Academic and Clinical Training in Cleft Palate for Speech-Language Pathologists

Academic and Clinical Training in Cleft Palate for Speech-Language Pathologists Linda D. Vallino, Ph.D., M.S., Norman J. Lass, Ph.D., H. Timothy Bunnell, Ph.D., Mary Pannbacker, Ph.D. Objective: The purpose of this study was to obtain information about academic and clinical training of speech-language pathology students in cleft palate (CP). Methods: Representatives of 232 accredited graduate programs in speechlanguage pathology were invited via e-mail to complete a web-based 32-item questionnaire. Questions focused on the type and nature of courses offered related to CP, availability of clinical practica, and number of hours of clinical experience by students. An item-by-item analysis was conducted and descriptive statistics obtained. Results: A total of 127 (54.7%) of the programs responded. Sixty-seven percent offered coursework exclusively devoted to CP, and for 53% of these it was a required course. For the programs that did not offer an exclusive course on CP, 35% indicated that CP was covered in other courses such as articulation, voice, or anatomy and physiology. Fifty-four percent of the programs offered clinical practica in CP. For these, a median of five students of a median graduate speech-language pathology class of 43 were enrolled in practica involving CP (range = 0 21), and students spent a median of 2 hours in practica involving CP (range = 0 100). Conclusions: Cleft palate is a complex disorder to which many students have limited exposure and for which more graduate training is unlikely since the 1993 American Speech-Language-Hearing Association (ASHA) certification changes. As a result, there is a need to look towards alternative methods to enhance the educational and clinical experiences of students and practitioners in cleft palate. KEY WORDS: academic training, cleft palate, clinical training, speech-language pathology Cleft lip and palate is the most common birth defect in the United States, affecting one of every 594 births (Centers for Disease Control, 2006). The effect of the structural anomalies on speech function is complex and often multifaceted, placing individuals with this condition at risk for communication disorders. The challenges for the speech-language pathologist who provides services to these individuals include identifying, often with multidisciplinary Dr. Vallino is Head of the Craniofacial Outcomes Research Laboratory, Center for Pediatric Auditory and Speech Sciences (CPASS) Alfred I. dupont Hospital for Children, Wilmington, Delaware. Dr. Bunnell is Head of the Speech Research Laboratory and Director of CPASS, Alfred I. dupont Hospital for Children, Wilmington, Delaware. Dr. Lass is Professor, Department of Speech Pathology and Audiology, West Virginia University, Morgantown, West Virginia. Dr. Pannbacker is Professor, Department of Rehabilitation Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana. Portions of this study were presented at the annual meetings of the American Cleft Palate-Craniofacial Association, April 4 9, 2006, Vancouver, British Columbia, and the American Speech-Language-Hearing Association, November 15 18, 2006, Miami, Florida. Submitted July 2007; Accepted November 2007. Address correspondence to: Dr. Linda Vallino, Alfred I. dupont Hospital for Children, A/R 214, 1600 Rockland Road, Wilmington, DE 19899. E-mail vallino@asel.udel.edu. DOI: 10.1597/07-119.1 input, the relative contribution of the various etiological factors contributing to communication problems (Peterson- Falzone et al., 2000) and recommending and providing treatment. Meeting these challenges successfully necessitates appropriate academic training that covers coursework in basic speech science, anatomy and physiology of the speech mechanism, and speech disorders as well as clinical training in the assessment, diagnosis, and treatment of speech disorders associated with cleft lip and palate. For many years researchers and practitioners have underscored the need for training focused on cleft palate in order to provide quality care to patients and their families. Spriestersbach (1968) acknowledged the effects of limited training on optimal care and advised that a clinician with cursory training should not manage an individual with cleft palate. Morris et al. (1978, p. 2) stated: Within the constraints of our current licensing laws, many practitioners who are legally qualified to provide treatment really know very little about the defect. In an article outlining the speech assessment of children with clefts, Philips (1986, p. 298) declared: Many clinicians have had little or no course work or clinical practicum preparing them for work with clients who have cleft palate. To explore these issues, Pannbacker et al. (1990) surveyed graduate programs in speech-language pathology 371

372 Cleft Palate Craniofacial Journal, July 2008, Vol. 45 No. 4 to determine the availability of training in cleft palate to their students. At the time of the study 17 years ago, almost all of the 134 programs surveyed provided one or more courses on cleft palate and 53% had available off-campus sites for clinical practica in cleft palate. When asked whether students were adequately prepared to work with patients with cleft palate, 81.4% indicated that training was adequate. The scope of practice set forth by the American Speech-Language-Hearing Association (ASHA, 2001) for speech-language pathologists involves the provision of services that include screening, assessment, diagnosis, and treatment for speech disorders. Since 1993, ASHA no longer requires training in any specific speech disorder area, stating more generically that programs offer courses in speech, language, and hearing disorders primarily affecting children and adults (ASHA, 1993). This allows required coursework in specific disorder areas such as fluency, voice, and cleft palate to be removed from the curriculum. To meet these new ASHA standards, many training programs have revised their curricula (Yaruss and Quesal, 2002). Related to training in cleft palate, this could mean that previously required coursework in this area would either be eliminated or incorporated into other courses such as articulation, voice, and speech anatomy and physiology which, in turn, could restrict the amount and type of information presented. The potential consequences of the changes made in academic and clinical training related to cleft palate as a result of the 1993 ASHA modification and its potential impact on cleft care is alarming. The purpose of this study was to examine the current academic and clinical training of speech-language pathology students in cleft palate. These findings are compared with the earlier Pannbacker et al. (1990) study that looked at student preparation in this area. Participants METHODS All 232 graduate training programs in speech-language pathology accredited by the American Speech-Language- Hearing Association (ASHA) were invited to participate in this survey study. The list of these training programs was obtained from the ASHA website (http://www.asha.org/ gradguide) during spring 2004. Questionnaire A 32-item questionnaire (Appendix A), modeled after the Yaruss and Quesal (2002) survey about fluency, was designed to gather information about academic and clinical education of cleft palate. Questions obtained information about: (1) program characteristics (e.g., number of students and faculty, program requirements), (2) academic coursework (e.g., nature and number of courses, teaching faculty), (3) clinical training and supervision (availability of practicum, number of students enrolled), and (4) changes in training after revision of ASHA s Certificate of Clinical Competence (CCC) requirements. A section was provided in the questionnaire for respondents to offer general comments about academic and clinical training or to expand on items on the questionnaire. The questionnaire was set up as a secure web form on the Nemours Biomedical Research (NBR) department web server. A hyperlink to this form was e-mailed in a cover letter to all program directors. This letter, approved by the Nemours Institutional Review Board, explained that the purpose of the study was to obtain information about the academic and clinical training that graduate students in speech-language pathology receive in cleft palate. The letter also explained that the decision to participate was completely voluntary, that all responses would be kept confidential, and that all identifying information would be deleted from the mailing list and completed survey. Respondents were also given the option to decline participation. A randomly generated, but unique, code value was associated with each e-mailed link. These codes were used to ensure that all access to the web form came via legitimate links that were e-mailed for the survey, and thus that we did not collect data from unsolicited sources. All data collected via the web form were stored in a secured database on the NBR web server for later analysis. The number of programs declining to participate was also tracked. In an effort to improve the number of responses, a follow-up e-mail reminder was sent to nonrespondents 10 and 20 days after the original e-mailing. The focus was to remind potential participants of the importance of this study and to return their questionnaires. Assigned codes for each program were maintained until the last reminder e- mail was sent and the data collection period was completed. Analysis The R statistical programming environment (RDC Team, 2005) was used for data analysis. An item-by-item analysis was conducted and descriptive statistics used to summarize the data were obtained. Thematic analysis, a qualitative analytical method (Creswell, 1998, 2003; Damico and Simmons-Mackie, 2003; Braun and Clarke, 2006), was used to identify patterns among the participants open-ended comments. This method provides information that is not always accessible when analysis is limited to quantitative assessment. All responses were collated for analyses and used to identify main themes and subthemes associated with academic and clinical training of cleft palate. RESULTS After the second mailing, 133 of the 232 surveys were returned and six programs declined to participate, yielding a total of 127 surveys (response rate 5 54.7%) that were

Vallino et al., ACADEMIC AND CLINICAL TRAINING IN CLEFT PALATE 373 TABLE 1 Median Program Size Students and Faculty Full-Time Number of Programs (IQR*) Part-Time Number of Programs (IQR*) Undergraduate 80 (48) 10 (16) { Graduate 43 (32) 5 (9){ Faculty 10 (6) 3 (5) * IQR 5 interquartile range. { 32/127 programs reported having part-time undergraduate students. { 45/127 programs reported having part-time graduate students. eligible for analysis. The majority of surveys (85%) were completed either by the chairperson of the training program or faculty member responsible for the cleft palate course. Other respondents completing the survey included program and clinic coordinators or directors. Program Characteristics A description of program size is in Table 1. As shown, the majority of students were enrolled full time. The median number of students enrolled in undergraduate and graduate speech-language pathology programs was 80 and 43, respectively. The median number of full- time faculty for the responding programs was 10. Program Duration The majority of responding programs were on the semester system. The median time to complete a graduate program in speech-language pathology was five semesters (119 programs) or seven quarters (eight programs). Academic Training Exclusive Cleft Palate Courses Two thirds (66.9%) of the responding programs surveyed offered a course exclusively devoted to cleft palate. In about half of these programs (52.9%), it was a required course. Thus, only approximately 33% of responding programs had a required and exclusive course on cleft palate. The most frequently taught course format was lecture (61.2%) followed by seminar (24.7%). Other formats involved an intensive week or weekend course (14.1%) on cleft palate. For most responding programs (82.4%), the course was offered annually; 10.6% offered the course biannually. Most programs (85.9%) offered the course to graduate students only and 3.9% offered it only to undergraduate students. The remaining 10.2% offered the course to both graduate and undergraduate students. No Exclusive Cleft Palate Courses One third (33.1%) of the responding programs did not offer a course devoted exclusively to cleft palate. These FIGURE 1 cleft palate. programs devoted a small percentage of time in other classes discussing cleft palate. The median percentage of time estimated by respondents for the topic to be covered in other courses was: articulation disorders (5%), voice disorders (10%), anatomy and physiology (4%), and other (5% unspecified by respondents). Topics related to cleft palate covered in these other courses included anatomy and physiology (93.3%), assessment (95.6%), and treatment (95.6%). Clinical Training Typical student enrollment in clinical practice involving More than half of the responding programs (54.3%) offered clinical practica in cleft palate, whereas 45.7% did not offer this experience. Most practica were offered at a cleft palate clinic (59.4%), followed by clinics at nonuniversity (27.5%) and university (20.3%) hospitals and other facilities (20.3%; e.g., summer camps for children with cleft palate and craniofacial anomalies, schools). (Note: respondents were asked to check all available facilities, making the total more than 100%). Of those who offered practica in cleft disorders, in an average year, five or fewer students enrolled (Fig. 1). Of these, most students spent 8 or fewer hours in assessment. Typically, programs had students spend more time on treatment, as illustrated in Figure 2. In contrast, 88% of the students get no clinical practicum experience in cleft palate. Changes in Program Requirements Seventeen of the 127 responding programs reported changes in requirements as a result of the current standards. With regard to coursework, 11 programs reported an increase in the number of credits and course-

374 Cleft Palate Craniofacial Journal, July 2008, Vol. 45 No. 4 FIGURE 2 Estimated number of clinical practicum hours students obtain in assessment, treatment, and other aspects of cleft palate. work, five indicated a reduction, and one did not comment about the effect of the changes. Three programs indicated an increase in clinical work, four had a reduction and 10 provided no additional information. Thematic Analysis Two major themes and additional subthemes emerged from the thematic analyses that were not identified through the quantitative analysis (Fig. 3). The focus of the first theme was that of educational preparation of students in cleft palate. From this, two subthemes, academic training and clinical training, emerged. The respondents concerns about academic training clustered around faculty shortage, variability of the course offerings, and the effect of changes in ASHA certification standards on selected coursework. Issues surrounding clinical training consisted of limited access to patients with clefts or a cleft palate team. The focus of the second theme was the impact of limited academic and clinical training, a theme that appeared to have evolved from the issues raised about educational preparation. Two associated subthemes identified were competency and ethical practice. Respondents identified issues of clinicians being under- or unqualified in cleft palate and of offering inappropriate/unnecessary treatment to patients with cleft palate that may have an impact on their welfare. The ethical concern here pertains to the prospect that unprepared clinicians would provide inappropriate or inadequate clinical services. Ethical practice issues raised were referring patients or charging for services not provided. Appendix B contains specific examples of comments expressed by participants according to the major themes. Comparison of Academic and Clinical Training Between 1990 and 2006 To explore whether changes in training of cleft palate occurred over time, selected survey questions were compared with those of Pannbacker et al. (1990) whose survey was conducted before the certification changes were implemented. As shown in Table 2, in 1990 almost all programs surveyed by Pannbacker et al. (1990) offered coursework in cleft palate, whereas in 2006 two thirds offered such coursework, a decline of 30%. More courses were offered at the graduate level in 2006 than in 1990. Like FIGURE 3 Thematic map showing major themes and subthemes of respondents comments about academic and clinical training.

Vallino et al., ACADEMIC AND CLINICAL TRAINING IN CLEFT PALATE 375 TABLE 2 Comparison of Academic and Clinical Training Programs Surveyed by Pannbacker et al. (1990) and the Current Study (2006) Pannbacker et al. (1990) Current Survey (2006) (Total Surveys5134/ (Total Surveys 5127/232 239 or 56%) or 55%) % of All Programs % of All Programs Surveyed Surveyed Academic training Offered coursework in cleft palate 99 67 Level of training program Undergraduate 47 4 Graduate 48 85 Both undergraduate/ graduate 5 10 Clinical practicum hours Reported 1 20 clock hours Diagnostics 62 24 Treatment 63 26 Reported 0 clock hour Diagnostic 9 71 Treatment 5 (for both diagnostics and treatment) Training programs offering practicum sites in cleft palate 53 51 Pannbacker et al. (1990), we also found that slightly more than 50% of the programs had accessible clinical sites in cleft palate. However, the most striking difference between the 1990 findings and those of the present study was the percentage of programs in which students obtained clinical experience. In 1990, 66% of the programs reported 1 to 20 clock hours in diagnostics and treatment. In contrast, only slightly more than 25% of the programs in 2006 reported 1 to 20 clock hours in these clinical areas. In 1990, 9% of the programs reported 0 contact hours in diagnostics and 5% reported 0 contact hours in treatment, whereas 71% in 2006 reported 0 contact hours for both these areas. DISCUSSION The purpose of this study was to obtain information about graduate academic and clinical training programs in cleft palate. Findings revealed that about two thirds of the responding accredited training programs in speech-language pathology provide an exclusive course in cleft palate for which approximately half make it a required course. One third of the programs incorporated this training into other courses. Although half of the programs offer clinical practica in cleft palate, very few students actually enroll, and of those few, most spend their time on treatment. The data collected for this research are inadequate to provide an answer to the question as to whether there is less training as a result of the revised ASHA CCC standards. Although it might be tempting to relate this data to the fact that only 17 respondents answered the question, one cannot discount the idea that it may have been too complicated to do the historical legwork necessary to compare today s offerings with those from over a decade ago or that the information is unavailable. Moreover, given a nonresponse rate of almost 50%, these data cannot adequately speak to this issue. In some respects the results of the changes made in the ASHA certification requirements have affected training in cleft palate. As shown by the comparisons made with the survey study by Pannbacker et al. (1990), there appears to be a decreasing trend of course offering and clinical experience. It was astonishing to see the striking change in the percentage of students obtaining clinical experience in cleft palate. Slightly more than 25% of the programs reported 1 to 20 clock hours in diagnostics and treatment, and 71% reported 0 contact hours in these clinical areas. The decline in coursework and clinical experience related to cleft palate cannot be ignored because of the profound impact it may have on the ultimate care of these patients. Looking at studies of academic and clinical training in cleft palate, the findings in this study are very similar to other speech disorder areas for which specific coursework or clinical experience is no longer required (Yaruss, 1999; van Mersbergen et al., 2000; Yaruss and Quesal, 2002). In fluency, Yaruss and Quesal (2002) report a trend towards fewer required classes, fewer clinical hours, and a greater likelihood that students could graduate without any academic and clinical training in fluency. Likewise in voice, van Mersbergen et al. (2000) also show that nearly one third of students could graduate without any clinical voice experience and that the coursework offered in voice was frequently incorporated into other courses on speech disorders. Notwithstanding fluency and voice, it is worrisome that speech-language pathology students may not be adequately prepared to work with individuals with cleft lip and palate. Thematic analysis of the respondents comments was valuable in identifying issues considered more complex than what would have been revealed using quantitative means alone. Specifically, the respondents pinpointed reasons for the alterations in coursework on cleft palate as being related to faculty shortage and the changes in the ASHA certification standards. The critical shortage of Ph.D. faculty in higher education (ASHA, 2006), compounded by the current ASHA standards eliminating required coursework in specialty areas, would clearly have a profound effect in preparing students to manage individuals with cleft palate. The implications of limited educational preparation on clinician competency and ethical practice also need to be recognized. Inadequate preparation either in the form of course offerings or in the information presented to the students may often lead to inappropriate or ineffective treatment (e.g., blowing or oromotor exercises) to manage speech in individuals with cleft palate and velopharyngeal inadequacy. The complexity of speech disorders associated with cleft palate requires that clinicians be adequately prepared to assess, diagnose, recommend, and treat affected individuals

376 Cleft Palate Craniofacial Journal, July 2008, Vol. 45 No. 4 and to also understand the importance of multidisciplinary team management. Any move towards required courses in cleft disorders will be unlikely to succeed given the changes in certification requirements. Because of the potential impact this has on patient care, alternate preparation strategies that can be incorporated into graduate training and even beyond that of graduate school warrant consideration. Adequate training is important because clinicians have an obligation to provide patients with services that are in accordance with the Codes of Ethics of ASHA (2003) and the American Cleft Palate-Craniofacial Association (ACPA, 2005 2006). This means that clinicians should provide services competently and use every resource including referral when appropriate to ensure high quality service. The challenges to training in cleft palate parallel those that have beleaguered training programs in fluency disorders (Yaruss and Quesal, 2002). One challenge is that of the pressure on training programs to provide a greater breadth of education to meet the needs of a broader scope of practice with limited resources to teach students about cleft palate. Another is the availability of patients and clinical placements. A reasonable way to meet these needs and that of limited training in cleft palate is use of the Core Curriculum on Cleft Palate and Other Craniofacial Anomalies created by the Education Committee of the American Cleft Palate-Craniofacial Association (ACPA, 2004). This curriculum guide that is available to educators covers the essential aspects and knowledge bases critical to understanding the cleft condition and guiding best practice. It is organized by patient age and by the discipline likely to be involved in cleft care and offers current and accurate information about the management of clefts. In addition, pertinent references are also provided. The Core Curriculum might be especially valuable at universities where resources to teach or mentor students about cleft palate are limited. What may be missed in graduate training will need to be obtained by postgraduate continuing education and ongoing collaboration between the cleft palate team and community speech-language pathologists who serve individuals who have cleft palate (Grames, 2004). Another valuable source of information on the scientific and clinical aspects of cleft palate conditions is ASHA s Division 5, Speech Sciences and Orofacial Anomalies. This Division has a peer-reviewed newsletter containing articles that are useful to academicians and practitioners and a listserv whereby a clinician can ask questions or seek advice about a case and get helpful responses. There is a need for more outreach and continuing education programs in the forms of workshops and in-services. The use of technology has paved the way for enhancing instruction by means of distance learning and on-line learning with its potential to reach a wider audience, offer available resources, and provide access to current information (Kuehn et al., 2006). In addition, there are web-based approaches to instruction about cleft palate, some of which have been described in the literature (Karnell et al., 2005). There are CD-ROMs whereby a student can interact with computer-stored content. More recently, pocket PC/mobile learning is available whereby a student can access courses stored in a mobile device or wireless server. These alternative approaches provide updated knowledge and skills consistent with new developments and expand coverage of cleft palate in graduate training programs and our scope of practice. The use of e-mail as the only means of data collection is a limitation of this study. It would have been useful to include one or more additional, non e-mail methods (e.g., regular mail, telephone contact) of correspondence. In addition, there is no information about the number of students who enrolled in elective courses containing cleft content relative to the total numbers of students in the program. That is, what proportion of those speech pathology students who plan to work or go on to work in environments serving children do not get any training in the area of speech disorders associated with cleft lip and palate? Further study of this question is warranted. Nonetheless, the study has been informative about training in cleft palate, and the thematic responses provided an added value. However, it would have been interesting to learn more about the programs that did not respond. The lack of responses may be more telling about how limited is the training in cleft lip and palate. It is likely that faculty having expertise or interest in cleft palate may have been more likely to respond to this survey than those who do not. Because faculty were not queried about their particular involvement with the specialty of cleft palate, it was not possible to ascertain this further. On the other hand, it is plausible that the programs that did not respond offer even less academic and clinical training in cleft lip and palate than those who did respond, providing even further evidence of inadequate preparation of students in the area of cleft lip and palate. Although we obtained information on whether cleft palate was a required course, it would have been useful to survey the number of programs that offered this course as an elective and how many students take it as such. The survey may not have entirely addressed all aspects of training relevant to cleft palate; however, the findings emphasized the need to support the coursework and clinical education of students in programs offering this topic and the need to support teaching beyond the classroom. Meritorious of further study are the number of students who actually enroll in an elective course on cleft palate, information about the material presented in other courses that include the topic of cleft palate (e.g., articulation, voice), and the use of technology in the education of students and practitioners about cleft palate. CONCLUSIONS Cleft palate is a complex disorder to which many students have limited exposure and for which more training at the graduate level is unlikely because of the 1993 ASHA certification changes. As a result, there is a need to look

Vallino et al., ACADEMIC AND CLINICAL TRAINING IN CLEFT PALATE 377 towards alternative methods to enhance the educational and clinical experiences of students and practitioners in the specialty of cleft palate. Acknowledgments. We thank the faculty of the university graduate programs in speech-language pathology that took the time to complete the survey to provide us with information about their academic and clinical training in cleft palate. We also acknowledge Drs. Scott Yaruss and Robert Quesal who kindly allowed us to adapt their 2002 survey to study graduate training in fluency. REFERENCES American Cleft Palate-Craniofacial Association (ACPA). Core curriculum for cleft palate and other craniofacial anomalies. 2004. Available at: http://www.acpa-cpf.org/educmeetings/corecurriculum2002a.pdf. Accessed May 30, 2007. American Cleft Palate-Craniofacial Association (ACPA). American Cleft Palate-Craniofacial Association Code of Ethics. ACPA 2005 2006 Membership-Team Directory. Chapel Hill, NC: ACPA: 2005. American Speech-Language-Hearing Association (ASHA). Membership and Certification Handbook of the American Speech-Language-Hearing Association: For Speech-Language Pathology. Rockville, MD: American Speech-Language-Hearing Association; 1993. American Speech-Language-Hearing Association (ASHA). Scope of Practice in Speech-Language Pathology. Rockville, MD: 2001. American Speech-Language-Hearing Association (ASHA). Code of ethics (revised). ASHA Supplement, 23. 2003:3 15. American Speech-Language-Hearing Association (ASHA). Focused Initiatives 2006. Available at: http://www.asha.org/about/leadership-projects/ national-office/focused-initiatives06-fi-default.htm. Accessed May 30, 2007. Braun V, Clarke V. Using Thematic Analysis in Psychology. Qual Res Psychol. 2006;3:77 101. Centers for Disease Control. Improved national prevalence estimates for 18 selected major birth defects United States, 1999 2001. MMWR Morb Mortal Wkly Rep. 2006;54:1301 1305. Creswell JW. Qualitative Inquiry and Research Design. Thousand Oaks, CA: Sage; 1998. Creswell JW. Research Design. Thousand Oaks, CA: Sage; 2003. Damico JS, Simmons-Mackie MN. Qualitative research and speech language pathology. Am J Speech Lang Pathol. 2003;121:131 143. Grames LM. Implementing treatment recommendations: role of the craniofacial team speech-language pathologist in working with the client s speech-language pathologist. Special Interest Division 5, Speech Science and Orofacial Disorders. Perspectives on Speech Science and Orofacial Disorders Newsletter. American Speech-Language- Hearing Association; 2004;14:6 9. Karnell MP, Bailey P, Johnson L, Dragan A, Canady JW. Facilitating communication among speech pathologists treating children with cleft palate. Cleft Palate Craniofac J. 2005;42:587 588. Kuehn DP, Kummer AW, D Antonio LL, Karnell MP. Cleft palate and speech: three models of focused education. Special Interest Division 5, Speech Science and Orofacial Disorders. Perspectives on Speech Science and Orofacial Disorders Newsletter. American Speech-Language- Hearing Association; 2006;16:17 21. Morris HL, Jakobi P, Harrington D. Objectives and criteria for the management of cleft lip and palate and the delivery of management services. Cleft Palate J. 1978;15:1 5. Pannbacker M, Landis P, Lass NJ, Middleton GF, Everly-Myers DS. A survey of speech-language training programs: current trends in cleft palate. Texas J Aud Speech Pathol. 1990;16:32 35. Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP. Cleft Palate Speech. St. Louis: Mosby; 2000. Philips BJ. Speech assessment. Semin Speech Lang. 1986;7:297 311. RDC Team. R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing 2005. Available at: http://www.r-project.org. Accessed February 20, 2007. Spriestersbach D. Some professional implications. In: Spriesterbach D, Sherman D, eds. Cleft Palate and Communication. New York: Academic Press; 1968:269 297. van Mersbergen M, Ostrem J, Titze IR. Preparation of the speechlanguage pathologist specializing in voice: an educational survey. J Voice. 2001;15:237 250. Yaruss JS. Current status of academic and clinical education in fluency disorders at ASHA-accredited training programs. J Fluency Disord. 1999;24:169 184. Yaruss JS, Quesal RW. Academic and clinical education in fluency disorders: an update. J Fluency Disord. 2002;27:43 63.

378 Cleft Palate Craniofacial Journal, July 2008, Vol. 45 No. 4 APPENDIX A ACADEMIC AND CLINICAL TRAINING IN CLEFT LIP AND PALATE We are asking for your help in providing information about the academic and clinical training of students in speech-language pathology (SLP) in the area of cleft palate. The data that we collect are important in identifying how future clinicians learn and gain experience about the disorder, which may have an impact on the services provided to these patients. Please take a few minutes to complete this survey. We appreciate your time and information. All responses will be kept strictly confidential. Thank you for your participation. Demographic Information 1. What is the approximate number of students enrolled in your undergraduate SLP program? % 2. How many undergraduate students are: Full-time % Part-time % 3. What is the approximate number of students enrolled in your graduate SLP program? % 4. How many graduate students are: Full-time % Part-time % 5. How many faculty members are in your department (including clinical supervisors)? Full-time % Part-time % 6. How long does it usually take a student with an undergraduate degree in SLP to complete your graduate program? Number of Semesters % or Number of Quarters % 7. How many minimum credit hours are required to complete your graduate program in SLP? % Academic Training 8. Do you offer coursework exclusively devoted to cleft palate? % No % Yes 9. If yes, is it a required course? % No % Yes 10. In what form is the course offered? % Seminar % Traditional lecture format % Other (Specify: ) 11. How often is the course offered? % Annually % Biannually % Other (Specify: ) 12. To whom is the course offered? % Undergraduate students % Graduate students % Both 13. Who teaches the course in cleft palate? (Please check all that apply) % Full-time faculty % Part-time departmental faculty % Adjunct part-time faculty 14. If cleft palate is not an exclusive course, is the topic of cleft palate covered in another course(s)? % No % Yes 15. If yes, please indicate the approximate percentage of time spent discussing cleft palate. % of a course on articulation disorders % of a course on voice disorders % of a course on anatomy and physiology of speech % Other (Specify: ) 16. Within the above courses, what aspects of cleft palate are taught? (Please check all that apply) % Anatomy/physiology % Assessment % Treatment % Other issues that involve cleft palate (Specify: )

Vallino et al., ACADEMIC AND CLINICAL TRAINING IN CLEFT PALATE 379 Clinical Training and Supervision 17. Are students offered clinical practica in cleft palate? % No % Yes 18. If yes, where do students receive their clinical practica with cleft palate patients? (Please check all that apply) % Cleft Palate/Craniofacial Clinic % University Speech and Hearing Clinic % University Hospital % Non-University Hospital % Other (Specify: ) 19. On average, approximately how many clinical practicum hours do students obtain in the following areas of cleft palate? Assessment Treatment Other (Specify: ) 20. In the past year, approximately how many students were enrolled in clinical practica that involved cleft palate? % 0 % 1-3 % 4-5 %.5 (Specify: ) 21. During the clinical practicum in cleft palate, what aspects of clinical care are required experiences for the student? (Please check all that apply) % Assessment % Treatment % Other (Specify: ) 22. Did your program requirements for cleft palate change after ASHA revised the standards for the CCC in 1993? % No % Yes 23. If yes, in what way did the requirements change? (Please check all that apply) % Reduced coursework requirements (e.g., changed required courses to electives) % Increased coursework requirements (e.g., added courses to curriculum) % Reduced clinical requirements (e.g., reduced clock hour requirement) % Increased clinical requirements (e.g., increased clinical clock hour requirement) 24. Position of person completing this form: % Department Chair % Faculty member % Clinic director % Other (Specify: ) 25. Additional comments:

380 Cleft Palate Craniofacial Journal, July 2008, Vol. 45 No. 4 APPENDIX B Theme 1 - Educational Preparation Academic Training ----- Students may take cleft palate as an elective. ----- It is a required course. ----- First year that the craniofacial course will not be required. ----- Get information on cleft palate in the organic speech disorders class. ----- Considering dropping the cleft palate course. ----- Summer workshop on cleft palate. ----- Increase student experience to cleft and craniofacial disorders both in the classroom and the clinic. ----- Our cleft palate class was cancelled due to faculty shortage. ----- We have grand rounds. ----- Discontinued as separate course and incorporated into the graduate voice class. ----- In the past, we have had grand rounds. ----- Changed course a lot as a result of change in ASHA standards. ----- Developing a video library to assure some level of familiarity. ----- This is the first year that the craniofacial anomalies course will not be offered. ----- Current orofacial course expanded to include myofunctional, oral motor, genetic syndromes associated with orofacial anomalies. ----- Cleft palate information that is taught to undergraduate students in the intro course. ----- Undergraduate focus is on normal processes. ----- In mid 90 s the graduate students petitioned the program to abolish the course; we did so. ----- The course in the past was a full 3 credit course. Clinical Experience ----- Not a requirement that they obtain specifically craniofacial experience. ----- There is limited and/or missed opportunity. ----- Not required to have clinical experience. ----- Instrumental and advanced clinical practice in cleft palate. ----- Do not have access to sufficient cleft lip/palate clinic. ----- Summer camp for experience with a variety of cleft palate and other craniofacial differences. ----- Not all students are enrolled in practicum re: cleft palate. ----- Students receive experience but very infrequently. ----- No required practicum in cleft palate. ----- Do not have specialized practicum. ----- Not in close proximity to a cleft palate clinic. Theme 2 - Impact of Limited Academic/Clinical Experience Competency ----- Concerns that SLP clinicians are either unqualified or underqualifed. ----- Inadequate or inappropriate speech therapy services. ----- Some clinicians do not even have a master s degree. ----- May never have taken a voice/resonance disorders class and/or a course in craniofacial anomalies. Ethics ----- Ethical violation of charging fee for inadequate services. ----- Unnecessary surgeries or over extensive surgeries. ----- Control of information given to parents. ----- Recommendations seen to be tailored according to school district caseload and staffing constraints rather than the child s specific needs.