Collaborating with Your Collaborating with Your Local Cleft TeamLocal Cleft Team

Cynthia Solot, MA, CCC/SLPCynthia Solot, MA, CCC/SLP The Children’s Hospital of PhiladelphiaThe Children’s Hospital of Philadelphia

Marilyn Cohen, BA; LSLPMarilyn Cohen, BA; LSLPCooper University HospitalCooper University Hospital

PurposePurpose

Introduction to the team approachIntroduction to the team approach

Provide a framework for interaction Provide a framework for interaction and collaboration with the local cleft and collaboration with the local cleft teamteam

Discuss the ethical mandates for Discuss the ethical mandates for

collaborationcollaboration

ASHA Code of EthicsASHA Code of Ethics

Individuals should provide services competentlyIndividuals should provide services competently Individuals shall use every resource including Individuals shall use every resource including

referral…to ensure high quality servicereferral…to ensure high quality service Recognize professional limitationsRecognize professional limitations Seek consultation and referral when a client’s Seek consultation and referral when a client’s

care exceeds an SLP’s competence beyond care exceeds an SLP’s competence beyond training and experiencetraining and experience

ACPA StandardsACPA StandardsEvaluation and Treatment Parameters (ACPA, 1993, 2000)Evaluation and Treatment Parameters (ACPA, 1993, 2000)

……For children with speech problems, For children with speech problems, reevaluations should take place as deemed reevaluations should take place as deemed necessary by members of interdisciplinary necessary by members of interdisciplinary team in consultation with local care providers team in consultation with local care providers andand

……when speech patterns are deviant, when speech patterns are deviant, arrangements should be made for speech-arrangements should be made for speech-language stimulation programs or remedial language stimulation programs or remedial servicesservices

Why a Cleft Team?Why a Cleft Team?

Availability of multi-specialties to provide Availability of multi-specialties to provide diagnostic information and treatment diagnostic information and treatment planning for a complex communication planning for a complex communication problemproblem

Expertise of individuals dealing with the Expertise of individuals dealing with the many sequelae associated with cleftingmany sequelae associated with clefting

A comprehensive approach to evaluation A comprehensive approach to evaluation and managementand management

Sequelae of CleftsSequelae of Clefts

Poor feeding abilityPoor feeding ability Otitis MediaOtitis Media Conductive Hearing ImpairmentConductive Hearing Impairment Deviations in vocal quality & resonanceDeviations in vocal quality & resonance Developmental and compensatory Developmental and compensatory

articulation problemsarticulation problems Increased incidence of language based Increased incidence of language based

learning disability and dyslexialearning disability and dyslexia

Sequelae ContinuedSequelae Continued

Malalignment of teeth and jawsMalalignment of teeth and jaws Emotional social problems, family Emotional social problems, family

adaptation to the disorder and to issues adaptation to the disorder and to issues related to appearance and learning delaysrelated to appearance and learning delays

Palatal insufficiency due to post operative Palatal insufficiency due to post operative fistulae and- or decreased palatal functionfistulae and- or decreased palatal function

Associated genetic syndromesAssociated genetic syndromes

Management of SequelaeManagement of SequelaeThe Team ApproachThe Team Approach

Core Team consisting of specialists from the following Core Team consisting of specialists from the following disciplines:disciplines:

Plastic SurgeryPlastic Surgery OtolaryngologyOtolaryngology Nursing Nursing Pediatrics Pediatrics GeneticsGenetics Speech PathologySpeech Pathology Audiology Audiology Pediatric DentistryPediatric Dentistry OrthodonticsOrthodontics PsychologyPsychology Social WorkSocial Work

Team Treatment & EvaluationTeam Treatment & Evaluation

Surgical managementSurgical management Comprehensive evaluations on a regular Comprehensive evaluations on a regular

basis that include the following:basis that include the following: Physical and developmental assessmentsPhysical and developmental assessments Hearing evaluationsHearing evaluations Speech and language assessmentSpeech and language assessment Dento-facial developmentDento-facial development Psycho-social adjustmentPsycho-social adjustment

The Role of The The Role of The Speech PathologistSpeech Pathologist

Assessment of speech and language Assessment of speech and language across the developmental continuumacross the developmental continuum Screening of receptive and expressive Screening of receptive and expressive

language developmentlanguage development Articulation profileArticulation profile

• Patterns of Articulation: conversational speech,Patterns of Articulation: conversational speech,Isolated phonemes and single wordsIsolated phonemes and single words

Motor speech skillsMotor speech skills Overall intelligibilityOverall intelligibility StimulabilityStimulability

Evaluations ContinuedEvaluations Continued

PhonationPhonation ResonationResonation

Perceptual and Instrumentation MeasuresPerceptual and Instrumentation Measures• NasendoscopyNasendoscopy• VideofluroscopyVideofluroscopy• Nasometer Nasometer • Pressure FlowPressure Flow

Nasal Air EmissionNasal Air Emission Oral Peripheral ExaminationOral Peripheral Examination Feedback to Families Feedback to Families

Why Collaborative Care?Why Collaborative Care?

Involves the professionals and family Involves the professionals and family members who provide members who provide child focused carechild focused care

Collaboration provides quality, Collaboration provides quality, comprehensive and efficient carecomprehensive and efficient care

Collaboration utilizes an inter-disciplinary Collaboration utilizes an inter-disciplinary approach to treatment and evaluationapproach to treatment and evaluation

Collaboration utilizes the expertise of the Collaboration utilizes the expertise of the cleft team together with community based cleft team together with community based providers due to diverse geographyproviders due to diverse geography

Goals of CollaborationGoals of Collaboration

Patient centered carePatient centered care Eliminates role confusionEliminates role confusion Creates a team approachCreates a team approach Diminish hierarchy- create professional equityDiminish hierarchy- create professional equity Provides a continuum of care that includes the Provides a continuum of care that includes the

home, school, community and thehome, school, community and thecleft-craniofacial teamcleft-craniofacial team

Mechanisms for CollaborationMechanisms for Collaboration

Written reports outlining treatment goals Written reports outlining treatment goals and progressand progress Therapist to team Therapist to team Team to therapistTeam to therapist

Phone reports and consultationsPhone reports and consultations Direct observationDirect observation

Barriers to CollaborationBarriers to Collaboration

Training & experience of community Training & experience of community providersproviders The generalist verses the specialistThe generalist verses the specialist

Cultural/Environmental DifferencesCultural/Environmental Differences Medical setting verses school settingMedical setting verses school setting

Willingness/desire to collaborateWillingness/desire to collaborate

Models for CollaborationModels for CollaborationUsing the Cleft TeamUsing the Cleft Team

Consultation for difficult diagnostic Consultation for difficult diagnostic problemsproblems

An educational resource for the speech An educational resource for the speech communitycommunity

Provision of evaluations that can not be Provision of evaluations that can not be accomplished in a community settingaccomplished in a community setting Imaging studiesImaging studies Surgical-medical evaluationSurgical-medical evaluation Specialized speech evaluationsSpecialized speech evaluations

Models for Community Models for Community CollaborationCollaboration

Speech therapy in a community settingSpeech therapy in a community setting Consultation with community educational Consultation with community educational

services such as child study teams, services such as child study teams, teachers, school psychologist and teachers, school psychologist and counselorscounselors

On going determination of progress and On going determination of progress and needs in a school or community needs in a school or community environmentenvironment

Limitations to ServicesLimitations to Services

EconomicsEconomics Medical need verses educational needMedical need verses educational need GeographicsGeographics School: federal, state and educational School: federal, state and educational

guidelinesguidelines Hospital: 3Hospital: 3rdrd party payer contracts, staff party payer contracts, staff

limitations and budgetary constraintslimitations and budgetary constraints HIPPA guidelinesHIPPA guidelines

Barriers to CareBarriers to Care

Economic: limitation of available financial Economic: limitation of available financial resourcesresources

Parental: social, economic and emotional Parental: social, economic and emotional constraintsconstraints

Parental buy in of treatment & evaluation Parental buy in of treatment & evaluation recommendationsrecommendations

Physical, mental and emotional conditions Physical, mental and emotional conditions of the childof the child

Case Study ICase Study I

5 year old boy5 year old boy Bilateral repaired cleft lip and palateBilateral repaired cleft lip and palate Hx. 3 years of oral-motor therapy in Hx. 3 years of oral-motor therapy in

community settingcommunity setting Speech characteristicsSpeech characteristics

• Consonant omissions, glottal stops & nasal Consonant omissions, glottal stops & nasal substitutionssubstitutions

Resonance is hypernasal with visible and Resonance is hypernasal with visible and audible nasal emission.audible nasal emission.

Recommendations for Recommendations for Collaboration Case 1Collaboration Case 1

Evaluation or re-evaluation by a cleft palate teamEvaluation or re-evaluation by a cleft palate team VP imaging studies recommended after development of VP imaging studies recommended after development of

sufficient consonant repertoire sufficient consonant repertoire Communicate recommendations from team evaluation to Communicate recommendations from team evaluation to

both family and community based SLPboth family and community based SLP Return to community based SLP for articulation therapy Return to community based SLP for articulation therapy

to to Stimulate consonant productionStimulate consonant production Eliminate compensatory articulationEliminate compensatory articulation Develop a home programDevelop a home program Provide periodic reports of patient’s progress to teamProvide periodic reports of patient’s progress to team

• Especially regarding consonant productionEspecially regarding consonant production

Case Study IICase Study II

7 year old girl in school based speech 7 year old girl in school based speech therapy. Not progressing.therapy. Not progressing.

Audible nasal emissionAudible nasal emission Hypernasality reportedHypernasality reported Normal language developmentNormal language development No overt cleft of the palateNo overt cleft of the palate Referred to cleft team for further Referred to cleft team for further

evaluationevaluation

Team Findings & Team Findings & Recommendations Case 2Recommendations Case 2

No SMCP or other palatal anomaly No SMCP or other palatal anomaly Tonsils of normal sizeTonsils of normal size Nasal emission on /s/ & /z/ both audible and Nasal emission on /s/ & /z/ both audible and

visiblevisible Resonance perceptually WNL = Phoneme Resonance perceptually WNL = Phoneme

Specific VPISpecific VPIRecommendations: Recommendations:

1. Trial school based speech therapy. 1. Trial school based speech therapy. SLP’s share techniquesSLP’s share techniques

2. 6 month reevaluation to assess progress and 2. 6 month reevaluation to assess progress and need for visualization studiesneed for visualization studies

Case Study IIICase Study III

3 year old boy 3 year old boy Late emergence of languageLate emergence of language Unintelligible speech Unintelligible speech Five word vocabulary & reduced phonemic Five word vocabulary & reduced phonemic

repertoirerepertoire HypernasalityHypernasality History of poor feeding as an infantHistory of poor feeding as an infant Behavior & attention difficulties notedBehavior & attention difficulties noted

Findings and Recommendations Findings and Recommendations Case 3Case 3

Mild facial dysmorphia Mild facial dysmorphia SMCP and VPISMCP and VPI Delayed receptive and expressive language on standardized testingDelayed receptive and expressive language on standardized testing Genetic and medical evaluations indicate a 22q11.2 deletion Genetic and medical evaluations indicate a 22q11.2 deletion

syndromesyndromeRecommendations:Recommendations:

1. Pre-school placement1. Pre-school placement2. Collaboration with school 2. Collaboration with school 2. Intensive one to one speech-language therapy2. Intensive one to one speech-language therapy3. Use of Total Communication 3. Use of Total Communication 4. Develop speech sound repertoire and expressive vocabulary4. Develop speech sound repertoire and expressive vocabulary5. Institute a home program5. Institute a home program

SummarySummary

Community and team are extensions of Community and team are extensions of each other each other

Lines of communication are openLines of communication are open Co-therapeutic model evolvesCo-therapeutic model evolves Goals of treatment are collaborative and Goals of treatment are collaborative and

realisticrealistic Techniques are shared and serve as a Techniques are shared and serve as a

gateway to both the medical model and an gateway to both the medical model and an educational modeleducational model