Speech screening for the child with clefting or suspected VP dysfunction may be completed by an SLP in a variety of settings, including a cleft palate-craniofacial team visit.
The SLP attends to signs of
- anatomical/structural differences (e.g., malocclusion, submucous cleft, fistula, or bifid uvula);
- resonance or nasal airflow problems;
- articulation errors that may be characterized as obligatory errors (due to structural differences) or as compensatory (learned) errors; and
- articulation errors that may be characterized as developmental in nature (i.e., traditional articulation and phonology disorders).
The screening protocol may also include a hearing screening and screening of expressive and receptive language skills. Screening may result in recommendations for additional assessments/examinations by the team and/or a comprehensive speech and language assessment.
Assessment and treatment of clefts may require use of appropriate personal protective equipment.
An SLP conducts a comprehensive speech and language assessment using both standardized and nonstandardized measures. (See ASHA's resource on
assessment tools, techniques and data sources).
Some infants and toddlers with clefts may be evaluated by an SLP in early intervention to identify language delays, even before they are seen by a team. An understanding of the speech and language characteristics of these children is essential for accurate assessment. For children who are not yet talking, the assessment includes measures of vocalization diversity and complexity, vocalization rate, and use of communicative gestures (Scherer, 2017). (For more information, see the Early Speech and Language Characteristics section of this Portal page, ASHA's Practice Portal pages Late Language Emergence and Early Intervention.)
For school-age children, the assessment may be conducted by the school SLP, who provides services to the child within the context of an educational setting. The assessment may also be conducted by the team SLP or by an SLP in another outpatient or private clinic. Collaboration between the team SLP and other SLPs involved in service delivery for a child with a history of cleft lip and palate is encouraged (ACPA, 2016).
Due to the likelihood of
transient or permanent hearing loss in this population, the comprehensive
assessment typically includes an audiologic assessment by an audiologist.
Comprehensive Assessment for Cleft Lip and Palate: Typical Components. Specific components of an assessment will depend on the individual's age and stage of development.
The assessment is conducted in the language(s) used by the child and his or her family, with the use of interpretation services as necessary (see ASHA's Portal Page,
Collaborating With Interpreters). Assessment takes into account speech and language characteristics unique to the linguistic background of the individual and the cultural variables that affect communication.
Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; WHO, 2001), comprehensive assessment is conducted to identify and describe
- impairments in body structure and function, including underlying strengths and weaknesses in speech sound production and verbal/nonverbal communication;
- co-morbid deficits or conditions, such as developmental disabilities or syndromes;
- limitations in activity and participation, including functional communication, interpersonal interactions with family and peers, and learning;
- contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation; and
- the impact of communication impairments on quality of life of the child and family.
Person-Centered Focus on Function: Cleft Lip and Palate [PDF] for an example of assessment data consistent with ICF. See also Neumann and Romonath (2012) for a discussion of the application of ICF to cleft lip and palate.
Assessment may result in
- diagnosis of a speech, language, resonance, voice, and/or feeding and swallowing disorder;
- determination of the type, severity, and possible cause of the disorder;
- recommendation for therapy (see
Guide to Treatment Decision-Making for Cleft-Type Speech [PDF] [Trost-Cardamone, 2013]);
- identification of barriers to child and family participation in everyday situations;
- referral for surgical, prosthetic, or other medical or dental intervention; and/or
- referral for genetic testing to rule out syndromes.
Studies of populations in Cambodia, China, Egypt, India, Kenya, Nigeria, Peru, Russia, and South Africa, have found that causal explanations of cleft lip and palate sometimes reflect religious beliefs (e.g., evil spirits or punishment for a past sin). Other causal explanations include a poor diet or starvation during pregnancy, viewing a solar eclipse during pregnancy, or having lived near a nuclear plant during pregnancy (Loh & Ascoli, 2011; Mednick et al., 2013).
Cultural beliefs about the cause of cleft lip and palate may influence a family's decisions about seeking treatment (Loh & Ascoli, 2011; Louw, Shibambu, & Roemer, 2006; Mednick et al., 2013). For example, individuals who believe that clefting is "fate" or "God's will" may not seek treatment, so as not to interfere with the spiritual world (Loh & Ascoli, 2011).
Cultural differences might also affect the interaction between the clinician and family, and cultural sensitivity on the part of the clinician is essential for developing trust. Professionals need to understand cultural differences—including differences in maternal reactions to the birth of a child with clefting—and learn to communicate across cultural lines when providing care (Black, Girotto, Chapman, & Oppenheimer, 2004; Strauss, 1997). Using ethnographic interviewing techniques can be an effective strategy for gathering information about cultural beliefs and concerns.
For more information, see ASHA's Practice Portal page,