You have accessSIG 5 Craniofacial and Velopharyngeal DisordersResearch Article21 Feb 2020

Academic Education of the Speech-Language Pathologist: A Comparative Analysis on Graduate Education in Two Low-Incidence Disorder Areas

    Abstract

    Background/Purpose

    When working with a specialized population, it is necessary to have the appropriate clinical and academic training. However, many speech-language pathologists report being ill-prepared regarding best practice when evaluating and treating patients with low-incidence disorders, particularly cleft palate/craniofacial anomalies and fluency disorders. The purpose of this study was to compare differences in graduate speech-language pathology coursework in the United States across two low-incidence disorder areas: cleft/craniofacial anomalies and fluency disorders.

    Method

    A review of the accredited graduate curricula offerings within these domains was completed. Information whether coursework in these areas was offered, if the course was taught as a full course or embedded within a related course, or whether the content was required or an elective, and if the course was taught by an expert was obtained.

    Results

    Significant differences were present in the amount, quality, and type of course content offered for cleft/craniofacial anomalies compared to fluency disorders. Only 72.83% of graduate speech-language pathologist programs offered content in cleft/craniofacial anomalies. Approximately one out of every four programs (27.17%) did not provide this content within the graduate curriculum. In contrast, content in fluency disorders was taught in 99.28% of graduate programs.

    Conclusion

    Results demonstrate that graduate training in topics related to cleft/craniofacial anomalies is significantly limited, particularly in comparison to another low-incidence communication disorder.

    Clefting is a multifactorial craniofacial anomaly that can lead to deficits in numerous areas, including speech, resonance, feeding, and psychosocial well-being. Clefting is associated with more than 400 known syndromes, and nonsyndromic prevalence rates include approximately 7,400 live births per year in the United States resulting in potential speech and resonance disorders for those affected (Parker et al., 2010; Winter & Baraitser, 1987). Despite reports from the Centers for Disease Control and Prevention (2006) that cleft lip/palate is the most commonly reported birth defect, regular treatment for cleft lip/palate remains a low-incidence disorder in the field of speech-language pathology outside of medical centers and children's hospitals (Parker et al., 2010). Due to this, there is often reduced instruction related to the etiologies, speech, resonance, and feeding deficits associated with cleft palate and velopharyngeal dysfunction in graduate programs for speech-language pathologists (SLPs; Vallino et al., 2008). There are also limited numbers of clinicians who can provide clinical expertise and training to students and practicing clinicians. However, clefting can have a devastating impact on a child's quality of life if not treated appropriately (Broder et al., 2017). Un-repaired or unsuccessfully repaired cleft palate can have a significant negative effect on speech development and intelligibility, often preventing successful integration of the affected individual into society (Berger & Dalton, 2009; Broder et al., 2014; Riski, 1995 and constituting a clinical population of patients that SLPs are likely to encounter on their caseloads at some point in their careers.

    When working with a specialized population, it is necessary to obtain the appropriate clinical and academic training. However, many SLPs report feeling inadequately prepared regarding best practice when evaluating and treating patients with cleft palate and craniofacial anomalies (Bedwinek et al., 2010). Not only is there reported to be inadequate clinical training offered to aspiring SLPs, there is also a lack of course-based instruction regarding the diagnosis and treatment for this population (Bedwinek et al., 2010; Vallino et al., 2008). Bedwinek et al. (2010) found that 72% of SLPs in preschools and other school settings had encountered a child with a history of cleft lip or palate. However, the majority revealed that they did not consider themselves competent to properly treat the patients in this population. Other reports have indicated that SLPs often feel less competent treating individuals with low-incidence disorders (fluency, voice, neurogenic communication disorders) compared to articulation and language disorders (Kelly et al., 1997). The American Speech-Language-Hearing Association (ASHA) states in the code of ethics that those performing assessment and treatment must be competent in that area, and without the proper educational training and supervised clinical practice to provide a foundation, this is unlikely.

    Similarly, fluency disorders are also considered to be a low-incidence population and are seen at similar rates in pediatric and school-based caseloads (Brisk et al., 1997). Implications for treatment outcomes are also comparable to individuals with cleft/craniofacial anomalies, given patients with fluency disorders are at an increased risk for negative psychosocial implications if left untreated or treated inappropriately (Blood et al., 2007; Hennessey et al., 2014).

    In contrast, however, likely due in part to efforts by ASHA's Special Interest Group (SIG) 4: Fluency and Fluency disorders and the Board Specialty Certification in Fluency, this communication disorder is frequently allocated a specific academic focus in speech-language pathology graduate programs, undoubtedly providing more satisfactory preparation for treatment of this population (Cooper, 1998; Yarrus et al., 2017). In addition to specialty certification and materials developed by the ASHA SIG 4, many online resources exist for expanding competence in fluency disorders. The National Stuttering Association and the Stuttering Foundation have developed numerous readily available resources and continuing education opportunities. These include free e-books, online video tutorials, parent and caregiver handouts, and coordinated national conferences and events. The impact of these additional educational resources further expands opportunities in preparation for treatment of this population.

    The purpose of this study was to assess the status of graduate preparation for cleft and craniofacial anomalies and fluency disorders in ASHA-accredited speech-language pathology programs across the United States. Specifically, this study aimed to compare offerings of cleft and craniofacial topics in the graduate speech-language pathology curriculum compared to that of another low-incidence disorder, fluency. This investigation sought to answer the following research questions:

    1. Is graduate coursework offered in the areas of cleft/craniofacial anomalies and/or fluency disorders?

    2. If coursework is offered, is this content embedded within a related course or taught in a dedicated course?

    3. Of the programs that offer a dedicated course in cleft/craniofacial anomalies and/or fluency disorders, is this course required or an elective?

    4. Is the coursework taught by someone considered to be an “expert” in the specialty area?

    Method

    In order to obtain the most comprehensive data set, an online review of accredited graduate programs in speech-language pathology across the United States was completed. A listing of all accredited graduate programs with the designation of communication sciences and disorders, speech and hearing sciences, and speech-language pathology was retrieved from ASHA's EdFind database (ASHA, n.d.). As of January 2019, a total of 277 programs across the United States were accredited (see Figure 1). Of these accredited programs, 276 were included in the analysis. Similar to Mills and Hardin-Jones (2019), one program was excluded due to being a satellite campus, which employed the same faculty and curriculum as the primary university.

    Figure 1.

    Figure 1. Map of accredited universities across the United States.

    Academic course catalogs, course descriptions, and department websites were referenced to gather information regarding graduate curricula. When no information was available online, program directors were contacted directly via telephone or e-mail to obtain course and instructor information. Data from these sources were combined into this analysis.

    Program data were recorded for both cleft/craniofacial disorders and fluency disorders. Similar to Mills and Hardin-Jones (2019), information regarding whether coursework in these areas was offered; if the courses were taught as full courses, special topics, or lectures embedded within related courses; or whether the content was required or an elective, and if courses were taught by an expert was gathered. Operational definitions of these variables are presented in Table 1. Specifically, a course taught by an expert was defined as “taught by someone who has published research in the specialty area and/or completed clinical work with the specialty population as noted on their available curriculum vitaes (CVs) and/or website bios.” Faculty names and curriculum vitaes were cross-referenced with PubMed indexed data related to publications within the specialty areas. Embedded content was defined as “any content taught as part of a special topic or an embedded lecture within a subsequently related course” (see Table 1).

    Table 1. Definitions of categories.

    Category Definition
    Course material taught Content was considered to be included in the graduate curricula if any content was taught regarding cleft/craniofacial disorders or fluency disorders, in any capacity, within the graduate program.
    Dedicated course Content was categorized as a dedicated/stand-alone course if a full-semester offering was available.
    Required course Content was identified as a required course if graduate students were required to complete a full-semester course within the topic area.
    Elective course Content was identified as an elective course if graduate students were not required to complete a full-semester course within the topic area, but a full-semester course within the topic area was optionally offered.
    Embedded content Content was categorized as embedded content or a special topic if content was only included as a portion of, or lecture(s) within, a related stand-alone course (e.g., a voice disorders course with a lecture about craniofacial anomalies or fluency disorders).
    Taught by expert Defined as coursework that is taught by someone who has published research in the specialty area, and/or a board-certified fluency expert, and/or completed clinical work with the specialty population.

    Results

    Descriptive statistics were computed for each type of course offering. Chi-square tests of homogeneity were computed, with adequate sample sizes established according to Cochran (1954).

    The total number of graduate programs in speech-language pathology offering cleft/craniofacial content was 201 out of 276 accredited programs (72.83%). Within the universities that offered craniofacial content, only half offered it as a dedicated course (53.73%, n = 108). The remainder of graduate programs provided this content as an isolated lecture or a special topic embedded within a related course (46.27%, n = 93). Furthermore, of the programs that offered a dedicated course in cleft/craniofacial anomalies, half offered it as an elective (50%, n = 54). Consequently, only 26.86% of graduate programs provided a dedicated and required graduate course for cleft palate/craniofacial anomalies. Approximately one fifth (19.93%) of cleft palate/craniofacial coursework was taught by an expert in the field of cleft and craniofacial anomalies (see Figure 2).

    Figure 2.

    Figure 2. Breakdown and comparison of course content and faculty expertise for fluency disorders and cleft/craniofacial anomalies.

    In contrast, curricula in fluency disorders were offered in 99.28% of graduate speech-language pathology programs in the United States (n = 274). Nearly all (94.53%, n = 259) were offered as a dedicated course, and of the dedicated courses, 95.37% (N = 247) were a required course in the graduate curriculum. Only 4.63% were offered as elective courses (n = 12). Half of all fluency courses (51.81%) were taught by an expert in the field of fluency disorders (see Figure 2). Figure 3 compares the number and type of course offerings for craniofacial anomalies versus fluency disorders.

    Figure 3.

    Figure 3. Sankey diagram showing the total number of fluency and craniofacial courses offered and the type of course offerings within each of these areas.

    Statistical comparison showed differences in each area that was assessed. Observed frequencies and percentages of course offerings for cleft/craniofacial and fluency content are presented in Table 2. A significant disparity was present between the content, type, depth, and faculty expertise of the courses being taught for fluency disorders versus craniofacial anomalies (see Figure 4). There was a statistically significant difference in the multinomial probability distributions between course offerings for craniofacial and fluency content (χ2 = 80.427, p ≤ .0001; α = .05). Craniofacial content was offered significantly less than fluency content. Provision of a dedicated, full-semester course versus embedded content was significantly different for craniofacial versus fluency disorders (χ2 = 109.837, p ≤ .0001; α = .05). Significant differences were present in the frequency of embedding cleft/craniofacial course content in related courses compared to embedding course content for fluency disorders. Cleft/craniofacial content was embedded within related coursework more often than fluency content. Significant differences were also found between elective and required course offerings for cleft/craniofacial disorders and fluency disorders as well (χ2 = 106.354, p ≤ .0001; α = .05). Courses related to fluency disorders were more often a required course in the graduate curriculum. Significant differences were also present related to the expertise of faculty teaching cleft/craniofacial and fluency content (χ2 = 22.22, p ≤ .0001; α = .05). Compared to fluency disorders, content for craniofacial disorders is provided less often in the graduate curricula and is taught more frequently by a nonexpert.

    Table 2. Summary table of course content for fluency disorders and cleft/craniofacial anomalies.

    Course type Content present
    Depth of content
    Yes No Dedicated Embedded Required Elective
    Cleft/craniofacial 201 75 108 93 54 54
    (72.83%) (27.17%) (53.73%) (46.27%) (50%) (50%)
    Fluency 274 2 259 15 247 12
    (99.28%) (0.72%) (94.53%) (5.47%) (95.37%) (4.63%)
    Figure 4.

    Figure 4. Side-by-side comparison of graduate curricula offerings for cleft/craniofacial disorders and fluency disorders.

    Discussion

    Current Status of Graduate Curricula in Cleft/Craniofacial and Fluency Disorders

    This study examined the curricula of two low-incidence disorders within the field of speech-language pathology, namely, cleft/craniofacial anomalies and fluency disorders. Results from this study indicate that training in craniofacial anomalies is significantly limited, particularly in comparison to fluency disorders. Academic programs surveyed in this study, in general, were more likely to offer fluency disorders as a dedicated course compared to cleft palate/craniofacial coursework. Courses in fluency disorders were also more likely to be required courses compared to craniofacial disorders, which is more often an elective or a special topic or unit embedded within a related course. This is consistent with results documented in the survey of cleft/craniofacial coursework reported by Mills and Hardin-Jones (2019), which found cleft/craniofacial content to be most frequently embedded in courses such as voice disorders, special populations, or dysphagia.

    Compared to an earlier study in fluency disorders (Yaruss, 1999), Yaruss and Quesal (2002) observed a reduction in the number of universities offering didactic education requirements related to fluency following updates to ASHA's accreditation standards in the 1990s. More recently, however, Yaruss et al. (2017) reported that, in comparison to the earlier survey (Yaruss & Quesal, 2002), more programs have increased academic coursework on topics related to fluency disorders. This increase is further reflected in the data obtained from this survey related to content taught in the area of fluency disorders. Programs were more likely to require training and coursework in the area of fluency disorders than compared to earlier survey reports (Yarrus et al., 2017; Yaruss & Quesal, 2002).

    In contrast, the current study demonstrated a continued decrease in the depth and breadth of curricular offerings within accredited programs across the area of cleft/craniofacial anomalies, consistent with previous studies (Mills & Hardin-Jones, 2019; Vallino et al., 2008). The percentage of universities offering graduate content in cleft palate/craniofacial anomalies has stayed relatively static between 2008 and 2019; however, the number of dedicated and required courses has decreased, while embedded content and elective courses have notably increased. This increase in embedded content and increase in elective status likely reduce the overall amount and depth of content that is being provided to students in this area. Similar trends in declining course offerings were observed by Vallino et al. (2008) in comparison to an earlier study in the area of cleft palate (Pannbacker et al., 1990). Pannbacker et al. (1990) completed a survey prior to changes in certification standards that were implemented by ASHA. In 1990, Pannbacker et al. found almost all programs had coursework in cleft palate, whereas in 2008, Vallino et al. (2008) found only two thirds of responding programs in the United States offered such coursework (Vallino et al., 2008). This represented a decline of 30% over the period between reviews. This study further demonstrates that approximately only one out of every four graduate programs has a dedicated course in cleft palate/craniofacial anomalies (26.86%) and a quarter of programs (27.17%) do not provide this content within the graduate curriculum. Consistent with recent findings identified by Mills and Hardin-Jones (2019), education and training on topics related to cleft palate within accredited programs remain limited, especially in comparison to that of fluency disorders.

    Mills and Hardin-Jones (2019) additionally provided information on training curricula in cleft/craniofacial anomalies that documented substantial differences across programs in the number of credits offered, duration of time or lectures spent on cleft/craniofacial content, and percentage of clinical opportunities in this area. These differences were present despite all programs being ASHA accredited and meeting current accreditation standards. ASHA's knowledge standard, IV-C, which combines the individual domains of voice and resonance disorders into one area, may contribute to these disparities in curricular offerings. Previous reports indicate that content related to cleft/craniofacial anomalies is most frequently embedded within a course entitled “Voice and Resonance Disorders,” often having a focus on voice disorders and laryngeal pathology with limited attention and content devoted to resonance disorders associated with cleft/craniofacial anomalies (Mills & Hardin-Jones, 2019). When programs embed content related to cleft/craniofacial anomalies within other related courses, a focus on providing adequate instruction is necessary and content must be embedded appropriately and consistently across the curriculum. If content is only briefly addressed in a “voice disorders” course, key training is missed across the numerous areas of clinical need for this population of patients. For example, if an academic program embeds this content within other graduate coursework, feeding deficits related to cleft palate should be included in a “pediatric dysphagia” course, speech sound errors, nasal emission, and compensatory articulation patterns found in individuals with cleft palate, and/or velopharyngeal dysfunction should be included in “articulation and phonology” courses. Resonance disorders associated with cleft palate and velopharyngeal dysfunction would need to be emphasized in the “voice disorders” course. It remains unclear if academic programs are consistently embedding content related to cleft/craniofacial anomalies across the curriculum when a dedicated course in cleft/craniofacial anomalies is not part of the curriculum. Mills and Hardin-Jones indicated, as programs move to consolidate course content across the curricula, a valid concern remains regarding the extent to which programs maintain or provide coverage of feeding, articulation, and resonance disorders related to cleft palate/craniofacial anomalies.

    Need for Curricula and Instructors With Expertise in the Topic Area

    There is a need for cleft/craniofacial content to be included in graduate curricula as this population requires the integration of numerous areas within the scope of speech-language pathology and SLPs are likely to encounter this population of patients on their caseloads across settings (Bedwinek et al., 2010). Lack of graduate education and clinical practicum experience appears to have led to a substantial population of SLPs who do not feel competent providing services (Bedwinek et al., 2010). Many SLPs are often very capable of providing the necessary speech (articulation) intervention services for this population but are unaware of how to apply their skillset due to lack of exposure, difficulty identifying perceptual speech and resonance qualities, uncertainty with management plans or available resources, and the complexity of diagnoses often associated with this population of patients (Bedwinek et al., 2010; Brunnegård et al., 2012; Kuehn & Henne, 2003; Kuehn et al., 2006). Exposure to this content in the graduate curricula within a dedicated and required course could provide the knowledge base necessary to facilitate development of competent clinicians and future experts in the area.

    In this study, only 19.93% of cleft/craniofacial content was taught by an expert, compared to 51.81% in topics related to fluency disorders. Both of these figures are strikingly low and highlight the limited access to faculty with expertise in these two low-incidence disorders. These findings are in agreement with observations from earlier survey studies nationwide in both cleft palate (Vallino et al., 2008) and fluency disorders (Yaruss & Quesal, 2002). Most notably, the area of faculty expertise and experience in cleft and craniofacial disorders appears to be significantly underrepresented. Future studies should examine this disparity and determine if this finding related to faculty expertise is consistent across all areas in the graduate curricula. In contrast, Mills and Hardin-Jones (2019) reported that program directors stated they considered 93% of faculty teaching dedicated courses and 56% of faculty teaching elective courses to be experts in the area. This finding differs from that of this survey, likely due to differing definitions of what was considered to be an expert. However, a large percentage (36%) of faculty teaching elective courses were reported as not having appropriate expertise in the area of cleft/craniofacial anomalies (Mills & Hardin-Jones, 2019). Additional study of this aspect is likely warranted, with a clear operational definition of “expert” to guide data collection.

    Clinical practicum experiences also offer opportunities for graduate students to expand their knowledge and achieve performance objectives for this population of patients. This study did not address graduate clinical training in this area. However, Mills and Hardin-Jones (2019) reported that the majority of graduate clinical training in this area is obtained from hospitals, cleft palate clinics, university clinics, and other means such as simulations and mission trips. Finding solutions to promote an increase in academic and clinical instruction at the graduate level with a specialist in cleft palate should be of priority to improve the quality of care for children born with cleft palate.

    The use of didactic treatment methods, such as specialized clinical training programs, has been proposed as a means to promote greater training options for graduate students (Grames & Stahl, 2017; Sheer-Cohen et al., 2017). del Carmen Pamplona et al. (2015) developed a mentoring program to improve speech-language pathology graduate students' ability to treat patients with cleft palate. Findings demonstrated that students receiving mentorship under the guidance of an experienced mentor with expertise in cleft palate showed greater clinical growth compared to those who had a clinical supervisor without such training. These findings support the importance of clinical supervision and instruction from SLPs who have experience in the assessment and treatment of patients with cleft palate and craniofacial anomalies.

    Scheer-Cohen et al. (2017) described a specialized training program that includes academic and specialized clinical training under a field expert. Although program outcomes have not been reported, this program offers an innovative approach to student education. However, it is not clear how clinical experience in lieu of graduate coursework may impact students' ability to perform in a specialized clinical training program (Yaruss et al., 2017). Yaruss et al. (2017) surmised that if students do not have the basic background and foundation for the specialized field, such as fluency disorders, they are likely ill equipped to handle a clinical training experience, even in the presence of a specialized expert in the field. Future research is needed to systematically examine outcomes using didactic and clinical training models and define recommended training approaches for academic programs to consider when faculty are lacking the expertise in a low-incidence area such as cleft care.

    Impact of Low-Incidence Populations on Inclusion in Curricula

    Although cleft palate is often considered a low-incidence disorder on the caseloads of SLPs, a nationwide survey revealed that 72% of preschool and school-based SLPs reported having worked with a child with a repaired cleft lip and/or palate (Bedwinek et al., 2010). The incidence of concomitant deficits associated with cleft/craniofacial anomalies (speech, resonance, feeding, etc.) increases the likelihood that a clinician will be faced with the need for recommending appropriate referrals and implementing clinical services within this population across work settings.

    In the area of fluency disorders, Craig et al. (2002) emphasized the importance of changing the views of stuttering being a “small” problem as a means to increase priority within academic and clinical training programs (Craig et al., 2002). Yairi and Ambrose (2005) indicated that, when the focus is on the minimal number of individuals being affected by a disorder, it de-emphasizes the nature of the problem to those impacted. The author further explains that different entities such as associations and foundations can advocate for such causes to alter the view of low-incidence disorders as being a “small” problem. A similar argument can be made for cleft palate and resonance disorders, which are reported to occur more frequently than fluency disorders (Canfield et al., 2006; Craig et al., 2002; Parker et al., 2010; Wilson, 1987).

    It would be reasonable to presume that a lack of academic and clinical training due to the assumption of this population being low incidence has the potential to lead to a greater likelihood of using non–evidence-based techniques, such as nonspeech oral motor exercises (NSOME; Lof & Watson, 2008; Watson & Lof, 2009). Lof and Watson (2008) found that 85% of clinicians surveyed used NSOME to treat speech sound errors. At that time, SLPs ranked cleft palate as the third most likely population with which they would use NSOME (Lof & Watson, 2008). This, in combination with the current body of research, certainly indicates the need for increased graduate coursework in cleft/craniofacial anomalies to better prepare clinicians to work with this population.

    Suggestions for the Future

    Provision of continuing education in cleft/craniofacial anomalies by specialists in the field has been emphasized as an area of priority, particularly given the reduced emphasis of cleft palate coursework within graduate programs (Bedwinek et al., 2010). Online self-study courses through the ASHA's continuing education library have also been developed as a means to offer professionals, as well as graduate programs, options for expert teaching in cleft care when faculty members are not available.

    Access to SLPs with expertise in cleft care on a local cleft palate craniofacial team can additionally be a resource to universities for teaching content related to cleft palate. Many of these professionals were involved in some capacity for providing lectures and clinical expertise to graduate students in this survey. However, these resources are more likely to be available in metropolitan areas because cleft palate craniofacial teams are often associated with a tertiary medical center (Grames, 2008). Access to collaborative telemedicine/telepractice resources and online curriculum instruction may further provide opportunities and access to this content in both preservice and in-service venues (Bedwinek et al., 2010; Whitehead et al., 2012). In this regard, Crowley (2017) have developed an extensive online library of videos and educational content related to assessment and intervention for cleft palate and craniofacial anomalies. Video modules, therapy handouts, and training for professionals and families are provided in both English and Spanish.

    Resources through ASHA SIG 5 (posters for conference presentations, webinars, online chats, online courses, etc.) and the American Cleft Palate Craniofacial Association (core curriculum documents and online resources) are also available to practitioners and caregivers who are in need of additional training. Organizations such as the American Cleft Palate/Craniofacial Association, Cleft Palate Foundation, and American Cleft Palate/Craniofacial Association Family Services have initiatives to further public awareness related to this area and have made efforts to bring together practitioners and the families they serve. Cooperative ventures are likely the most important line of response for promoting training in cleft care (Grames, 2008). Specialized task forces representing clinicians and academicians in cleft care may be a viable solution to offering recommendations to address the decline in academic and clinical training in cleft care. Given the updated 2020 ASHA certification standards, particularly those related to interprofessional practice, which is a long-standing pillar within the treatment guidelines for cleft/craniofacial anomalies, meaningful recommendations should be identified and discussed.

    Conclusion

    Significant differences are present in the amount, quality, and type of course content offered for cleft/craniofacial disorders compared to fluency disorders, both of which are low-incidence populations. Education and training opportunities in cleft/craniofacial disorders are significantly limited, particularly in comparison to fluency disorders. Specialized task forces representing clinicians and academicians within specialty areas may be a viable solution to developing recommendations to address the decline in academic and clinical training in cleft care.

    Research is needed to systematically examine outcomes using different training models and define recommended training approaches for academic programs to consider when faculty lack expertise in this area. It would be of particular interest to assess if perceived SLP preparedness for treating individuals with fluency disorders and other low-incidence disorder areas differs from the reported preparedness SLPs perceive for treating cleft/craniofacial anomalies. This may provide insight into how enhanced academic course offerings impact perceived skill in clinical service provision. Finding solutions to promote an increase in academic instruction with specialists should be of priority to improve the quality of care for children born with cleft and craniofacial disorders and other low-incidence populations.

    References

    Author Notes

    Disclosures

    Financial: Kazlin N. Mason has no relevant financial interests to disclose. Hannah Sypniewski has no relevant financial interests to disclose. Jamie L. Perry has no relevant financial interests to disclose.

    Nonfinancial: Kazlin N. Mason has no relevant nonfinancial interests to disclose. Hannah Sypniewski has no relevant nonfinancial interests to disclose. Jamie L. Perry has no relevant nonfinancial interests to disclose.

    Correspondence to Kazlin N. Mason:

    Editor: Brenda Louw

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