Bringing Active Learning to Cleft Palate

By: Linda D. Vallino, PhD, CCC-SLP/A, FASHA, Center for Pediatric Auditory and Speech Sciences, Nemours/A.I. DuPont Hospital for Children, Wilmington, Delaware

Dennis M. Ruscello, PhD, CCC-SLP, FASHA, West Virginia University, Morgantown, Virginia

David J. Zajac, PhD, CCC-SLP, FASHA, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina

Authors of Cleft Palate Speech and Resonance: An Audio and Video Resource

Individuals with cleft and craniofacial anomalies represent a complex heterogeneous population. Like their medical presentations, their communication impairments can be diverse in nature and severity, the result of various causative factors.  Although some individuals with cleft palate may have normal sounding speech others will not. Some will present with obligatory errors that occur as a direct result of velopharyngeal dysfunction (VPD) (e.g., hypernasality, audible nasal air emission, nasalized plosives). Others will present with learned maladaptive articulations that occur as compensation for VPD (e.g., glottal stops, pharyngeal stops, fricatives, and affricates). Individuals with cleft palate may also present with obligatory errors as a direct consequence of oral structural anomalies (i.e., frontal distortions). Even still, there are those patients with and without cleft palate who produce unusual articulations such as nasal fricatives (i.e., phoneme-specific nasal emission) (Vallino, Ruscello, & Zajac, in press; Zajac & Vallino, 2017). Any one or more of these errors as well as those errors unrelated to the cleft palate can co-occur. Given the complexity of speech problems in this population, the student of speech-language pathology might find this all quite confusing. Misidentification of errors can lead to misdiagnosis and inappropriate treatment recommendations. The challenge to any instructor is how to effectively teach cleft palate, a complex disorder, to students; and create a successful transfer of evidence-based knowledge and skill to real-life clinical practice that will result in optimal care for the clients they will come to serve.


Traditional Teaching of Cleft Palate

A most pressing issue in the area of cleft palate is that clients with this disorder constitute a low incidence population, and many clinicians have limited academic exposure and/or clinical training in this area (Vallino, Lass, Bunnell, & Pannbacker, 2008). The typical, and most dominant, approach to teaching a course in cleft palate speech is pedagogical. The instructor disseminates (didactic) information about the features of the various speech disorders (i.e., resonance, nasal air emission, articulation, phonation) associated with cleft palate and students are passive recipients of this knowledge. Instructors may supplement the material presented with a textbook on cleft palate that includes illustrations using snippets of recorded speech samples of a particular speech feature to which the students simply listen. Presentations of case studies are rare. The students take notes on the information presented, only to recall it on a written examination (Siegel, Omer, & Agrawal, 1997). They are thought to understand the material based on the grade received for the course. As is known, the grade a student receives is not always a valid or accurate predictor of the student being able to apply his or her knowledge (Albanese & Mitchell, 1993).

The advantages of this traditional didactic approach are that it introduces the student to a fairly broad array of speech disorders associated with cleft palate that might not be otherwise covered in any other course, and the instructors have maximum control over the material presented. The disadvantage of this type of teaching is that it is essentially unstimulating, and that information presented this way tends to be forgotten rather quickly. As Jaebi (n.d.) pointed out, the didactic approach lacks student focused learning, emphasis on critical thinking, and process-oriented learning.  Importantly, it lacks interactivity. Students too have different learning styles and preferences, and if the goal in teaching is to make all students successful learners then this predominant one-way approach is not always a good learning fit for all.

The students who sit in our classrooms in 2018 are millennials. They have grown up with and interact constantly with technology, and this is affecting how they want to be taught. For this reason, it only makes sense that technology be used to bring to the student an interactive approach to their learning about speech problems associated with cleft palate. Classrooms are equipped with this technology (i.e., Smart Boards, data projectors and projection screens or LCD/TV monitors, DVD players, audio systems, and capabilities for video conferencing), which can easily provide access to real-life examples. Students learn well and retain information well when they are engaged, when they are active participants in the learning process.

Cleft palate is a specialty in speech-language pathology that particularly lends itself to learning both in the classroom and experientially, through problems and problem solving. The very nature of this “visible” disorder, the complex case histories, and the multiple disciplines involved can present genuine challenges for the student. However, these challenges can be used to actively involve the student in real-life situations.

Creating a hybrid of traditional classroom learning, problem-based learning and experiential learning translates to a student who becomes a confident, competent, resourceful, and effective speech-language pathologist. It’s about creating a student-centered approach to learning.  The goal is to provide the student with the necessary tools and resources to apply the skills learned to real-life practice.

Problem-Based Learning

Problem-based learning (PBL) is a student-centered approach to teaching that uses problem scenarios to promote concept learning and problem-solving abilities (Barrows, 1996; Hmelo-Silver & Eberbach, 2012; Savery, 2006). Its application has been promoted in the fields of medicine and health disciplines, including speech-language pathology (Burda & Hageman, 2015; Whitehill, Bridges, & Chan, 2014). In contrast to didactic teaching in which the knowledge is provided to the student, PBL turns to the student to apply his or her knowledge.  Through a discussion-based approach and questioning, an instructor facilitates students’ critical ways of thinking without providing them with solutions. Students work in collaborative groups to learn what they need to learn in order to solve the problem. They are presented with a case history (or scenario) that involves a challenge—much like in the real clinical world for which they have to provide a solution (see Box 1).

Box 1. Problem scenario (case history)

This is a 6-year-old male with paired bilateral cleft lip and palate. The lip was repaired at 3 months and the palate at 10 months of age. He has a history of otitis media with effusion treated with myringotomies and pressure-equalization tubes. Current audiologic examination showed normal hearing sensitivity, bilaterally. This child has a history of speech therapy beginning with Early Intervention. His speech is characterized by mild hypernasality, pharyngeal fricatives and stops as well as an /r/ distortion. During the perceptual assessment, it was a challenge for him to repeat sentences and he had to be redirected to task several times. The family is concerned about this child’s hypernasality and expressed that his teachers do not easily understand him.

After reading the patient’s history, the students begin by identifying the knowledge they have about the condition. They need to ask themselves, what facts do I already have and what else do I need to understand in order to resolve this problem? The students have to research the areas where they have identified gaps in their knowledge and the uncertainties they must resolve before finding the solution to the problem and making treatment recommendations. During this process, they have to sort through relevant evidence using a variety of resources.

The advantages of this type of learning include developing the student’s ability to make decisions and effectively solve problems, becoming analytical, working as a team, raising awareness of the complexity of issues, developing an ability to extend learning beyond a presented problem, and integrating theory and practice (Gentry, 2000, p. 13).


Experiential Learning

Anchored to PBL, is experiential learning (EL). PBL uses realistic problems to set up the learning leading to a diagnosis and recommendation. EL is a continuous process whereby knowledge is created through an authentic experience (Kolb, 1984). As in PBL, the instructor directs and facilitates. EL is a participatory event and, in effect, a holistic approach to learning in which the student progresses through a cycle of four integrated processes: concrete experience, reflective observation, abstract conceptualization, and active experimentation. (Kolb, 1984).  These features are summarized in Table 1. Central to both EL and PBL is encouraging critical and independent thinking in the student.

Table 1. Summary of key features of experiential learning (adapted from Kolb, 1984)

Stages Feature
Concrete experience Actively experiencing an activity
Reflective observation of the new experience Active reflection on experiences based on personal experience or what is known
Abstract conceptualization New ideas about the problem are formed or modifications of previous conceptions
Active experimentation Apply ideas to practical experience

Both PBL and EL are indispensable to learning through problem solving and although they would be particularly meaningful in a specialty as complex as cleft palate, they have been insufficiently explored in this specialty.  The strength of learning comes from an integration of these two approaches. PBL provides an opportunity to apply a student’s knowledge to a relevant problem. EL provides the experience through avenues such as audio and/or video recordings which bring the problem to life. It draws the connection between the history and the actual presentation of the problem, and further supports ongoing problem comprehension. Moreover, in contrast to didactic teaching, the instructor’s role in PBL and EL is transformed from one that disseminates all the information and answers to one of guidance and facilitation. Gentry (2000, p. 11) noted that instructors in this role often experience revitalization about teaching and a renewed interest in the topic being presented.

Integrating PBL and EL in the Classroom for Cleft Palate        

The experience of audio and/or videotape recordings can be effective when in teaching a course in cleft palate where it is important to integrate coursework and an experience, while also addressing the learning preferences of the student. The recordings are more than just a speech sample, and when presented alone, are ineffective in learning about cleft palate. The true value of these recordings along with case histories and other supplemental information is the added “real-life” dimension to teaching that is unavailable in textbooks even with their short speech samples. They help explain concepts and act as a trigger for discussion. Because the recordings can be played over and over again or stopped at various points, students have an opportunity to hear those aspects of speech that they may have missed or did not understand the first time and to also engage in further discussion about the problem.

A true experiential learning in cleft palate involves audio and video recordings and all of the steps and processes from PBL and EL. Figure 1 illustrates this type of learning within the classroom.

The first step involves a concrete experience in which an audio and/or video recording of the case is presented. The second step involves making observations and reflecting on what was heard and seen in the experience, facilitated by the instructor, and engagement with peers. Using a white board, a systematic approach to problem-solving can be illustrated. Here, the facilitator or instructor can be helpful in offering guiding questions that lead to further understanding of the problem.  Third, the remarks and discussions lead to abstract conceptualization (analysis) and conclusions about the problem and recommendations. During this time misinformation and confusion about the client and speech can be clarified. The fourth step is to test this new-found knowledge during independent practices using real-world problems and/or clinical placements.  This process is a valuable guide in understanding any case regardless of complexity.

In summary, a hybrid of didactic, problem-based learning, and experiential learning will enhance the training experience of the student studying cleft palate. Audio and video recordings can be effective in this process where integration of theory and actual practice are so vital. The role of these recordings is to provide concrete experience along with other steps in the learning process. Given that there have been so few opportunities like this in the past, we have written our new textbook, Cleft Palate Speech and Resonance: An Audio and Video Resource, to facilitate problem based and experiential learning in the classroom (Vallino et al., in press).



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