2.5. THE ROLE OF THE SPEECH-LANGUAGE THERAPIST IN THE ASSESSMENT AND MANAGEMENT OF CHILDREN WITH CLEFT LIP
2.5.1. Assessment
2.5.1.4. Feeding Evaluation
Following the assessment of oral motor skills, the Speech-Language Therapist should conduct an assessment of the child’s feeding abilities, dependant on the child’s age.
The Speech-Language Therapist plays an important role, together with the nurses and medical doctor in evaluating the child’s ability in terms of feeding. Children with clefts are at risk for difficulty with feeding, especially before repair of the cleft.
Children with cleft palate may have problems with feeding as the normal anatomy of the oral cavity is compromised (Stengelhofen, 1990).
“Early feeding difficulties and pre-surgical orthodontic treatment will influence the intra-oral physiology which is the basis for later speech development” (Stuffins, 1984, cited in Stengelhofen, 1990, p. 65). According to Arvedson and Brodsky (2002), the evaluation of feeding should occur at three stages, namely the neonatal stage, infant stage and toddler stage. All aspects of feeding should be considered at all stages, in addition to the difficulties commonly seen in cleft lip and/or palate, such as increased feeding time. As the child grows, other aspects such as self feeding are considered (Wolf & Glass, 1992). During the assessment of feeding at the neonatal stage, the clinician should evaluate oral sensory-motor development, the availability of nutritional food as well as parent-child interaction. Uys’s (2008) feeding evaluation
for the at risk infant looks at the following areas: medical history, current state and behaviour of the infant, physical examination, oral feeding history, mother and child interaction during feeding, oral structures at rest, as well as the functioning of the oral structures during the oral and pharyngeal stages of swallowing, particularly with regard to non nutritive and nutritive sucking. Observations regarding the oesophageal stage of swallowing are also included. With regard to cleft lip and/or palate, of particular importance is the ability to maintain a latch and seal during breast or bottle feeding, and the possibility of nasal regurgitation secondary to the cleft of the palate (Wolf & Glass, 1992).
At the infant stage, children are usually progressing from breastfeeding or bottle feeding to the puree/soft diet (Arvedson & Brodsky, 2002). This stage requires an evaluation of the infant’s tongue movements, pre-chewing skill, as well as the ability to propel the bolus from anterior to posterior.
During todderhood, evaluation of feeding and swallowing should include assessment of lip closure, chewing function, anterior-posterior propulsion of the bolus as well as the pharyngeal stage of swallowing (Arvedson & Brodsky, 2002). The evaluation of feeding and swallowing should always consider the child’s nutritional status, i.e.
weight gain, which thereby indicates collaboration with a dietician (Gopal, 2009).
There are a number of protocols for feeding evaluations available commercially, such as McCurtin’s (1997) Feeding Assessment Checklist. Research studies have also resulted in feeding evaluation resources, such as Uys’s (2008) Feeding evaluation form for at risk infants. These protocols are developed for general feeding evaluations and are not cleft specific.
In addition to the discussion on subjective instruments above, there exist objective assessments for the infant and toddler, such as fibreoptic endoscopic evaluation of swallowing (FEES) as well as Videofluoroscopy. These may be used either routinely or in exceptional circumstances, dependant on the institution as well as whether equipment and trained personnel are available (Speech-Language Therapist 6., personal communication, August 19, 2009).
2.5.1.4. Communication (Speech, Language, Voice and Resonance) 2.5.1.4.1. Speech Assessment
According to Gopal (2009) the assessment of the child with cleft lip and/or palate speech sound system may be either perceptual (subjective) or instrumental.
At the infant stage, the Speech-Language Therapist is usually concerned with the ability of the child to vocalise and babble, and, if so, the repertoire of pre-speech sounds used (Gopal, 2009). During toddlerhood, an assessment of the child’s speech sound system generally includes the Speech-Language Therapist eliciting a speech sample, at both word and connected speech levels, and determining the phonetic inventory as well as subjective intelligibility of the toddler. Shipley and McAfee (2008) state that speech samples are especially important in diagnosing disorders of speech production, and conversational samples are more representative of how the child usually speaks in the natural environment. Stimulability testing should also be conducted, to determine whether the client’s productions can be improved when given a model, instructed or when prompting of the articulators occurs (Shipley & McAfee, 2008). Stimulability testing also assists when planning therapy. The use of recording, either audio or video, assists when transcribing and analysing the speech sample (Gopal, 2009).
Formal tests for the assessment of speech may also be used where available, however these should be used with caution where not standardised on South African English speakers. This includes the Goldman Fristoe Test of Articulation (2-21 years), (Goldman & Fristoe, 2000), used commonly in the Western Cape (Pascoe, Maphalala, Ebrahim, Hime, Mdladla, Mohomed & Skinner, 2010) and the Clinical Assessment of Articulation and Phonology (2.6 – 8.11 years) (Secord, 2002).
With regard to voice and resonance, the Speech-Language Therapist should observe for disorders of phonation as associated with the velopharyngeal incompetence, commonly seen in children or adults with cleft lip and/or palate. These include hoarseness, soft voice, monotone and strangled voice. Instrumental (objective) assessments are required for all disorders of resonance and/or audible nasal emission (ACPA, 2007). Instrumental assessments allow for the ruling out of any nasal
emission due to velopharyngeal dysfunction as well to identify improvement in velopharyngeal competence following Speech-Language Therapy (Vijapur, 2006).
Instrumental speech assessment procedures are not frequently used in South Africa, possibly due to funding reasons or perhaps due to some procedures requiring specialised training. These include videoflurosocopy, nasoendoscopy as well as nasometry (Gopal, 2009).
2.5.1.4.2. Language Assessment
The ACPA (2000) recommends screening and assessment of children with cleft lip and/or palate at an early stage to allow for early identification of speech-language disorders.
At the infant stage, assessment generally includes observations of parent-child interactions, to determine any effects the cleft may have on the bonding process (Peterson-Falzone et al., 2006). Gopal (2009) suggests an assessment of parent-child interaction, means of communication (e.g. verbal or non verbal), as well as receptive and expressive language skills (in terms of morphology, syntax and semantics). In addition, the use of eye gaze, eye contact and pragmatic skills such as turn taking should be observed (Rossetti, 2001).
During toddlerhood, the Speech-Language Therapist’s assessment of language involves a more in-depth assessment of receptive and expressive language skills.
Assessment may involve the therapist eliciting a language sample from the child, and then engaging in analysis of the sample via informal measures such as the Language Assessment, Remediation and Screening Procedure (LARSP) (Crystal et al., 1976, cited in Owens, 2004) in the case of English speakers.
A number of formalised checklists and tests also exist for the assessment of language (English) skills from birth to three years, which are listed in the tables below.
Table 2.3.: Checklists for language development
Name of Checklist/Inventory
Authors Year
Communication and Symbolic Behaviour Skills Developmental Profile (6- 24 months)
Wetherby and Prizant 2002
McArthur Bates Communicative
Development Inventory (8-37 months)
Philip, Dale, Reznick and Bates 2007
Receptive-Expressive Emergent Language Scale (REELS) (0 – 3 years)
Bzoch, League and Brown 2003
Table 2.4.: Formal assessments/Norm referenced tests of language
Name of test Age Range Author Year
Early Language Milestones Scales (ELM 2)
0 - 3 Coplan 1987
Test of Early Language Development (TELD)
2 - 7 Hresko, Reid and Hammill 1999
Rossetti Infant Toddler Language Scale
0-3 Rossetti 1990
Preschool Language Scale 4 0 - 6 Zimmerman, Steiner and Pond
1992
The New Reynell
Developmental Language Scales
2 - 7 Edwards, Letts and Sinka 2011