndromes/anomalies may take form. SLPs play an integral role in the “screening, assessment, diagnosis, treatment of speech and language problems, and feeding and swallowing problems associated with cleft lip and palate” (ASHA, 2016a, para. 4). According to ASHA’s Scope of Practice in Speech-Language Pathology, the professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research (ASHA, 2016b). The roles listed there include, but are not limited to, 1) to counseling persons with cleft lip and palate and their families regarding communication- and feeding/swallowing-related issues and providing education aimed at preventing further complications relating to these conditions; 2) educating other professionals about the needs of persons with cleft lip and palate and the role of SLPs in diagnosis and management; 3) screening individuals who present with cleft lip and palate; 4) determining the need for further assessment and/or referral for other services; 5) conducting a comprehensive, culturally and linguistically appropriate assessment of speech, language, resonance, voice, or feeding problem associated with cleft lip and palate; 6) diagnosing speech, language, resonance, voice, or feeding disorders associated with cleft lip and palate; 7) developing treatment plans, providing treatment, documenting progress, and determining appropriate dismissal criteria; 8) consulting and collaborating with other professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate (ASHA, 2016b). An imperative part of the SLPs role in the treatment of individuals with craniofacial syndromes/anomalies involves adhering to the ASHA Code of Ethics and knowing the responsibilities outlined for this population in the Scope of Practice.

Transdisciplinary Teams

A large portion of the roles outlined for speech-language pathologists in ASHA’s Scope of Practice allude to the collaborative team of professionals beside whom SLPs serve children with craniofacial syndromes/anomalies. SLPs serve as essential members of an interdisciplinary team that works with individuals who have cleft lip and palate and their families/caregivers (IPE/IPP, 2018). This partnership is actually called a transdisciplinary team, because its members come together from the beginning to jointly communicate, exchange ideas, and work together to come up with solutions to problems. A newer approach to service and education—which is known as interprofessional education (IPE) and interprofessional collaborative practice (IPP)—demonstrates a collaborative approach. According to ASHA, “IPE as an activity that occurs when two or more professions learn about, from, and with each other to enable effective collaboration and improve outcomes for individuals and families whom we serve” (IPE/IPP, 2018, para. 1). This looks like multiple service providers from different professional backgrounds coming together to provide comprehensive healthcare or educational services by working with children and their families, caregivers, and communities to deliver the best care across settings. Ultimately, the transdisciplinary team determines goals for a patient or client jointly. A large part of the SLP’s role includes working with this transdisciplinary team to establish the holistic treatment that is best suited for patients with craniofacial syndromes/anomalies.

Impact of Oral and Pharyngeal Structures on Speech

 Speech differences that occur from cleft lip and palate may persist post-surgery and for many years into adulthood. Speech-language pathologists assess the impact these differences have on a person’s quality of life. This is accomplished by assessing specifically the impact of voice and articulation on ease of communication and self-esteem in social, vocational, and educational settings (Kummer, 2014). According to Kummer (2014), speech differences can persist for several reasons, including:

“lack of access to adequate speech services when the child was younger, resulting in 1) habituated speech patterns (compensatory articulations) that may be more difficult to change; 2) persistent anatomic obstacles to normal speech, such as severe malocclusion or untreated VPD; 3) expectations of failure; 4) poorly developed self-monitoring skills; and 4) a lack of motivation” (Kummer, 2014, pp. 614-615).

At times, persistent speech errors are indicative of ongoing occlusal or dental problems. Surgical procedures such as maxillary advancement are completed in a child’s teen years, and treatment of related errors or speech distortions by the SLP may need to occur afterward (Kummer, 2014). After surgery, speech is reevaluated by the SLP to assess for resonance and articulation to ensure the absence of newly developed or worsening symptoms. In the instance of any newly developed or worsening symptoms post-surgery, SLPs will initiate additional speech therapy. According to Peterson-Falzone et al. (2010), persons with persisting speech difficulties post-surgery must be highly motivated to participate in speech therapy to combat learned misarticulations that have increased in strength due to habit (Peterson-Falzone et al., 2010). An SLP must not only provide appropriate speech therapy to address these misarticulations but must also provide motivational coaching and counseling to these patients post-surgery.

Conclusion

Speech-language pathologists play a critical role in the treatment of patients with cleft lip and palate pre- and post-surgery. The SLP’s role includes education of craniofacial anomalies, familiarity of the surgical and orthodontic timeline, and treatment for the impact of oral and pharyngeal structures on speech, and the types of errors related to clefts and velopharyngeal dysfunction (VPD). In addition, SLPs who treat patients post-surgery must play the role of motivational coach and counselor to suspend remaining habitual misarticulations. Overall, when depicting the craniofacial team who rehabilitates children with cleft lip and palate, it is imperative to include the role of the speech-language pathologist.

References

American Speech-Language-Hearing Association. (2016a). Code of ethics in speech-language pathology [Code of Ethics]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.

Bedwinek, A. P., Kummer, A. W., Rice, G. B., & Grames, L. M. (2010). Current training and continuing education needs of preschool and school-based speech-language pathologists regarding children with cleft lip/palate. Language, Speech, and Hearing Services in Schools, 41, 405–415.

Dailey, S., & Wilson, K. (2015). Communicating with a cleft palate team: Improving coordination of care across treatment settings. Perspectives on Speech Science and Orofacial Disorders, 25, 35–38.

Interprofessional Education/Interprofessional Practice (IPE/IPP) (2018). Interprofessional practice in action. World Health Organization. Retrieved from: https://www.asha.org/Practice/Interprofessional-Education-Practice/

Peterson-Falzone, S. J., Hardin-Jones, M. A., & Karnell, M. P. (2010). Cleft palate speech. St. Louis, MO: Mosby.

Peterson-Falzone, S. J., Trost-Cardamone, J. E., Karnell, M. P., & Hardin-Jones, M. A. (2016). The clinician’s guide to treating cleft palate speech. St. Louis, MO: Mosby.

Kummer, A. W. (2014). Speech therapy. In A. W. Kummer (Ed.), Cleft palate and craniofacial anomalies: Effects on speech and resonance (3rd ed., pp. 614-652). Clifton Park, NY: Cengage Learning.

Zajac, D. J., & Vallino, L. D. (2017). Presurgical and Surgical Management. In D. J. Zajac & L. D. Vallino (Eds.), Evaluation and management of cleft lip and palate: A developmental perspective (pp. 129–226). San Diego, CA: Plural