[Characterization of children with cleft lip or palate]

We reviewed 237 cases of children with cleft lip and/or palate from the Department of Human Communication. Sociodemographic data, diagnoses, surgeries, family structure, family problems reported, psychological evaluation, conduct report, disabilities and emotional indicators were all considered. All these categories are reviewed from a systemic perspective in which each is directly inter-related and directly responsible (along with other factors that must be researched) for the outcome and well being of the patient.

Réparation chirurgicale néonatale des fentes labiales : impact psychologique chez les mères

AIM

To investigate the psychological impact on mothers of an early neonatal cleft lip repair.

METHODS

Between January and December 2004 mothers of 24 infants born with a cleft lip completed psychological interviews and questionnaires 1 month after neonatal repair. We evaluated the psychological impact on mothers of antenatal and postnatal diagnosis. We noted the parental preferences for the timing of cleft repair and their satisfaction after neonatal repair.

RESULTS

Stress, incomprehension and anxiety were often noted. Most mothers preferred their infant to receive neonatal repair. We noted a great satisfaction after neonatal cleft lip repair.

DISCUSSION

We are currently encouraging early repair in the full-term baby as the optimum, reliable and safe method of management of newborns with cleft lip. Mothers expressed a preference for and greater satisfaction with neonatal repair. Parental preferences should routinely be considered in deciding the timing of this procedure.

Perceptions, expectations, and reactions to cleft lip and palate surgery in native populations: a pilot study in rural India

OBJECTIVE

Many charitable organizations conduct overseas missions to correct cleft lip and palate where surgical care is unavailable. However, little is known about cultural and societal attitudes regarding the cleft deformity.

METHOD

A 15-item questionnaire was designed to elicit from parents general knowledge concerning cleft lip and palate, beliefs regarding its causation, and expectations of what surgery would accomplish. Shorter second and third questionnaires were administered after the screening process and after surgery. The initial phase of this project was undertaken in Deesa, a midsized rural town in India. Fifty-two families were selected randomly for the initial questionnaire. These interviews were conducted verbally, assisted by translators. Children in 25 of these 52 families subsequently underwent surgery.

RESULTS

The results of the interviews indicated that 64% of parents did not limit their child's social interaction and were not ashamed to be seen in public. Twenty-six percent exercised some constraints, and 10% kept their children totally isolated, not permitting them to leave the house or attend school. Regarding causation, the vast majority (84%) ascribed the cleft to "God's will" and 10% to sins committed in past lives. Only one parent acknowledged the influence of genetics, although several had a positive family history. Environmental factors were not an issue. Most families expected their child's life to be better when the facial deformity was corrected. Marriage prospects were the main concern, more so for girls than boys. Educational opportunity was a second strong theme.

CONCLUSIONS

A greater understanding of the beliefs and expectations in this region was gained by means of this study.

Serum lipid fatty acids, phonological processing, and reading in children with oral clefts

Reading skill is suggested to be related to phonological processing ability and polyunsaturated fatty acids (PUFAs). Here we investigated whether fatty acids (FAs) are related to phonological processing, whether the relations between PUFAs and reading generalize to other FAs, whether these relations are mediated by phonological processing, and whether relations of FAs are specific for language-related functions. Blood samples of 49 ten-year-old children with oral clefts were collected for FA proportion analysis in serum cholesteryl esters and phospholipids. On the same day, they performed tasks of phonological processing, reading, and both verbal and nonverbal intelligence. Sequential regression analyses (adjusted for age, gender, and cleft type) showed that phonological processing was inversely related to myristic acid in phospholipids and positively related to eicosapentaenoic acid in cholesteryl esters. Reading was inversely related to palmitoleic and gammalinolenic acids in phospholipids. The relations between FAs and reading were not mediated by phonological processing and FAs related only to language-related functions.

Evaluation of esthetic, functional, and quality-of-life outcome in adult cleft lip and palate patients

OBJECTIVE

Evaluation of esthetic, functional, and health-related quality-of-life (HRQoL) outcomes in adult patients with a repaired cleft lip and palate. The treatment for all patients was based on the so-called Vienna concept.

PATIENTS/DESIGN

Seventy adult patients with a repaired complete cleft lip and palate, ranging in age from 18 to 30 years, were included in the study. Esthetic and functional outcomes were assessed by the patients themselves and by five experts using a visual analog scale. Patients also completed the MOS Short-Form 36 questionnaire to evaluate health-related quality of life.

RESULTS

Patients rated their esthetic outcome significantly worse than the experts did. No significant differences were observed in the ratings for function. Female patients, especially, were dissatisfied with their esthetic outcomes. In a personal interview, nearly 63% of them asked for further treatment, particularly for upper-lip and nose corrections. The health-related quality-of-life questionnaire revealed low scores for only two subscales, namely social functioning and emotional role. In most subscales of health-related quality of life, patients who desired further treatment had significantly lower scores than did patients who desired no further treatment.

CONCLUSION

Surgery of the lip and nose appears to be of prime importance for patients with a cleft lip and palate. Cleft patients who do not request secondary treatment are not always satisfied with the treatment. Patients with realistic expectations in regard to further treatment should be treated by specialists, whereas those with unrealistic expectations should be referred to a clinical psychologist.

Association Between School Performance, Breast Milk Intake and Fatty Acid Profile of Serum Lipids in Ten-Year-Old Cleft Children

The fatty acid profiles of serum lipids were examined in 53 ten-year-old cleft children. The children presented with different cleft types (cleft lip, cleft lip and palate, isolated cleft palate and submucuous cleft palate) and were recruited from the Finnish Cleft Center. We also studied associations between serum lipid fatty acids and early breast milk intake, cognitive development in terms of preschool language learning and school achievement. The fatty acid profiles of serum lipids did not differ between boys and girls. The proportion of myristic acid in serum cholesteryl esters (CE) was higher and proportion of nervonic acid in phospholipids (PL) lower in children with isolated palatal clefts than in those with submucuous clefts. Out of the present children, 30% and 60% received breast milk less than 1 or 3 months, respectively. The proportions of docosahexaenoic acid in CE and in PL were significantly higher in the children whose breast milk intake was longer than 3 months. The number of children requiring special education was higher among those who received breast milk less than 1 month than among those with longer breast milk intake. In conclusion, the fatty acid profiles of serum lipids seem to be comparable among children with different cleft types. Short breast milk intake was associated with poorer school performance.

Impact social sur de jeunes adultes du traitement standardisé de fentes labiomaxillopalatines unilatérales complètes traitées dans l’enfance

France has a population of about 60 million peoples and each ten years data about the standard of living are collected by the central bureau of statistics, we considered the collection of data on 5000 households in 1999 in our geographical area would afford a unique opportunity to compare the equivalent status of French adults with repaired cleft of the lip and palate (CLP). Aspects of social adjustment were investigated in a sample of 82 French adults 18-35 years old with repaired complete unilateral cleft of the lip and palate (CLP). All subjects received a standardized regimen of care from the Burgundy cleft palate team of Dijon. The investigation, based on response to a questionnaire, partly replicated a national survey of social and economic life in the population (Standard of living survey Burgundy, INSEE France 1999), so that adults with complete clefts could be compared with a large control sample of the same age. The control group was constituted by subjects between 18 and 35 years in the standard of living survey Burgundy 1999, INSEE France, they were taken from a regional probability sample of households. This report covers education, employment, and marriage. The significant difference between groups was assessed by: Student's t-test or analysis of variance for continuous variables and chi2 test for categorical variables. The results demonstrated that there are significant differences in educational attainment and employment between adults with cleft of the lip and palate and other people. Fewer with cleft of the lip and palate marry, and when they marry they do so later in life, scholarship history showed significant delay in the cleft of the lip and palate group, independence regarding housing was lower in the cleft of the lip and palate group. If cleft of the lip and palate adults functioned within normal limits with regard to employment. However, levels of income were substantively lower than control groups. It would appear that cleft subjects experience some limitation in their ability to secure vocational and economic rewards from society. As a conclusion we can say regarding our results that the cleft of the lip and palate group, even with the smallest degree of malformation (unilateral without associated malformation), showed a significant delay in the independence process.

The psychosocial effects of cleft lip and palate: a systematic review

This systematic review examined the published scientific research on the psychosocial impact of cleft lip and palate (CLP) among children and adults. The primary objective of the review was to determine whether having CLP places an individual at greater risk of psychosocial problems. Studies that examined the psychosocial functioning of children and adults with repaired non-syndromal CLP were suitable for inclusion. The following sources were searched: Medline (January 1966-December 2003), CINAHL (January 1982-December 2003), Web of Science (January 1981-December 2003), PsycINFO (January 1887-December 2003), the reference section of relevant articles, and hand searches of relevant journals. There were 652 abstracts initially identified through database and other searches. On closer examination of these, only 117 appeared to meet the inclusion criteria. The full text of these papers was examined, with only 64 articles finally identified as suitable for inclusion in the review. Thirty of the 64 studies included a control group. The studies were longitudinal, cross-sectional, or retrospective in nature.Overall, the majority of children and adults with CLP do not appear to experience major psychosocial problems, although some specific problems may arise. For example, difficulties have been reported in relation to behavioural problems, satisfaction with facial appearance, depression, and anxiety. A few differences between cleft types have been found in relation to self-concept, satisfaction with facial appearance, depression, attachment, learning problems, and interpersonal relationships. With a few exceptions, the age of the individual with CLP does not appear to influence the occurrence or severity of psychosocial problems. However, the studies lack the uniformity and consistency required to adequately summarize the psychosocial problems resulting from CLP.

Family environment of individuals with oral clefts in Argentina

OBJECTIVE

The purpose of this investigation was to study the social environment of families of children with different types of nonsyndromic oral clefts (OC) and to compare these groups with a control population of families of children without clefts.

DESIGN

The study compared three nonsyndromic oral cleft groups and the control group using the Moos Family Environment Scale, which examines cohesion, expressiveness, conflict, independence, achievement-orientation, intellectual-cultural orientation, active-recreational orientation, moral-religious emphasis, organization, and control.

SETTING

All parents of children with nonsyndromic oral clefts from a large craniofacial clinic in Buenos Aires, Argentina, were identified and were enrolled in this study between June 2000 and August 2001. Control families were ascertained from the pediatrics service of a hospital located in the vicinity of the craniofacial clinic.

PARTICIPANTS

One hundred and sixty-five parents were selected, based on having a child with nonsyndromic unilateral cleft lip with or without cleft palate (UCL/P), bilateral cleft lip with or without cleft palate (BCL/P), or isolated cleft palate (ICP). One hundred and eighty control parents with no family history of congenital anomalies were selected, as well.

RESULTS

There was no major difference in the social environment of families of children with different types of nonsyndromic oral clefts. When compared with families in the control group, families of children with nonsyndromic oral clefts scored better in all three subdimensions of family relationship, revealed a high level of independence, and showed better structure and organization than control families did; however, families of children with nonsyndromic oral clefts reported participating in fewer recreational activities.

CONCLUSIONS

Overall, families of children with nonsyndromic oral clefts displayed a good social environment. Efforts should be focused to involve them in recreational activities.

Prenatal diagnosis of facial clefts: evaluation of a specialised counselling

QUESTIONS UNDER STUDY/PRINCIPLES

Prenatal diagnosis of cleft lip and palate has raised many questions concerning the best way to inform the parents and offer appropriate support during the remaining pregnancy to help prepare a positive birth experience. Prenatal counselling differs according to who is responsible, and to that person's knowledge of the practical aspects of care and the impact of the malformation on the child's quality of life. The aim of the study was to evaluate our current techniques and modify them when appropriate.

METHODS

29 couples having experienced prenatal diagnosis were asked to respond retrospectively to a questionnaire. Personal obstetric and family history, timing and quality of information provided and their impressions at birth were considered.

RESULTS

The parents used several sources of information: the obstetrician, the counsel by the cleft team surgeon, the parents support groups and the Internet. 93% of the parents felt well prepared psychologically for the birth of their child and concerning the practical aspects of care. 54% felt relieved that their child was less affected than imagined. 96% considered prenatal diagnosis a benefit.

CONCLUSION

Basic information should be provided soon after ultrasound confirmation, followed by progressively more detailed technical discussions over the remaining pregnancy.

Anxiety, Depression, and Quality of Life in Mothers of Children with Cleft Lip/Palate

Multidisciplinary care for patients with cleft lip and palate (CLP) includes the surgical correction of the facial disfigurement and the rehabilitation of functional deficits to optimize the communicational competence of the affected patient. Although the well-being of the mother of a CLP child is an important protective factor for the child, up to now literature has paid only little attention to this topic. In this study, 50 mothers of CLP children aged 1-10 years were examined using the 36-item Short-Form Health Survey and the Hospital Anxiety and Depression Scale (HADS) to screen for quality of life, anxiety and depression. Surprisingly, the data obtained indicate no group-specific alterations of these items when compared with normal controls. In cases with a deteriorated quality of life, the results of the HADS were pathologic as well. In general, mothers of CLP children aged more than 12 months do not require psychological screening. In individual cases, screening for relevant emotional aspects may be restricted to using the HADS.

A Girl's Experience of Congenital Trauma

This paper addresses the centrality of conflict in psychic trauma, as evidenced in the psychoanalytic treatment of an adolescent girl with a congenital life-threatening and disfiguring condition that necessitated multiple surgical procedures in early childhood. The focus is twofold: to elucidate certain characteristics of analysis in the adolescent phase that promote the integration of early trauma; and to shed light on the modes of therapeutic action of psychoanalysis. Case material is presented indicative of the psychic consequences of early medical traumata, including the impairment of the ego's capacity to utilize anxiety as a signal function that mobilizes defense, the failure of repetition to effect mastery of the trauma, the predominant use of aggression in the interest of defense, and distortions in self and object representations. The author offers evidence to show that conflicts over aggression and oedipal desires, characteristic of adolescent girls who have not been subject to trauma, were involved in the defensive function of her patient's pervasive sense of defectiveness. She postulates that the interpretation of conflict and defense is the analyst's attuned response to the mind of the patient, and points to the resulting increase in the capacity to observe and to exercise volitional control over heretofore unconscious, automatic mental processes as evidence of the mutative function of dynamic interpretation.

[The treatment of cleft lip, cleft palate and other dysmorphisms: the ideal technic and therapeutic reality]

Good results in any surgical or orthodontic procedure require expert technique, well adapted to the problem and scrupulously executed. A technique that would achieve the best results can be described as "ideal" and can serve as a theoretical model for all similar cases. But, in dealing with apparently similar problems: cleft lips and palates, Class II or Class III cases... in reality, we are treating individual patients, none quite the same as any other. These differences derive from the varying characteristics of individual patients and from the varying and unpredictable responses of their tissues, and from their varying capacities to accommodate to and withstand insults, suffering, and the sensory-motor effects of their deformities and of the treatment they undergo, and, finally, from their variable readiness to submit to and to pay for treatment with their time and with their money. Any therapeutic technique must take into account these realities which sometimes oblige us to modify an ideal technique so that it will fit the specialized needs of a patient, an accommodation that can be defined as "therapeutic realism". When we ignore this reality, we risk the paradox of providing patients with technically ideal results that they find unsatisfactory or discover that what we thought was a technically mediocre outcome has delighted our patient: ultimately, it is the patient's judgment that determines the "therapeutic result" and is, in effect, the Final Evaluation of the technical result.

Being a Sibling

The purpose of this descriptive exploratory study was to explore the meaning of being a sibling using Parse’s human becoming perspective. Twelve children between 5 and 15 years of age with a younger sibling with a cleft lip and palate or Down Syndrome participated. Through semi-structured interviews and the use of art, children talked about their experiences. Major themes portrayed the complex and paradoxical nature of being a sibling. The themes also revealed that having a sibling with special circumstances includes some unique opportunities and challenges. The finding of this study is the descriptive statement, being a sibling is an arduous charge to champion close others amid restricting-enhancing commitments while new endeavors give rise to new possibilities. Implications for nursing are discussed in the context of understanding being a sibling.

Questionnaire for measuring oral health-related quality of life in eight- to ten-year-old children

PURPOSE

This study measured oral health-related quality of life for children, which involved the construction of child perceptions questionnaires (CPQs) for ages 6 to 7, 8 to 10, and 11 to 14. The purpose of this study was to present the development and evaluation of the CPQ for 8- to 10-year-olds (CPQ8-10).

METHODS

Questions (N=25) were selected from the CPQ for 11- to 14-year-olds based on the child development literature and input from parents, child psychologist, and teacher of grades 3 and 4. Validity and reliability were evaluated on 68 and 33 children, respectively.

RESULTS

There was a positive moderate correlation between the CPQ8-10 score and overall well-being rating (R=.45). The level of impact was slightly higher in the orofacial than in the pediatric dentistry group (mean score=19.1 vs 18.4, respectively). Hypotheses concerning the relationship between the CPQ8-10 score and number of decayed surfaces were confirmed with R=.29, and the mean score higher in caries-afflicted than caries-free children (21.1 vs 14.7). The Cronbach's alpha and intraclass correlation coefficients were 0.89 and 0.75, respectively.

CONCLUSIONS

Results suggest good construct validity, internal consistency, reliability and test-retest reliability, but do not demonstrate discriminative validity. This is consistent, however, with theoretical models of oral disease and its consequences. Further research is required, as these are preliminary findings based on convenience sampling.

Probleme und Bewältigungsverhalten von Jugendlichen mit Lippen-Kiefer-Gaumenspalte

OBJECTIVE

The purpose of this study was to improve the psychological care of young patients with cleft lip and palate by gaining insight into those problematic areas in which social conflicts arise and coping-strategies become necessary for the patients.

METHODS

The procedure included semi-standardized interviews with 20 patients aged between 12 - 17 and their mothers. Every interview was recorded on tape, transcribed, analyzed contextually and categorized.

RESULTS

Four areas of main problems showed up: the time of surgery, the experience of being rejected or teased by peers, remaining visible defects and how to integrate them into self-percept, the problems of the siblings. The mothers showed more pessimistic perceptions regarding the coping strategies of their children and the helpful role of parental support. Consequences for individual support and family therapy are derived.

Psychological issues in cleft lip and palate

The treatment of cleft lip and palate extends over the infancy, childhood, and adolescence of individuals who are born with this condition. The children and their families contend with multiple surgeries throughout these years. Depending on the severity of the cleft, the families may also need to cope with speech therapy, ear infections, learning disabilities,and various orthodontic treatments. The end result of these treatments and interventions should be a child, teen, or adult who is an appropriately contributing member of society at each stage of development. The psychological support needed to enable a child to meet that goal should be provided by family, school, the surgeon, and other members of the cleft treatment team. These adults should demonstrate a belief in the child's ability to cope with the challenges of cleft lip and palate treatment and should focus the child on the efficacy he will gain from having had the experience of growing up with a cleft lip and palate.

Parents' experiences of having a child with cleft lip and palate

BACKGROUND

Giving birth to a child with cleft lip and palate (CLP) can be emotionally traumatic for parents. The facial appearance awakens feelings and reactions in the family and other people. Feeding these children in the neonatal period is known to be difficult. Previous research has mainly dealt with visual defects, feeding and speech problems. There is a lack of studies about parents' experiences of having a child with CLP.

AIMS

This study was performed to investigate parents' experiences of having a child born with a cleft lip or CLP, and how they perceive encouragement and social and mental support from professionals, family and friends.

METHOD

A phenomenographic approach was used. The study was performed at a university hospital in central Sweden. Twenty families (20 mothers and 12 fathers) were interviewed using guided interviews.

FINDINGS

Two categories, consisting of three and two subcategories, emerged. Informants described their experiences of having a child with CLP, how they slowly adapted to this situation, the first meeting with their child, support from professionals, and reactions from family and other people. Parents commented on the craniofacial team with satisfaction. Due to a low level of knowledge, other professionals often had difficulty in handling the situation and a poor quality of advice on feeding was reported. Family and friends commented on the child positively or by being neutral, which was seen as a lack of interest. A visible scar on the face was seen as a problem, especially for girls. Most informants expressed anxiety about possible problems with speech.

CONCLUSIONS

Parents did not look upon their child as handicapped but as having a congenital defect or 'flaw'. The findings of this study could be used in staff education to promote understanding of parents' experiences and how best to help them. They could also be used in the general media to improve public understanding. Future research could explore staff perceptions of this sensitive clinical area.

A case study of amnion rupture sequence with acalvaria, blindness, and clefting: clinical and psychological profiles

The purpose of this article is to report the case of a 10-year-old girl born with anophthalmia, bilateral oblique facial clefts, and missing scalp and bones over the temporal and parietal areas of the cranial vault bilaterally. Early amnion rupture seems to be the most probable cause of this rare combination of anomalies. Because no similar case has been reported in the literature so far, we describe here the clinical and psychosocial history of this unusual patient, who has been able to live the intellectually and socially normal life of a blind child in spite of the major craniofacial deformities. The already completed and possible future therapeutic strategies are discussed.

Possibilities and Limitations of Comprehensive Treatment of Mentally Retarded Patients with Cleft Lip, Alveolus and Palate

The comprehensive, successful treatment of patients with cleft lip, alveolus and palate requires numerous surgical interventions and very close cooperation between various medical and dental specialists. The willingness and ability of the patient to undergo treatment are undoubtedly important factors in achieving optimal treatment outcomes. The presented case report shows that limited compliance makes it much more difficult for speech pathologists and orthodontists to treat mentally retarded patients. Only with combined orthodontic therapy and orthognathic surgery could the dental and skeletal abnormalities be corrected in adulthood.

A Report of Behavioral Data on Three Groups of Patients With Craniofacial Disorders

Longitudinal follow-up data on development and school placement are presented for three groups of patients. Having had or not having had early surgical intervention and stimulation distinguishes the two groups of patients with craniosynostosis. The third group is patients with cleft lip and palate who received early intervention but did not achieve minimal criteria for communication by age 22 months. Educational placement (for patients 8 to 20 years of age) follows the pattern of distribution of students nationally for patients who had early intervention.