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Research Article
Impact of an International Training on
Interventionists’ Expertise in Cleft Palate Speech:
Results From Oaxaca, Mexico
Catherine J. Crowley,
a
David Yanowitch,
b
Miriam Baigorri,
c
Kyung Hae Hwang,
a
Kelly Nett Cordero,
d
Alejandro Gonzalez,
e
Mariane Goes,
f
Diana Bohórquez,
g
Nicholas Sierra,
g
Socorro Grijalva Zavaleta,
e
and Erika S. Levy
a
a
Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY
b
Columbia Secondary School for Math, Science,
and Engineering, New York, NY
c
Department of Communication Sciences and Disorders, Long Island University–Brooklyn, NY
d
Phoenix
Children’s Hospital, AZ
e
Smile Train, Mexico City, Mexico
f
Smile Train, Inc., São Paulo, Brazil
g
Mobile Surgery International, Oaxaca, Mexico
AR T I CLE I N F O
Article History:
Received October 24, 2023
Revision received December 31, 2023
Accepted January 24, 2024
Editor-in-Chief: Rita R. Patel
Editor: Kate Bunton
https://doi.org/10.1044/2024_AJSLP-23-00397
Correspondence to Catherine J. Crowley: cjc49@tc.columbia.edu.
Disclosure: The authors have declared that no competing financial or
nonfinancial interests existed at the time of publication.
AB ST R A C T
Purpose: International cleft lip and palate surgical charities recognize that
speech therapy is essential for successful care of individuals after palate repair.
The challenge is how to ensure that cleft speech interventionists (i.e., speech-
language pathologists and other speech therapy providers) provide quality care.
This exploratory study investigated effects of a two-stage cleft training in
Oaxaca, Mexico, aimed at preparing speech interventionists to provide
research-based services to individuals born with cleft palate. Changes in the
interventionists’ content knowledge and clinical skills were examined.
Method: Twenty-three cleft speech interventionists from Mexico, Guatemala,
and Nicaragua participated in a hybrid two-stage training, completing an online
Spanish cleft speech course and a 5-day in-person training in Oaxaca. In-
person training included a didactic component and supervised clinical practice
with 14 individuals with repaired cleft palates. Testing of interventionists’ con-
tent knowledge and clinical skills via questionnaires occurred before the online
course (Test 1), immediately before in-person training (Test 2), and immediately
after in-person training (Test 3). Qualitative data on experience/practice were
also collected.
Results: Significant increases in interventionists’ overall content knowledge and
clinical skills were found posttraining. Knowledge and clinical skills increased
significantly between Tests 1 and 2. Clinical skills, but not knowledge, showed
further significant increases between Tests 2 and 3. Posttraining, intervention-
ists demonstrated greater expertise in research-based treatment, and fewer
reported they would use nonspeech oral motor exercises (NSOME).
Conclusions: Findings provide preliminary support for such two-stage interna-
tional trainings in preparing local speech interventionists to deliver high-quality
speech services to individuals born with cleft palate. While content knowledge
appears to be acquired primarily from the online course, the two-stage training
incorporating in-person supervised practice working with individuals born with
cleft palate may best enhance continued clinical skill development, including
replacement of NSOME with evidence-based speech treatment. Such trainings
contribute to building capacity for sustainable quality services for this popula-
tion in underresourced regions.
Most children born with cleft palate, with or with-
out cleft lip (CP ± L), develop inaccurate speech produc-
tion due to anatomical differences that interfere with typi-
cal speech sound articulation. Even after surgical repair of
American Journal of Speech-Language Pathology •Vol. 33 •1456–1470 •May 2024 •Copyright © 2024 The Authors
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
1456
their cleft palate, approximately 70% of the children con-
tinue to implement the compensatory speech patterns they
developed before the surgery (Hardin-Jones & Jones,
2005; Lancaster et al., 2020). A guitar metaphor helps
explain this phenomenon: The surgeon gives the child a
new guitar (representing the repaired speech mechanism),
but the child does not know how to play it. The role of
the speech-language pathologist (SLP) is to show the child
how to play that guitar, that is, how to use the repaired
speech mechanism. With a newly intact speech mechanism
but without well-guided practice in using it, most children
with CP ± L continue their habituated speech error pat-
terns after the surgery, resulting in persistent speech
errors. Some common CP ± L compensatory errors
include errors produced outside the oral cavity, such as
glottal backing of stop consonants and pharyngealization
or nasalization of fricatives, among other articulatory
place substitutions (Harding & Grunwell, 1998). Such
errors may lead to poor intelligibility and social isolation
(van der Plas et al., 2013).
It is therefore imperative for individuals with CP ± L
post–surgical repair to receive high-quality instruction on
how to use their repaired speech mechanism, with practice
that will lead to new speech production habits. For most
children with CP ± L and no comorbid conditions, when
an initial palate repair surgery is successful and the speech
interventionist provides quality cleft speech treatment, the
child’s speech articulation can be completely corrected. In
some cases, an additional surgery to improve velopharyn-
geal closure for speech may be needed when the child is
approximately 4 years of age or older; however, again,
the expectation is that the child will have typical speech
(Blakeley & Brockman, 1995).
Providing quality speech treatment for this popula-
tion requires that SLPs and other speech therapy providers
receive training in evidence-based assessment and treatment
of speech disorders associated with CP ± L. Unfortunately,
there is a paucity of SLPs and related professionals who
provide speech treatment internationally with appropriate
CP ± L treatment training. In low- and middle-income
countries, in particular, children typically do not receive
quality cleft speech treatment. Often, there are very few
trained CP ± L SLPs, and those who are trained lack the
knowledge and skills to provide quality speech services
(Alighieri et al., 2020; Baigorri et al., 2020, 2021; Mason
et al., 2020; Prathanee et al., 2011; Sommer et al., 2023).
In some resource-limited countries where SLPs nor-
mally do not have access to specialized training in CP ±
L, intensive cleft speech missions or camps take place in
initiatives to provide speech therapy for children with CP ±
L. These are primarily missions or camps that aim to treat
the children who have had CP ± L surgery and who still
present with cleft palate–related speech disorders (Sell
et al., 2011). Some of these efforts also involve training
the parents in how to support their children’s speech
development postsurgery. Research support for these
intensive cleft speech clinics and camps improving the chil-
dren’s speech comes from findings of posttreatment
decreases in the children’s articulation errors (Prathanee
et al., 2011), glottal stops (Andrade et al., 2023), and
overall CP ± L compensatory errors (C. Pamplona et al.,
2005; M. C. Pamplona & Ysunza, 2017), as well as fewer
articulation errors and improved nasalance scores (Luyten
et al., 2016) and composite speech scores (indicating
reduced presence of weakness, glottal stops, and other
misarticulations; Lindeborg et al., 2020). Such initiatives
and the results they may generate provide opportunities to
help the children and families who attend, as well as infor-
mation on efficacy of particular speech treatments for
future implementation.
Most of the initiatives discussed above are more
mission based in that local capacity is not intentionally
developed, as their focus is on providing services to the
children in immediate need, rather than training SLPs to
implement effective treatment strategies for future clients.
Additionally, even with parental support, few, if any, of
the children with CP ± L who receive speech therapy in
missions or camps improve their speech to the extent that
they no longer need the services of an SLP (Alighieri et al.,
2020; M. C. Pamplona & Ysunza, 2017; Prathanee et al.,
2011). Therefore, without capacity building of local clini-
cians, the children progress through only the first few steps
of the treatment they need to achieve their full potential in
speech. Furthermore, the numerous children with CP ± L
who do not attend these initiatives will obviously not benefit.
Consequently, for a greater and longer term positive
impact on cleft care globally, the need for quality cleft
speech therapy training of SLP and related professionals
has been identified in the research. For example, based on
survey responses from SLPs in Uganda, Alighieri (2020)
noted that “Surprisingly, the most important factor hamper-
ing the accessibility of cleft care was a lack of knowledge
about patients with a CP ± L in the SLPs themselves. In
accordance, more than half of the SLPs indicated that their
educational program included insufficient information about
this population” (p. 5). Similarly, when the surveyed partici-
pants in a comprehensive cleft care conference in the North
Africa and Middle East region, half of whom were SLPs,
were asked about interventions needed to improve cleft care
in their countries, the most frequent answer (36.4%) was
improving professional training (Kantar et al., 2019).
In many countries, various professionals may be
responsible for providing speech services to individuals
with CP ± L. These clinicians, termed speech
Crowley et al.: Impact of International Cleft Palate Training 1457
• • •
interventionists here, include SLPs, phoniatrists, physical
therapists, psychologists/educational psychologists, occu-
pational therapists, and special education teachers, among
other professionals. Thus, while the individuals with CP ±
L do receive much needed speech therapy in the intensive
programs geared to treating them, true capacity building
involves training the speech interventionists in knowledge
and skills that they can continue to use after the short-
term intensive camps and clinics. That is, for each child or
adult who receives intensive cleft speech therapy, that per-
son’s speech can benefit; however, with each interventionist
who acquires the expertise required to provide quality
speech therapy, many individuals with CP ± L over the
many years of that interventionist’s career can receive qual-
ity speech therapy. Moreover, if those interventionists train
future interventionists, the capacity is further increased.
Missions Training Interventionists for
Capacity Building
International cleft surgical charities have recognized
that speech therapy is essential in cleft care and that there
is a strong need to train local speech interventionists to
provide continued care to children with CP ± L, with
greater focus on capacity building over the past decade
(Kantar et al., 2019; Sommer et al., 2023).
1
The challenge
is how to ensure that speech interventionists provide qual-
ity care. To this end, free online courses have been devel-
oped to provide overviews of CP ± L and instruct inter-
ventionists on its appropriate assessment and management
(e.g., Baylis, 2021; Crowley & Baigorri, 2016; Grames,
2015). Additionally, several CP ± L initiatives have been
launched internationally to train interventionists in person
in research-based assessment and treatment of children
and adults with CP ± L (e.g., see Kuehn & Henne, 2003;
Sommer et al., 2023).
1
Trainings of community health workers who will work with the sup-
port of SLPs (e.g., Lindeborg et al., 2020; Shunmugam et al., 2017;
Wirt et al., 1990) are outside the scope of this article as the focus here
is on trainings of interventionists who will design and implement CP
± L speech treatment plans independently. This article is also not
focused on the development of academic speech therapy programs
(e.g., Wickenden et al., 2001).
Despite the increasing number of online courses and
international trainings for speech interventionists (Alighieri
et al., 2020; Kantar et al., 2019; Lindeborg et al., 2020;
Sommer et al., 2023), little research has examined the effi-
cacy of such trainings. While online courses may include
online quizzes or assessments for interventionists to com-
plete successfully to receive credit or certification, no pretest
is typically provided to permit assessment of baseline to
posttest knowledge changes. Similarly, for in-person train-
ings, pre- to posttest knowledge changes are not often
reported. Research studies have, however, shown partici-
pant satisfaction with interventionist training. For example,
Kantar et al. (2019) found high satisfaction among SLPs
and other participants who attended their 3-day interna-
tional and multidisciplinary cleft care workshop. One study
that did examine changes, based on questionnaires com-
pleted before and after a 2-day CP ± L training in Uganda,
found that SLPs rated their general knowledge of speech in
individuals with CP ± L and their self-confidence in diag-
nosing and treating the population as significantly higher
after the training (Alighieri et al., 2020).
Content Knowledge and Evidence-Based
Clinical Skills
However, beyond assessing participant satisfaction
and self-ratings of knowledge and self-confidence, investi-
gating more objective changes is important to establishing
the impact of such programs on CP ± L intervention.
Such measures include investigating speech intervention-
ists’ content knowledge and clinical skills following such
courses and trainings and gaining greater insight into
how interventionists plan to change their practice as a
result. Ultimately, such findings would help optimize
interventionist trainings to improve sustainable quality
care to individuals with CP ± L glo bally.
Crucial to appropriate treatment for children with
CP ± L are interventionists’ (a) knowledg e of the effects
of CP ± L on speech production and (b) clinical skills
involving identifying and remediating CP ± L speech
errors (Golding-Kushner, 2004; Kummer, 2020; Lien
et al., 2023; Peterson-Falzone et al., 2016). The only
research data we are aware of on speech interventionist
knowledge generated by CP ± L training programs were
reported in Prathanee et al.’s (2011) study of a 4-day cleft
speech therapy camp in Thailand with a 1-day follow-up
6 months later, directed by four SLPs and an audiologist.
This study focused primarily on the outcomes of treatment
on 13 children with CP ± L but also reported significant
gains in the pre- to postcamp basic knowledge related to
CP ± L of 13 parents/caregivers and four health providers
who attended the training. The health providers ’ profes-
sions are not mentioned, nor is the nature of the knowl-
edge assessed, other than that it was basic. It is also
unclear whether the health providers were local and could
continue the therapy once the experts left.
Beyond basic knowledge about the nature of CP ± L,
speech interventionists’ comprehensive understanding of
how speech is typically produced and the effects of CP ± L
on speech production is required in order to support the
development of postsurgery speech in CP ± L; thus, gains
in such knowledge following interventionist courses and
trainings should be assessed. Furthermore, it is important
1458 American Journal of Speech-Language Pathology Vol. 33 1456–1470 May 2024
to ascertain whether research-based clinical skills are also
successfully gained through such training. Clinical skills
are defined for these purposes as the ability to conduct
appropriate speech assessment and treatment of individuals
with CP ± L. Clinical assessment skills include auditory
identification of compensatory errors in assessment tests
and conversation. Clinical treatment skills entail provision
of appropriate evidence-based therapy techniques. These
include effective strategies to elicit oral speech sounds, first
in simple phonological structures, then in increasingly com-
plex phonological contexts, followed by coaching parents in
how to practice speech strategies at home between sessions.
A problem identified in the speech-language pathol-
ogy field is that, although best practice requires that inter-
ventionists apply treatments that have research evidence
supporting their efficacy, clinical strategies implemented
internationally (and locally) are sometimes not evidence
based (Ruscello & Vallino, 2020). The use of nonspeech
oral motor exercises (NSOMEs) is one such prevalent treat-
ment practice. These exercises are meant to develop motor
patterns for speech sound production by providing practice
with nonspeech motor movements, such as blowing, tongue
elevation, and other nonspeech tasks, frequently employing
tools such as straws, horns, and tongue depressors (Strode
& Chamberlain, 1997). NSOMEs are implemented with
many children with speech disorders, including CP ± L,
despite their efficacy contradicted by research evidence
(Lof & Watson, 2008; Parra-López et al., 2022; see Rus-
cello & Vallino, 2020, for an overview related to CP ± L).
In contrast, although there is no consensus regarding a pre-
ferred specific treatment approach for CP ± L, articulation-
or phonology-based treatments that focus on correction of
compensatory cleft errors in articulation and are task-
specific to speech (Lof & Watson, 2008; Parra-López et al.,
2022) have consistently shown positive effects on speech pro-
duction in CP ± L (Alighieri et al., 2022; Hanley et al., 2023;
Ruscello & Vallino, 2020; Sand et al., 2022). Therefore, it is
important for speech interventionists to incorporate such
evidence-based treatment approaches into their practice.
In summary, if children with CP ± L are to receive
the quality services they need, more training is required for
local interventionists to gain sufficient knowledge of CP ±
L and to implement research-based clinical approaches to
improving speech in this population. Furthermore, research
evidence is needed to document whether these relatively
brief interventionist trainings do, in fact, successfully impart
such content knowledge and clinical skills.
Purpose
The purpose of this preliminary study was to investi-
gate the effects of a relatively comprehensive international
interventionist training program in Oaxaca, Mexico, on
CP ± L–related knowledge and clinical skills of speech
interventionist attendees from Mexico, Guatemala, and
Nicaragua. As described in further detail in the Method
section, this sequential, two-stage (online and in-person)
training program involved completion of a Spanish online
cleft speech therapy course (Crowley & Baigorri, 2016),
followed by a 5-day in-person training in Oaxaca on the
assessment and treatment of individuals with CP ± L. The
in-person component included supervised clinical practice
with individuals with repaired cleft palates. Intervention-
ists were instructed to complete three tests provided in
questionnaire format: Test 1 from home immediately prior
to the online cou rse, Test 2 in Oaxaca immediately before
the in-person training, and Test 3 on the final day in
Oaxaca after the training had ended.
The study was designed to assess whether the online
course and subsequent in-person training would result in
increased speech interventionist knowledge and skills.
Based on interventionists’, parents’, and surgeons’ feed-
back from prior similar speech interventionist trainings
and research suggesting participant satisfaction and basic
knowledge gains from interventionist trainings (Alighieri
et al., 2020; Kantar et al., 2019; Prathanee et al., 2011), it
was hypothesized that following the two-stage training,
significant gains would be found in the speech interven-
tionists’ knowledge and clinical skills. More specifically,
as knowledge was the focus of the online course, content
knowledge was expected to increase following this first
stage of the training (Prathanee et al., 2011). However,
clinical application, including identifying compensatory
speech errors, was also discussed and demonstrated in the
course videos (Baigorri et al., 2021); thus, clinical skills
were also expected to increase. Following the in-person
training, the interventionists’ knowledge was expected to
have been more cemented and therefore have increased
further. Clinical skills, which were practiced intensively in
the in-person component, were expected to increase exten-
sively. Self-reports of interventionists’ knowledge and
plans for clinical practice were expected to follow a simi-
lar pattern (Alighieri et al., 2020; Kantar et al., 2019;
Prathanee et al., 2011). Of particular interest for assess-
ment, we anticipated that interventionists would increase
their ability to identify common cleft palate compensatory
speech errors. In terms of treatment, interventionists were
expected to increase their plans to incorporate research-
based speech sound production instruction rather than
NSOMEs into their clinical practice. However, because
this was the first such study performed, our hypotheses
remained guarded. The answers to the questions posed in
this study were expected to contribute to the field’sknowl-
edge and practice by providing a preliminary assessment of
an approach to increasing expertise of speech intervention-
ists and building local capacity for cleft speech therapy.
Crowley et al.: Impact of International Cleft Palate Training 1459
• • •
Method
Participants
A total of 37 participants were invited by Smile
Train and Mobile Surgery International (MSI) to attend
the 5-day Cleft Palate Spe ech and Feeding Training.
The attendees included speech interventionists, CP ± L
surgeons, and a health administrator. Not only speech-
language therapists (known in Mexico as terapeutas del
habla y lenguaje) were included, but also other speech
interventionists. These speech interventionists included
phoniatrists, occupational therapists, physical therapists,
psychologists/educational psychologists, and special educa-
tion teachers, who provide speech therapy to children
born with cleft palates when there are not enough trained
speech-language therapists to provide the services. For the
study, data from the 23 speech interventionists who
attended the entire training and completed questionnaires
in the instructed time frame were analyzed. The study was
designated exempt by the institutional review board at
Teachers College, Columbia University.
Fourteen individuals with repaired cleft palate came
for speech therapy each day. These included nine children
(seven boys, two girls), who ranged in age from 3;4 to
16;1 (years;months), with a mean age of 8;5, and five
adults (four men, one woman), who ranged in age from
20;11 to 28;9, with a mean age of 25;0. No comorbidities
or syndromes were diagnosed for any of these individuals
except for one 4-year-old who had been diagnosed with
Robin sequence at birth. All were from the Oaxaca area
and spoke Spanish as their native language, including one
adult who also spoke Zapotec as his native language.
Questionnaires
Three similar questionnaires were used to test cleft
speech interventionists at three different times on their
content knowledge and research-based clinical skills in
assessment and treatment of CP ± L, as well as to collect
information on their demographics, experience, practice,
and impressions of the impact of the training on their
knowledge and clinical practice. Tests 1, 2, and 3 consisted
of 21, 27, and 23 questions, respectively, including multiple-
choice and open-ended questions. Differences between the
questionnaires included additional qualitative questions
about the online course and demographics in Test 2 and
qualitative questions about the entire training in Test 3.
The questionnaires were developed primarily from
existing instruments that had been used as posttests in the
first author’s previous international CP ± L trainings for
the purpose of improving the trainings. Throughout the
approximately 11 years of these trainings, the first author
modified and expanded the questions for clarity and for
more comprehensive input from interventionists. Ques-
tions that were repetitive or unclear in previous trainings or
led to responses that did not address clinical skills or con-
tent knowledge were eliminated over the years. The ques-
tions on NSOMEs were adapted from a training by the
first author in Guatemala, with data reported in a previous
study (Baigorri et al., 2021). Unlike in previous trainings,
in the present study, many of the same questions were also
asked in a pretest (in Test 1, before the online course).
Prior to data analysis, three content experts reviewed
the questions for clarity. These experts were the first, third,
and last authors, who are American Speech-Language-
Hearing Association (ASHA)–certified PhDs with years of
clinical and teaching experience in CP ± L, as well as trans-
lational research experience, including in survey studies.
The 12 quantitative questions were validated by the
experts for accuracy, with 100% agreement across responses
and were all included in the analysis. These questions com-
prised five multiple-choice content knowledge questions
and seven clinical skills questions. Examples of multiple-
choice content knowledge questions were, “Indicate the
place of articulation for the following sound: Where is /k/
produced?” (this question was accompanied by a diagram
with places of articulation and corresponding letters for
multiple choice) and “Which speech sounds are most likely
to have errors in cleft palate speech?” Examples of the clin-
ical skill questions were, “Which compensatory error do
you hear in this video?” and “How do you treat the speech
disorder in this video?”
Qualitative questions inquired about the interven-
tionists’ demographics, professional experience, current
and planned approaches to cleft speech therapy, their
impression of the knowledge and skills learned from the
course/training, and how they thought their practice would
change based on the online course and in-person training.
For the qualitative questions, only those that were deter-
mined to be clear and unambiguous by consensus of the
experts were included in the analysis. For example, “Have
you received a training or taken a course on the impor-
tance of NSOMEs in treating speech sound disorders?”
was excluded because of lack of clarity in that courses are
not likely to focus on the importance of NSOMEs but
still might recommend them as therapeutic strategies.
The sequential two-stage hybrid interventionist
training was conducted in February 2023. Before the inter-
ventionists traveled to the in-person training, they were
instructed to complete an online questionnaire (Test 1)
via Qualtrics (between February 5 and 19, 2023) and
then complete Crowley and Baigorri’s (2016) Leaders Pro-
ject online Spanish cleft palate speech course La Terapia
del Habla para la Fisura del Paladar: Evaluación y
1460 American Journal of Speech-Language Pathology Vol. 33 1456–1470 May 2024
Tratamiento (Speech Therapy for Cleft Palate: Evaluation
and Treatment). The in-person training took place at a
conference center at a hotel in Oaxaca, Mexico. At this
center, the interventionists completed a second question-
naire (Test 2) on paper at the beginning of the first day of
training (February 20, 2023). The 5-day, in-person training
then took place, as described below. This training included
a didactic component and a clinical component assessing
and treating the individuals with CP ± L who came to the
center daily. At the end of the last day of in-person training
(February 24, 2023), each interventionist completed the
posttraining questionnaire (Test 3) on paper in the confer-
ence center.
Online Course
Before attending the training, the interventionists
completed the asynchronous online Spanish cleft palate
speech course (Crowley & Baigorri, 2016). This course is
available for free online at https://www.leadersproject.org/
ceu-courses-2/la-terapia-del-habla-para-la-fisura-del-paladar-
evaluacion-y-tratamiento-asha-0-4-ceu-self-study-course/.
The course content and videos, all in Spanish (also avail-
able in English), include information on CP ± L and its
assessment and treatment. Instruction is on content, such as
anatomy and physiology, and place of articulation of con-
sonants, as well as more clinical skills information such as
identification of CP ± L compensatory errors, correct and
incorrect therapy strategies and techniques, how to perform
speech and oral exams, and ways to move through each
step of the cleft speech therapy hierarchy (Baigorri et al.,
2021). Research-based speech treatment techniques that
focus on correcting articulatory placement for speech
production are demonstrated (Golding-Kushner, 2004;
Kummer, 2020; Peterson-Falzone et al., 2016), and
explanations are provided regarding why working
directly with speech, rather than employing NSOMEs,
improves speech production (Parr a-López et al., 2022;
Ruscello & Vallino, 2020). The invited inter ventionists
were required to receive a score of at least 80% correct
on a 57-question, multiple-choice Leaders Project assess-
ment to receive a certificate of completion, which they
sent to the Smile Train training manager.
In-Person Training
The 5-day in-person training was designed to pro-
vide content delivery and skill building, covering similar
information to the online course, but with greater empha-
sis on developing clinical skills, as well as additional topics
such as velopharyngeal imaging and surgery. The training
materials (in Spanish) are available at https://www.
leadersproject.org/2016/11/11/entrenar-a-los-entrenadores/.
The training was taught primarily by the first author, with
guest lectures from two other doctoral-level and ASHA-
certified SLPs and three plastic/craniofacial surgeons. The
didactic component was similar to that of the asynchro-
nous online course but took advantage of the in-person
venue to assist the interventionists in developing their clin-
ical skills. A significant area of instruction included
detailed hands-on activities demonstrating production and
remediation of compensatory articulation errors. The
training materials, all in Spanish, were available to the
interventionists and included all PowerPoints, videos, and
assessment and treatment materials.
Each day included lectures and class activities on
CP ± L assessment and treatment, with the following
topics focused on during the morning didactic compo-
nents: Day 1 focused on the anatomy and physiology and
building skills of what to listen for and how to administer
the cleft speech Spanish assessment screener. Assessment
and treatment of cleft palate speech were covered in Day
2. Day 3 addressed treatment of cleft palate speech across
sounds, with additional ear training. Information was pro-
vided on Day 4 on what to do before palate surgery, and
feeding and nasopharyngeal endoscopy demonstrations
were given. Day 5 described palatal repair surgery and
featured lectures by three plastic/craniofacial surgeons.
The afternoon didactic components involved further aca-
demic content and review.
Within the 8 hr of class daily, the individuals with
repaired CP ± L received two speech therapy sessions of
approximately 1 hr each, totaling nine sessions over the
5 days. (The first day included Test 2 in the morning and
only one [longer] speech therapy session involving a thor-
ough speech assessment and identification of treatment
goals.) The rest of the day was devoted to the didactic com-
ponent of the speech interventionist training. These individ-
uals were recruited by the cleft surgical team at MSI in
Oaxaca to receive free intensive cleft palate speech therapy
at the trainings.
The speech therapy sessions took place in the out-
door spaces of the conference facility, in small groups,
with approximately three interventionists per individual
with CP ± L. More experienced interventionists were paired
with less experienced interventionists. The interventionists
assessed the compensatory errors of the individuals with CP ±
L and provided evidence-based treatment focusing on correct-
ing articulatory placement for speech production (Golding-
Kushner, 2004; Kummer, 2020; Peterson-Falzone et al.,
2016). They practiced perceiving the difference between the
correctly articulated sounds and the compensatory errors and
progressed through the steps of the speech therapy hierarchy
(Baigorri et al., 2021) with the individual with CP ± L.
The same individuals with CP ± L attended twice a
day for speech therapy and worked with the same
Crowley et al.: Impact of International Cleft Palate Training 1461
• • •
interventionists daily. The training team, composed of
three ASHA-certified PhDs (the first, fifth, and last
authors), circulated among the 14 groups, to provide feed-
back to the interventionists and model appropriate assess-
ment and treatment as needed. The interventionists also
worked with the parents/caregivers, daily, practicing the
skills needed to counsel parents and helping them see the
benefit to the child’s speech of their participation in their
child’s speech therapy goals.
The speech therapy sessions were aligned, in part,
with the topics of the didactic component. Days 1–3
focused on clinical implementation of the morning’s lec-
ture topics, including developing perceptual skills and
acquiring various treatment strategies and how to interpret
the results of the assessment screener. Days 4–5 focused
primarily on treatment, including identifying clinical strat-
egies to address particular speech errors, as well as impli-
cations of nasopharyngeal endoscopic studies for individ-
uals with CP ± L with persistent resonance concerns. The
individual speech therapy goals for each child were identi-
fied after the first therapy session, using the assessment
screener. The cleft speech therapy hierarchy of discrimina-
tion, single sound, syllables, words, sentences and phrases,
and conversation (Baigorri et al., 2021) was reinforced in
the training. This offered a step-by-step structure for ther-
apy, dependent on the child’s initial skills and progress
throughout the training. At the end of each day, each
group gave an oral case report to the other intervention-
ists on progress or challenges and plans for the next day’s
session to discuss solutions and develop the intervention-
ists’ reporting skills needed as future members of cleft and
craniofacial teams. Immediate and individualized feedback
was provided to each group by the training team.
Data Analysis
Of the 37 professionals who attended the training,
the surgeons’ and administrator’s data were excluded from
the analysis because of their absence during some of the
training due to their work obligations. Furthermore, sev-
eral speech interve ntionists did not complete the question-
naires and/or online course in the instructed time frame,
including one interventionist who withdrew from training
after experiencing a medical issue on the first day. This
left a total of 23 speech interventionists who completed all
three tests at the instructed timepoints and whose data
were analyzed for this study.
Following the training, responses on Qualtrics (from
Test 1) and on the paper copies (for Tests 2 and 3) were
transferred to an Excel spreadsheet by research assistants
who were naive to the training. Anonymity was maintained
by using numeric coding for the respondents. Quantitative
questions were scored as correct (1) or incorrect (0) for a
maximum possible score of 12/12 per respondent. For the
qualitative questions, researchers coded the open-ended
responses into themes and indicated the percentages of
interventionists who mentioned each theme. The question-
naires and training had ecological validity in that similar
procedures and posttests have been implemented pedagogi-
cally to train interventionists and identify future trainers
internationally.
Effects of the online course were measured quantita-
tively in terms of differences in total test scores from Test 1
(pre–online course) to Test 2 (post–online course/pre–in-
person training). Potential further benefits of the subsequent
in-person training were measured by differences in total test
scores from Test 2 to Test 3 (post–in-person training). Finally,
effects of the entire two-stage training experience were mea-
sured in terms of differences between total test scores in Test
1 and Test 3. The questions were further divided into those
quantifying content knowledge versus those quantifying
research-based clinical skills for analysis of changes in these
two essential components of successful intervention.
To determine if CP ± L speech interventionists
exhibited significant increases in their content knowledge
and research-based clinical skills after completing the two-
stage training (online and in-person), repeated-measures
analysis of variance (ANOVA) was performed with test
scores (from Tests 1, 2, and 3) as the dependent variable.
The dependent variables were total test score, content
knowledge score, and clinical skills score. Subsequently,
post hoc pairwise comparisons were performed with
Bonferroni correction. The study was exploratory in this
early stage of the research (Robey, 2004) in that this
international interventionist study was the first of its kind,
and controls such as comparison conditions would have
been logistically or financially difficult in the resource-
limited region. To the extent possible, controls were incor-
porated, including research assistants naive to the project
analyzing the data and present ation and coding of the
data to mask timepoints and identifying information.
Results
Interventionists’ Characteristics
and Clinical Experience
The speech interventionists’ responses to the demo-
graphic and clinical experience questions are shown in
Table 1. Twenty-one of the 23 interventionists practiced
in Mexico, one practiced in Guatemala, and one practiced
in Nicaragua. The largest number of interventionists
received a degree in speech-language pathology (n =10),
followed by phoniatrics (n =3), and psychology/
educational psychology (n = 3). Years of clinical experience
1462 American Journal of Speech-Language Pathology Vol. 33 1456–1470 May 2024
varied for interventionists from minimal (0–1 year) to more
than 30 years of experience. As for clinical experience in
CP ± L, interventionists most frequently indicated working
with individuals with cleft palate “daily” (30%, n =7) or a
“few times a week” (30%, n =7).
Table 1. Years practicing speech therapy and frequency working with individuals with cleft palate, with or without cleft lip (CP ± L).
Years practicing speech
therapy No. of interventionists
Frequency working with
individuals with CP ± L No. of interventionists
0–1 4 Never 1
2–5 4 A few times/year 3
6–10 4 A few times/month 5
11–19 3 A few times/week 7
20–29 4 Daily 7
>30 4
Changes in Total Test Scores
Of interest were the interventionists’ overall test
score changes following the online CP ± L course and the
in-person training. The average total test scores with con-
tent knowledge and research-based clinical skills combined
for the 23 interventionists at each of the three timepoints
are presented in Figure 1. A repeated-measures ANOVA
revealed that the interventionists’ total test score increased
significantly across the test timepoints, F(1.562, 34.372) =
29.104, p < .001. Post hoc analysis with a Bonferroni
adjustment revealed a significant increase in total test
score following completion of the online course, specifi-
cally from Test 1 to Test 2 (mean difference = 2.043, 95%
CI [1.087, 3.0], p < .001). A significant increase in total
test score was also found following the in-person training,
from Test 2 to Test 3 (mean difference = 1.304, 95% CI
[0.294, 2.314], p = .009). Increases in total test score from
pre–online course (Test 1) to post–in-person training (Test
3) were statistically significant, as well (mean difference =
3.348, 95% CI [1.931, 4.764], p < .001).
Figure 1. Mean total test score (out of 12 points) across 23 interventionists on Test 1, Test 2, and Test 3. Standard error bars are included.
Test 1 = pre–online course; Test 2 = post–online course/pre–in-person training; Test 3 = post–in-person training. ****p ≤ .0001. **p ≤ .01.
Changes in Content Knowledge
The questions were subsequently divided into the
five that assessed content knowledge (e.g., typical and CP
± L articulation) and seven that assessed research-based
clinical skills (e.g., identification of compensatory errors
as played on video). Figure 2 displays the average score of
content knowledge in the 23 participants across all three
tests. A repeated-measures ANOVA revealed significant
increases in content knowledge score among the test time-
points, F(1.63, 35.857) = 6.576, p = .006. A post hoc anal-
ysis with a Bonferroni adjustment revealed significant
Crowley et al.: Impact of International Cleft Palate Training 1463
• • •
increases in content knowledge score from Test 1 to Test 2
(mean difference = 0.391, 95% CI [0.001, 0.782], p =.049)
and from Test 1 to Test 3 (mean difference = 0.739, 95%
CI [0.125, 1.353], p = .015). The difference between Test 2
and Test 3 content knowledge score, however, was not sta-
tistically significant (mean difference = 0.348, 95% CI
[0.207, 0.903], p = .356), indicating no further significant
changes in content knowledge as a function of the in-
person training.
Figure 3. Mean clinical skills score (out of 7 points) across 23 interventionists on Test 1, Test 2, and Test 3. Standard error bars are included.
Test 1 = pre–online course; Test 2 = post–online course/pre–in-person training; Test 3 = post–in-person training. ****p ≤ .0001. ***p ≤ .001. **p ≤ .01.
Figure 2. Average score (out of 5 points) in content knowledge across 23 interventionists on Test 1, Test 2, and Test 3. Standard error bars
are included. Test 1 = pre–online course; Test 2 = post–online course/pre–in-person training; Test 3 = post–in-person training; ns =
nonsignificant. *p ≤ .05.
Changes in Clinical Skills
Figure 3 displays the average scores for research-
based clinical skills in the 23 interventionists at each of
1464 American Journal of Speech-Language Pathology Vol. 33 1456–1470 May 2024
the three test timepoints. A repeated-measures ANOVA
revealed a significant increase in clinical skills score across
the three test timepoints, F(1.5, 32.995) = 31.168, p <.001.
Further examination using a Bonferroni adjustment for
post hoc analysis revealed a significant increase in clinical
skills score after the completion of the online course, from
Test 1 to Test 2 (mean difference = 1.652, 95% CI [0.796,
2.508], p < .001). A further significant increase in clinical
skills score was found after the completion of in-person train-
ing, from Test 2 to Test 3 (mean difference = 0.957, 95% CI
[0.337, 1.576], p = .002). Overall, the clinical skills score after
the tw o-stage training was significantly higher than the
baseline pretraining score, that is, from Test 1 to Test 3
(mean difference = 2.609, 95% CI [1.544, 3.674], p < .001).
Qualitative Results
The speech interventionists were asked to identify
what they felt were the three most important takeaways
after completing the online course (in Test 2) and after
completing the 5-day, in-person training (in Test 3). Table 2
shows the percentage of interventionists who identified
particular themes at these two test times. After completing
the online course, the majority of interventionists identi-
fied cleft speech treatment strategies as topics learned,
while nearly half identified compensatory error identifica-
tion and typical sound production/development, and just
under a quarter identified cleft speech treatment hierarchy
and the ineffectiveness of NSOMEs in cleft speech treat-
ment as takeaways. Similar themes were identified after the
completion of the in-person training; however, compensa-
tory error identification, cleft speech treatment strategies,
and cleft speech treatment hierarchy were more balanced in
their mention, with the issue of NSOMEs trailing behind.
Table 2. Percentage of speech interventionists who identified a
particular theme learned from the online course and from the in-
person training.
Online course In-person training
Theme % Theme %
Cleft speech treatment
strategies
91 Cleft speech treatment
strategies
70
Compensatory error
identification
43 Compensatory error
identification
61
Typical sound production/
development
43 Cleft speech treatment
hierarchy
61
Cleft speech treatment
hierarchy
22 Ineffectiveness of
NSOMEs in cleft
speech treatment
17
Ineffectiveness of
NSOMEs in cleft
speech treatment
22
Note. Multiple themes were counted in interventionist responses.
NSOMEs = nonspeech oral motor exercises.
Additionally, interventionists were asked how they
thought their clinical practice would change as a result of
the online and in-person training. Representative comments
included, “My ability to hear and accurately identify com-
pensatory errors has improved,”“I now see cleft palate
with a different set of eyes and ears,” and “I have better
strategies to help patients improve their articulation in a
quicker and effective way that will make permanent
changes.”
Prior to taking the online course (Test 1), interven-
tionists were asked about their current use of NSOMEs.
Out of the 23 interventionists, nine (39%) interventionists
self-reported not implementing NSOMEs in their clinical
practice when treating speech sound disorders. Of interest,
when the same question was asked after the online course
and before the start of the in-person training (Test 2)
about their current use of NSOMEs, 13 (56%) interven-
tionists self-reported not implementing NSOMEs in their
clinical practice.
To determine whether interventionists intended to
change their clinical practice, they were asked about their
projected use of NSOMEs. In Test 2, after completing the
online course, a large majority of interventionists indicated
that they would not use NSOMEs in treatment. At the
end of the in-person training, in their responses to Test 3,
all except one interventionist reported that they would not
use NSOMEs in treatment going forward. See Table 3 for
use of NSOMEs as reported by interventionists.
Discussion
In light of the need for sustainable high-quality speech
treatment for children with CP ± L internationally, this
exploratory study assessed the effects of a two-stage (online
and in-person) training in Mexico on CP ± L–related
knowledge and skills of speech interventionists from Mexico,
Guatemala, and Nicaragua. By the end of the training, the
interventionists had gained both content knowledge and clini-
cal skills necessary for improving the speech production of
individuals with cleft lip and palate. Significant gains in
Table 3. Interventionists who self-reported to never use non-
speech oral motor exercises in treatment.
Test timepoint
%o
f
interventionists
Test 1/Pre–online course: Currently “never”
use NSOMEs
39
Test 2/Post-online course/pre–in-person
training: Projected to “never” use NSOMEs
74
Test 3/Post in-person training: Projected to
“never” use NSOMEs
97
Note. NSOMEs = nonspeech oral motor exercises.
Crowley et al.: Impact of International Cleft Palate Training 1465
• • •
content knowledge and clinical skills were found upon com-
pletion of the online course (Crowley & Baigorri, 2016).
Through the subsequent in-person training, their clinical skills
continuedtoimprove significantly, whereas their content
knowledge did not. These findings suggest that such trainings,
which include supervised clinical practice with individuals
with CP ± L, can provide importan t preparation for practi-
tioners to provide high-quality services to individuals with CP
± L internationally. Content delivery appears to occur primar-
ily from the online course, whereas clinical skill-building con-
tinues through the in-person component of the training. While
the CP ± L literature has primarily indicated that workshops
training children or interventionists can improve the speech
of individuals with CP ± L (Andrade et al., 2023; Lindeborg
et al., 2020; Luyten et al., 2016; C. Pamplona et al., 2005;
M. C. Pamplona & Ysunza, 2017; Prathanee et al., 2011),
our findings further suggest that such training may also
benefit local speech interventionists to provide longer term
quality clinical care to individuals with CP ± L.
Changes in Content Knowledge and Clinical
Skills Following Online Course
During the online course, the interventionists gained
both content knowledge and clinical skills. Gains in knowl-
edge had been expected as a result of the content pro-
vided, as this result was also found following Prathanee
et al.’s (2011) in-person course. It should be noted that
while statistically significant, the content knowledge gains
were small. As for the improvement in clinical skills fol-
lowing the online course, we are not aware of other stud-
ies that have tested speech interventionists’ pre- and post-
course (or pre- and posttraining) clinical skills. It is nota-
ble that through this online course alone, without an in-
person component, most interventionists in this study had
still developed their “clinical ear” to the point that they
could better identify compensatory strategies such as glot-
tal stops and pharyngeal fricatives. The interventionists’
clinical skills were likely enhanced, in part, through the
online course’s videos of adults producing compensatory
errors, with commentary provided, as well as videos show-
ing treatment of individuals with CP ± L and a video
about inappropriate use of NSOMEs. Furthermore, while
there are other free online cleft courses (e.g., Baylis, 2021;
Grames, 2015), the Leaders Project course may be unique
in requiring viewers to pass a rigorous online assessment
for certification and its availability in Spanish. This assess-
ment includes clinical skill questions, with some questions
requiring interventionists to hear and identify compensa-
tory errors and to watch and select correct versus incor-
rect speech therapy strategies, for example. These online
modules and assessment requirements likely contributed to
the interventionists’ clinical skill development, despite the
remote asynchronous delivery mode.
Our findings suggest that even without attending
an in-person training, speech interventionists may still
benefit fro m the online course, both in their knowledge
and in their clinical skills. The interventionists’ improve-
mentfrom theonlinecoursealone hasparticularrele-
vance to the larger international community. While the
vast majority of interventionists globally will not have
an oppo rtunity to attend an in-person training, many
have access to the free online course, which is available
in English and Spanish and canbetranslated intoother
languages.
An important caveat, however, is that the interven-
tionists in the current study were required to pass the rig-
orous 57-question online course assessment following the
Leaders Project course with at least 80% accuracy in order
to continue to the in-person training, and this requirement
likely contributed to their motivation and learning. This
course assessment is available in English, Spanish, French,
Bahasa, and Vietnamese, but interventionists globally who
do not speak these languages will not be able to complete
the assessment. Thus, while interventionists who do not
complete the assessment would likely still gain some
knowledge and skills from the online course, it is not evi-
dent that they would learn the materials to the same
extent as the interventionists did in the current st udy.
Changes in Clinical Skills, But Not Content
Knowledge, Following In-Person Training
The interventionists’ content knowledge had been
expected to improve further through the in-person training
(Prathanee et al., 2011). However, although they answered
more knowledge questions correctly following the training,
the increase was not statistically significant. Studies with
greater numbers of interventionists are needed to verify
this finding. Nonetheless, this exploratory study suggests
that while interventionists gained both knowledge and
clinical skills from the online course, the in-person compo-
nent of the training further enhanced primarily their clini-
cal skills, not their knowledge. One explanation might be
simply that most of the needed content knowledge had
already been acquired from the online course, allowing
the clinical skills to develop because the foundational con-
tent knowledge had been built. Additionally, much of the
new content introduced in the in-person course did not
have corresponding questions in the posttests. These topics
included, for example, ways to identify, view, and address
velopharyngeal insufficiency with live nasopharyngeal
endoscopic studies of some of the individuals with CP ±
L. Thus, any increased knowledge in these areas may not
have been reflected in the results. Development of the next
iteration of tests will include addition of questions on
more varied topics covered in the training. These may
1466 American Journal of Speech-Language Pathology Vol. 33 1456–1470 May 2024
reveal greater gains and provide more insight on remain-
ing gaps in the interventionists’ knowledge and skills.
The further improvement in interventionists’ clinical
skills through the in-person training had been anticipated,
as the didactic component of the training included interac-
tive practice with other interventionists in identifying and
remediating compensatory CP ± L errors. Perhaps more
relevant to the clinical gains, the in-person training
included two sessions per day of supervised clinical work
with children and adults with CP ± L. These sessions pro-
vided practice in identification of the individuals’ compen-
satory errors, selection of treatment targets, and delivery
of research-based speech treatment. The benefit of this
supervised clinical component of the training was high-
lighted by the interventionists’ responses to the qualitative
question about their favorite part of the training.
Responses included, “the clinical practice with the patients
and receiving support fr om the mentors,”“working with
patients and seeing significant and quick improvement
when using effective strategies,” and “the individual super-
vision from the mentors when working with patients.”
Alighieri et al. (2020) similarly found that the Ugandan
interventionists felt that the “hands-on” component of
that training approach would be useful in their clinical
practice. Thus, although it is impossible to determine
which component of the Oaxaca in-person CP ± L train-
ing led to the clinical gains, the findings may support the
inclusion of such immersive “hands-on” supervised experi-
ences in cleft trainings.
Certainly, the online course is more feasible and
cost-effective than in-person training and, as our findings
may suggest, may still be beneficial to the interventionists’
knowledge and skills. Nonetheless, our findings of total
score improvement in response to the online course and
further improvement in response to the in-person training
provide preliminary support for incorporating both online
and in-person components to optimize interventionists’
CP ± L learning.
Increasing Speech-Based Treatment and
Reducing the Use of NSOMEs
Because the provision of evidence-based treatment is
crucial to improving speech production in individuals with
CP ± L, both the online and in-person components of the
training devoted considerable time to instructing interven-
tionists about speech-based strategies to implement and
methods to avoid. Positive changes in the interventionists’
understanding of and plans for evidence-based treatment
were found after the training. For example, the online
course resulted in increased projected use of speech-based
therapy strategies and reduction in plans to implement
NSOMEs, and the in-person training yielded further such
changes. Thus, despite the international prevalence of
speech therapy techniques not supported by research
(Brumbaugh & Smit, 2013; Hardin-Jones & Chapman,
2008; Hardin-Jones et al., 2006; Lof & Watson, 2008;
Parra-López et al., 2022; Ruscello & Vallino, 2020), online
and in-person education about treatments that are
evidence-based and those that are not may reduce the
implementation of NSOMEs and rep lace them with
evidence-based speech treatment.
Limitations and Future Directions
While this exploratory study had considerable eco-
logical validity in reporting on a training that took place
as it often does in a country with few resources for CP ±
L, this also limited experimental control. Without a con-
trol group, for example, it was not possible to determine
the effects of specific components of the training or of the
order in which the components took place or to disentan-
gle the effects of instruction from interventionists’ motiva-
tion when providing supervised treatment to the individ-
uals with CP ± L. These limitations were largely due to
feasibility and logistics of the training, which required
coordination of large numbers of interventionists and sur-
geons from three countries, as well as local children and
adults with CP ± L who could participate in the 5-day
training. Additionally, as the questionnaires were based
on instruments originally developed for clinical training
purposes, their validity was not rigorously tested. The
questions raised should be further explored under more
controlled conditions, with further questionnaire valida-
tion and a larger population of speech interventionists.
The gains in clinical skills and especially in content
knowledge were not robust. This may have been, in part,
an artifact of asking only seven clinical questions and five
content questions, potentially yielding ceiling effects, espe-
cially at the end of the in-person training. Therefore, addi-
tion of quantitative questions, as well as clarification of
qualitative questions, are in progress for upcoming train-
ings, including questions addressing the role of nasopha-
ryngeal endoscopic studies in determining treatment direc-
tions. These modifications will provide opportunities for
responses that may better reflect the interventionists’ gains
in both knowledge and clinical skills.
Additionally, to increase and sustain the knowledge
and skills gained in such trainings, efforts have been made
to provide ongoing support after the trainings have ended.
For example, a follow-up intensive cleft clinic took place
3 months after the Oaxaca training, offering the Mexican
speech interventionists furthe r intensive supervised clini-
cal experience with a variety of individuals with CP ± L.
Other initiatives to provide ongoing support include men-
toring programs in which the interventionist is paired
Crowley et al.: Impact of International Cleft Palate Training 1467
• • •
with a cleft speech expert communicating remotely (e.g.,
Sommer et al., 2022). Although the results of the present
study are promising despite the brevity of a 5-day training,
future studies should determine the optimal intensity and
frequency of such trainings and of follow-up support.
Finally, as most interventionists worldwide will
likely not attend in-person trainings, efforts are being
made to make the free course materials on leadersproject.
org accessible to more speech interventionists and individ-
uals with CP ± L of numerous language backgrounds in
the following ways: The updated online courses are avail-
able in English and Spanish, with French in process. The
website also offers free downloads of assessment screeners
and therapy materials developed specifically for the pho-
nological systems of more than 30 languages, with addi-
tional languages in progress. Additionally, the interven-
tionist in-person training materials are available in
English, Spanish, French, Bahasa, and Vietnamese.
Conclusions
These findings provide preliminary support for two-
stage hybrid CP ± L trainings to successfully prepare local
speech interventionists to deliver high-quality services to
individuals with CP ± L internationally. While content
delivery appears to result from the online course more
than from the subsequent in-person training, the two
stages of training, incorporating supervised practice work-
ing with individuals with CP ± L, may best enhance con-
tinued clinical sk ill development, including replacement of
NSOMEs with evidence-based speech treatment. Such
cleft trainings may contribute to building capacity for sus-
tainable quality intervention in the many underresourced
regions with individuals with CP ± L.
Data Availability Statement
Because of the nature of this study, the speech data
are not available to the public, in compliance with institu-
tional review board requirements. Additionally, many of
the questions are in use in current and upcoming interna-
tional trainings and might bias future results if included
here. However, upon request, the spreadsheets with dei-
dentified participant data and the questionnaires may be
available from the first author.
Acknowledgments
This study was funded, in part, by a gift to Teachers
College Columbia University from Maureen Topper and
by Smile Train, México, and Mobile Surgery Interna-
tional, Oaxaca. Special thanks to all of the interventionists
and individuals and their families with cleft palate, with
or without cleft lip, who participated. Great thanks to
Amy Rodriguez, Jackie, Burpee, and Arianna Salgado
and thanks also to Carol Berrios, Mical Gomez, Natalie
Lyman, and Leat Ruben for their assistance in Oaxaca.
The authors are also grateful to Daiana Chang and
Magdaline Kotsakis f or their research assistance.
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