Visible difference amongst children and adolescents: issues and interventions

Identifying Psychosocial Risk Factors Among Families of Children With Craniofacial Conditions: Validation of the Psychosocial Assessment Tool-Craniofacial Version

OBJECTIVE

To evaluate the psychometric properties of the Psychosocial Assessment Tool-Craniofacial Version (PAT-CV), a screening instrument for psychosocial risk in families of children with craniofacial conditions, and to examine risk classification of patients in a craniofacial population.

DESIGN

Prospective, cross-sectional, single-center study.

SETTING

Interdisciplinary cleft lip and palate/craniofacial center at a US children's hospital.

PARTICIPANTS

Parents/caregivers (n = 242) of 217 children ages 1 month to 17 years being treated for a congenital syndromic or nonsyndromic craniofacial condition completed the PAT-CV and validating measures from July 2015 to July 2016. The PAT-CV was completed by 121 caregivers a second time to assess test-retest reliability.

MAIN OUTCOME MEASURES

PAT-CV, Child Behavior Checklist, Adult Self-Report, Pediatric Quality of Life Inventory, Craniofacial Experiences Questionnaire, and Family Environment Scale.

RESULTS

Construct validity of the PAT-CV was supported by significant correlations ( P < .001) between PAT-CV total and subscale scores and the validated measures. PAT-CV total scores categorized 59.9% of families within the universal risk group, 32.3% within the targeted risk group, and 7.8% within the clinical range. Good criterion validity was indicated by significantly higher scores ( P < .0001) obtained on the validated measures for those in the targeted and clinical risk groups. Internal consistency (Cronbach's α = 0.86) and test-retest reliability for the PAT-CV total score ( r = 0.77, P < .0001) were acceptable.

CONCLUSIONS

The PAT-CV appears to be a reliable and valid screening instrument for psychosocial risk. Accurate identification of risk and implementation of appropriate interventions may contribute to improvements in medical and psychosocial outcomes.

Experience of Being Young With Psoriasis: Self-Management Support Needs

Psoriasis is a long-term condition with a possibly cumulative life course impairment. Young people struggle to minimize its effects on appearance and functioning. To date, the self-management needs of adolescents suffering from psoriasis have been underinvestigated. Using focus groups and individual interviews, we present an interpretive description of young people's experiences of living with psoriasis, the challenges they face, and the support they need to relieve suffering and come to terms with their condition. This process is characterized by loneliness, the self-imposition of limitations, and the lack of personalized knowledge and communication skills to manage the impact of disease and society's reactions. Our study provides insight into needs of early interventions tailored to address condition, role, and emotional management, involving parent education, peer support, storytelling, and roles for professionals. We argue that further research should involve young people, their parents, and professionals in the development and evaluation of interventions.

Exploring Iranian β-Thalassemia major patients' perception of barriers and facilitators of adherence to treatment: A qualitative study

Background

Despite the clinical importance of adherence to treatment in β-Thalassemia Major (β-TM) patients, poor adherence remains a prevalent and persistent problem in these patients.

Objective

The aim of this study was to explore Iranian β-TM patients’ perception regarding the barriers and facilitators of adherence to their treatments.

Methods

In this qualitative study, data were collected using purposeful sampling and semi-structured interviews with 18 β-TM patients, 3 family members and 5 healthcare professionals (total=26) in Sari, northern Iran, between August 2015 and May 2017. Data were analyzed using conventional content analysis with the support of MAXQDA software. All the interviews were transcribed verbatim. Data were coded and grouped under specific categories.

Results

We identified and classified the perceived barriers of patients’ adherence to treatment into six main categories including: (I) long distance challenges, (II) delayed occurrence of complications, (III) fatigue of healthcare providers, (IV) staff workload, (V) insufficient follow-up of healthcare workers, and (VI) busy everyday life. Also, nine main categories emerged as facilitators including: (I) concern of appearance changing, (II) outcomes of treatment, (III) good awareness, (IV) parental monitoring, (V) fear of complications, (VI) social activity, (VII) marriage as a facilitator, (VIII) friendly interaction with the medical staff, and (IX) trusting the medical staff.

Conclusion

Our findings provide a broad range of context-specific facilitators and barriers to treatment adherence perceived by Iranian β-TM patients. These factors improve our understanding of the complex and multifactorial nature of adherence to treatments. Health care providers can use these findings in designing and implementing appropriate interventions to promote β-TM patients’ adherence to treatment.

Cosmetic Surgery and Body Dysmorphic Disorder - An Update

With the increasing volume and popularity of cosmetic procedures and surgeries, physicians in related specialties are increasingly likely to encounter patients with body dysmorphic disorder. Given the ethical, safety, and legal considerations involved in aesthetic procedures in these patients, accurate identification and appropriate selection for procedures is crucial.

Recruiting young people with a visible difference to the YP Face IT feasibility trial: a qualitative exploration of primary care staff experiences

BACKGROUND

Qualitative research methods embedded within feasibility trials are of significant value as they can provide important information for a definitive trial, often unable to be fulfilled by quantitative methods alone. In addition, such information can aid researchers running other trials or evaluating interventions on a similar topic. Aim This study aimed to explore GP and nurses' experiences of recruiting to a trial exploring the feasibility of evaluating YP Face IT, a novel online psychosocial intervention to support young people with appearance-altering conditions.

METHODS

During the recruitment period, a focus group with participating GPs and nurses explored recruitment challenges. In addition, at the end of the recruitment period, telephone interviews were conducted with eight GPs and nurses involved in recruiting to the study, in order to inform a definitive trial of YP Face IT. Transcripts were subjected to thematic analysis. Findings Despite reporting that the study was valuable and interesting, interviewees struggled to recruit in-consultation. They appeared to lack confidence in raising the sensitive issue of a visible difference and adopted strategies to avoid mentioning the topic. Participants felt the nature of the target population, as well as pressures of the primary care environment presented challenges to recruitment, but welcomed YP Face IT as an intervention that could address unmet support needs. Primary care staff may benefit from training to help them raise the subject of a visible difference with young people in order to identify those that require additional support.

A Qualitative Study to Explore the Views and Attitudes towards Prenatal Testing in Adults Who Have Muenke Syndrome and their Partners

Muenke syndrome constitutes the most common syndromic form of craniosynostosis, occurring in 1 in 30,000 live births. The phenotype is variable, ranging from no clinical findings to complex presentation. Facilitating reproductive decision making for couples at genetic risk of having a child with Muenke syndrome is an important aspect of genetic counselling. Prenatal genetic testing for Muenke syndrome is accurate; however the value of testing is uncertain with a variable phenotype. The purpose of this study was to explore attitudes towards prenatal testing in couples where one partner had tested positive for the Muenke mutation. We used a qualitative approach based on thematic analysis and collected data using individual semi-structured interviews with eight parents. Five key themes were: The Muenke journey; Impact and knowledge of diagnosis; Knowledge and attitude to prenatal testing; Stigma and sharing of information; and Information retention. Knowledge of Muenke syndrome and prenatal testing was poor. Genetic information was provided when treatment of their affected child was their paramount concern. Couples reported not sharing genetic information with family due to fear of stigmatisation. Couples cannot make reproductive decisions if lacking appropriate understanding of the choices: timely genetic counselling regarding prenatal testing is needed when relevant to them.

Body Image and Quality of Life in Adolescents With Craniofacial Conditions

OBJECTIVE

To evaluate body image in adolescents with and without craniofacial conditions and to examine relationships between body image and quality of life.

DESIGN

Case-control design.

SETTING

A pediatric hospital's craniofacial center and primary care practices.

PARTICIPANTS

Seventy adolescents with visible craniofacial conditions and a demographically matched sample of 42 adolescents without craniofacial conditions.

MAIN OUTCOME MEASURE

Adolescents completed measures of quality of life and body image including satisfaction with weight, facial and overall appearance, investment in appearance (importance of appearance to self-worth), and body image disturbance (appearance-related distress and impairment in functioning).

RESULTS

Adolescents with craniofacial conditions reported lower appearance investment (P < .001) and were more likely to report concerns about facial features (P < .02) compared with nonaffected youth. Females in both groups reported greater investment in appearance, greater body image disturbance, and lower weight satisfaction compared with males (P < .01). Within both groups, greater body image disturbance was associated with lower quality of life (P < .01). The two groups did not differ significantly on measures of quality of life, body image disturbance, or satisfaction with appearance.

CONCLUSIONS

Body image and quality of life in adolescents with craniofacial conditions are similar to nonaffected youth. Relationships between body image and quality of life emphasize that appearance perceptions are important to adolescents' well-being regardless of whether they have a facial disfigurement. Investment in one's appearance may explain variations in body image satisfaction and serve as an intervention target, particularly for females.

Parental, child, and adolescent experience of chronic skin conditions: A meta-ethnography and review of the qualitative literature

Childhood skin conditions can affect the quality of life of children, adolescents, and families. As such, paediatric dermatological conditions have been the focus of a number of qualitative studies and there is now a need to integrate the findings. A meta-ethnography was carried out with the existing 12 studies, which included nine studies examining parental experiences and three studies of child experiences. Meta-ethnographic analysis of the studies identified themes focused on the child's sense of stigmatisation and the challenges for families that arose from this. Common experiences across studies were feelings of difference relating to the appearance of the skin. The results highlight that children and adolescents can experience negative social reactions and that parents may struggle with some aspects of the physical management of the condition. The studies indicate the need to examine in more detail the psychosocial aspects of childhood skin conditions and the role played by stigmatisation.

Study protocol of the YP Face IT feasibility study: comparing an online psychosocial intervention versus treatment as usual for adolescents distressed by appearance-altering conditions/injuries

INTRODUCTION

A significant number of adolescents suffer extensive and enduring difficulties such as social anxiety, body image dissatisfaction, low self-esteem and bullying as a result of conditions or injuries that affect their appearance (eg, craniofacial and skin conditions, treatment side effects and scarring). Evidence-based psychosocial interventions to meet their specific needs are currently lacking. YP Face IT, developed by the UK's Centre for Appearance Research in collaboration with clinical experts and young people, is an innovative online psychosocial intervention designed to offer this group immediate support, advice and coping strategies. It has been endorsed by young people, their parents/carers, GPs, clinical psychologists and health professionals working with those affected by appearance-related conditions.

METHODS AND ANALYSIS

Young people aged 12-17 with an appearance-altering condition/injury that self-identify as experiencing appearance-related distress, teasing or bullying will be invited to participate via GP practices and UK charities. Consenting participants will be randomised to the intervention (YP Face IT) or the treatment as usual (TAU) control group. Outcome measures will be completed by young people and their parents/carers at baseline, 13, 26 and 52 weeks. Primary outcome measures will be the Body Esteem Scale and the Social Anxiety Scale for Adolescents. Participants will complete other health-related outcome measures and resource use questionnaires for health economic analysis. We will assess recruitment rates, acceptability of the YP Face IT programme, adherence and retention to treatment, questionnaire completion rates, variation of TAU in Primary Care and the feasibility of GP practice staff supervising young people's use of YP Face IT.

ETHICS AND DISSEMINATION

This feasibility trial protocol (V.1, 3 March 2014), received a favourable ethical opinion from the NRES Committee South West-Frenchay (reference number 14/SW/0058). Findings will be disseminated through academic peer-reviewed publications, conferences and to participating GP practices and charities supporting those with conditions affecting appearance.

TRIAL REGISTRATION NUMBER

ISRCTN40650639; Pre-results.

Quality of life and adjustment in children and adolescents with Moebius syndrome: Evidence for specific impairments in social functioning

INTRODUCTION

Moebius syndrome is a rare congenital disorder characterized by congenital facial paralysis and impairment of ocular abduction. The absence of facial expression in people with Moebius syndrome may impair social interaction. The present study aims at replicating prior findings on psychological adjustment in children and adolescents with Moebius syndrome and providing first data on quality of life.

PARTICIPANTS AND METHODS

Parents (n=26) and children and adolescents (n=14) with Moebius-Syndrome completed the KINDL(R) (Questionnaire for Measuring Health-Related Quality of Life in Children and Adolescents), the SDQ (Strengths and Difficulties Questionnaire), and a newly devised questionnaire on the global, social, and emotional impact of Moebius syndrome, including a scale that addressed what conjectures were made concerning the thoughts of other people about a child with Moebius syndrome.

RESULTS

In comparison with normative data, quality of life was reduced for the subscale Friends (large effect for both parental ratings and self-report) and the Total Score of the KINDL(R). Parents reported elevated levels of peer problems on the respective subscale of the SDQ. In SDQ self-report data, cases classified as abnormal were observed on Peer Problems only. Moebius-specific scales showed adequate reliabilities, and were related, most notably for parent-report, to quality of life. 29% of children reported feelings of anger when being stared at, and wished that they were not affected by Moebius syndrome.

CONCLUSIONS

Although most children and adolescents in our sample did not show behavioral problems or reduced quality of life, our results indicate that their emotional and social development should be closely monitored. Maintaining satisfying peer relationships seems to be a special challenge for children and adolescents with Moebius syndrome.

Shared Surgical Decision Making and Youth Resilience Correlates of Satisfaction With Clinical Outcomes

The aim of this study was to identify factors associated with youth satisfaction with surgical procedures performed to address oral cleft or craniofacial conditions (CFCs). It was hypothesized that youth mental health, participation in decision making, perceived consequences of living with a CFC, and coping strategies would be associated with satisfaction with past surgeries. A total of 203 youth between the ages of 11 and 18 years (mean age = 14.5, standard deviation = 2.0, 61% male participants, 78% oral cleft) completed a series of questionnaires measuring depression, self-esteem, participation in decision making, condition severity, negative and positive consequences of having a CFC, coping, and satisfaction with past surgeries. Multiple regression analysis using boot-strapping techniques found that youth participation in decision making, youth perception of positive consequences of having a CFC, and coping accounted for 32% of the variance in satisfaction with past surgeries (P < 0.001). Youth age, sex, and assessment of condition severity were not significantly associated with satisfaction with surgical outcome. Depression, self-esteem, and negative consequences of having a CFC were not associated with satisfaction with past surgeries. Youth should be actively involved in the decision for craniofacial surgery. Youth who were more satisfied with their surgical outcomes also viewed themselves as having gained from the experience of living with a CFC. They felt that having a CFC made them stronger people and they believed that they were more accepting of others and more in touch with others' feelings because of what they had been through.

Developing young person's Face IT: Online psychosocial support for adolescents struggling with conditions or injuries affecting their appearance

A participatory action approach with potential users and clinical experts was employed to design and evaluate the acceptability of young person’s Face IT (YP Face IT), an online intervention incorporating cognitive behavioural therapy and social skills training for adolescents with appearance-related anxiety as a result of a visible difference. Workshops with adolescents and clinicians informed a prototype YP Face IT which underwent a usability analysis by 28 multidisciplinary health professionals and 18 adolescents, before 10 adolescents completed it at home. Acceptability data obtained online and via interview were analysed using content analysis. Participants found YP Face IT acceptable and believed it would provide much needed and easy access to psychosocial support. They requested that it should be made widely available either as a self-management tool requiring minimal supervision from a health professional or to compliment therapist-led care.

Coping with congenital hand differences

BACKGROUND

Although functional outcomes following reconstruction for congenital hand differences are frequently described, much less is known regarding children's ability to cope with the psychosocial effects of these conditions. The authors qualitatively explored stress and coping mechanisms among children following reconstructive surgery for congenital hand differences.

METHODS

Forty patients and their parents participated in semistructured interviews examining children's stress related to hand functioning and appearance, emotional responses to stress, and coping strategies. Interviews were audio-taped, transcribed, and analyzed thematically. A consensus taxonomy for classifying content evolved from comparisons of coding by two reviewers. Themes expressed by participants were studied for patterns of connection and grouped into broader categories.

RESULTS

In this sample, 58 percent of children and 40 percent of parents reported stress related to congenital hand differences, attributed to functional deficits (61 percent), hand appearance (27 percent), social interactions (58 percent), and emotional reactions (46 percent). Among the 18 children who reported stress, 43 percent of parents were not aware of the presence of stress. Eight coping strategies emerged, including humor (12 percent), self-acceptance (21 percent), avoidance (27 percent), seeking external support (30 percent), concealment (30 percent), educating others (9 percent), support programs (21 percent), and religion (24 percent).

CONCLUSIONS

Although children with congenital hand differences often experience emotional stress related to functional limitations and aesthetic deformities, many apply positive coping mechanisms that enhance self-esteem. Clinicians caring for children with congenital hand differences should inform families about potential sources of stress to direct resources toward strengthening coping strategies and support systems.

A systematic review of patient reported outcome measures (PROMs) used in child and adolescent burn research

INTRODUCTION

Patient reported outcome measures (PROMs) can identify important information about patient needs and therapeutic progress. The aim of this review was to identify the PROMs that are being used in child and adolescent burn care and to determine the quality of such scales.

METHODS

Computerised and manual bibliographic searches of Medline, Social Sciences Index, Cinahl, Psychinfo, Psycharticles, AMED, and HAPI, were used to identify English-language articles using English-language PROMs from January 2001 to March 2013. The psychometric quality of the PROMs was assessed.

RESULTS

23 studies met the entry criteria and identified 32 different PROMs (31 generic, 1 burns-specific). Overall, the psychometric quality of the PROMs was low; only two generic scales (the Perceived Stigmatisation Questionnaire and the Social Comfort Scale) and only one burns-specific scale (the Children Burn Outcomes Questionnaire for children aged 5-18) had psychometric evidence relevant to this population.

CONCLUSIONS

The majority of PROMs did not have psychometric evidence for their use with child or adolescent burn patients. To appropriately identify the needs and treatment progress of child and adolescent burn patients, new burns-specific PROMs need to be developed and validated to reflect issues that are of importance to this population.

Two world views: Perspectives on autistic behaviours

This article reports on a study, utilising phenomenological methodology, which used interview and video narratives to collect data from 10 young people with autism and their parents. Data analysis employed multistage, primarily ethnomethodological methods in order to interpret and understand experiences of autism. The study found that parents, arguably influenced by the medical and psychological perspectives through which ‘autism’ has evolved, problematise what children with autism do as pathological. This article juxtaposes parents’ understandings against how children with autism, themselves, account for what they do, by exploring respective accounts of children’s obsessions and ritualistic behaviours.

Clinical care in craniofacial microsomia: a review of current management recommendations and opportunities to advance research

Craniofacial microsomia (CFM) is a complex condition associated with microtia, mandibular hypoplasia, and preauricular tags. It is the second most common congenital facial condition treated in many craniofacial centers and requires longitudinal multidisciplinary patient care. The purpose of this article is to summarize current recommendations for clinical management and discuss opportunities to advance clinical research in CFM.

How children with facial differences are perceived by non-affected children and adolescents: perceiver effects on stereotypical attitudes

Children with a facial difference are presumed to be at risk of social stigmatization. The purposes of this study were twofold: (1) to assess the effect of facial differences on social perceptions by unaffected children and adolescents; and (2) to identify perceiver characteristics that predict stereotypical attitudes toward facial differences. Participants were 344 non-affected children and adolescents, ages 8-17 years. Participants rated digitally altered images of 12 children depicted either with or without a facial difference. Results show that participants attributed less favorable characteristics to children with a facial difference than to those without. Moreover, participants reported less willingness to interact with or befriend a child with a facial difference. Significant predictors of low discriminative attitudes were older participant age and previous contact with someone with a facial difference. Our data call attention to the need for public education programs targeted at reducing negative attitudes toward facial differences.

Psychological and psychosocial functioning of children with burn scarring using cosmetic camouflage: a multi-centre prospective randomised controlled trial

BACKGROUND

Burns leave patients with long-term physical scarring. Children with scarring are required to face challenges of reintegration into their community, including acceptance of an altered appearance and acceptance by others. This can be difficult given society's preoccupation with physical appearance. Limited research exists investigating validity of cosmetic camouflage as a psychosocial intervention for children with scarring. This study investigated whether using cosmetic camouflage (Microskin™) had a positive impact on health-related quality of life, self-concept and psychopathology for children and adolescents (8-17 years) with burn scarring.

METHOD

A prospective multi-centre randomised controlled trial was conducted across Australian and New Zealand paediatric hospitals. 63 participants (49 females, mean age 12.7 ± 2.1 years) were enrolled. Data points were baseline (Time 1) and at 8 weeks (Time 2) using reliable and valid psychometric measures.

RESULTS

Findings indicate there were significant improvements in socialisation, school and appearance scales on the Paediatric Quality of Life Inventory and psychopathology scores particularly peer problems decreased. However self-concept remained stable from baseline throughout intervention use.

CONCLUSION

Cosmetic camouflage appears to have a positive impact on quality of life particularly socialisation. Cosmetic camouflage is a valid tool to assist children with scarring to actively participate socially within their communities.

Evaluation of the similarities and differences in response patterns to the Pediatric Quality of Life Inventory and the Child Oral Health Impact Scores among youth with cleft

PURPOSE

To examine (a) the pattern of responses to a generic health-related quality of life (HRQL) measure (Pediatric Quality of Life Inventory--PedsQL) and an oral health-related quality of life (OHRQoL) measure (Child Oral Health Impact Profile--COHIP), and (b) the associations of these scores with surgical recommendation status among youth with cleft.

METHODS

Cross-sectional data (baseline) regarding clinicians' surgical recommendations and quality of life (QoL) measures were examined from an ongoing observational study on treatment outcomes. Approximately one-third of the racially and geographically diverse sample (N = 1,200; mean = 11.6 years) received surgical recommendations to correct either visible (aesthetic) or invisible (functional) defects. Effect sizes were used to quantify differences in QoL based on surgical recommendation and to compare the sensitivity of the PedsQL and COHIP subscales. Using Pearson coefficients, the scores of those recommended for surgery were compared with those without a surgical recommendation.

RESULTS

A moderate correlation (0.52) was found between the total scores on the PedsQL and COHIP (p < 0.0001). Subscale correlations between the QoL measures ranged from 0.19 to 0.48 with the strongest correlation between the PedsQL Emotional (r = 0.47) and COHIP Socioemotional Well-being subscale. The effect size for the COHIP Socioemotional Well-being (0.39) was larger than the PedsQL Social/Emotional (0.07/0.11) subscale (Z = 5.30/Z = 4.64, p < 0.0001, respectively), and the total COHIP (0.31) was significantly greater than the total PedsQL scale (0.15, z = 2.65, p = 0.008).

CONCLUSIONS

A significant relationship was found between generic HRQL, OHRQoL, and surgical needs among youth with cleft with the COHIP having larger effect sizes than the PedsQL among surgical groups.

Living with Difference: Experiences of Adolescent Girls with Cleft Lip and Palate

Objective

This study explored the experiences of adolescent girls with cleft lip and palate who were preparing for orthognathic surgery.

Design

A qualitative study, based on a phenomenological approach, explored adolescents’ experiences. Two 1-hour semistructured interviews were conducted before surgery, and member checking was employed to verify findings with each participant.

Setting

A tertiary care pediatric hospital in central Canada.

Participants

A criterion sampling technique was used to recruit a sample of seven participants with cleft lip and palate ranging in age from 15 to 20 years who were scheduled for cleft orthognathic surgery.

Results

Participants described experiencing teasing, bullying, and stares. In many cases, participants sought to resist and dismiss negative social attitudes about their visible difference while working to combat this with a positive view of who they really are. To varying degrees, participants felt constricted in engaging in the community as they were worried what others thought of their visible difference. They worked at finding ways to reduce the impact of social stigma through coping strategies, social supports, and reconstructive surgery.

Conclusions

Adolescent girls can experience strain associated with living with a facial difference; however, they find strategies to cope with the perception of difference. Reconstructive surgery is viewed as a means to increase confidence. Further intervention is needed in understanding and addressing stigma and fostering resiliency related to female adolescents living with a facial difference.

Looking ‘the same’: Experiences of women who have had corrective surgery for breast asymmetry

Qualitative interviews with ten women found that following corrective surgery for congenital breast asymmetry, women were still concerned with the symmetry of their breasts and expressed high ideals regarding symmetry. Although women found an improvement in body confidence, some felt their confidence and socializing would be further improved with time. Women were secretive about their breast asymmetry and their surgery, being fearful of negative reactions from other people. It is necessary to establish and improve patients’ expectations of the outcome of surgery particularly regarding symmetry, as well as providing psychological and social support to women after surgery.

Scarring, disfigurement, and quality of life in long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor study

PURPOSE

Childhood cancer survivors are at increased risk for adverse outcomes and chronic medical conditions. Treatment-related scarring, disfigurement, and persistent hair loss, in addition to their long-term impact on psychological distress or health-related quality of life (HRQOL), have received little attention.

PATIENTS AND METHODS

Self-reported scarring/disfigurement and persistent hair loss were examined in 14,358 survivors and 4,023 siblings from the Childhood Cancer Survivor Study. Multivariable models were used to examine associations with demographic and cancer treatment. The impact of disfigurement and hair loss on HRQOL (ie, Medical Outcomes Short Form-36) and emotional distress (ie, Brief Symptom Inventory-18) was examined.

RESULTS

Survivors reported a significantly higher rate of scarring/disfigurement compared with siblings for head/neck (25.1% v 8.4%), arms/legs (18.2% v 10.2%), and chest/abdomen (38.1% v 9.1%), as well as hair loss (14.0% v 6.3%). In age-, sex-, and race-adjusted models, cranial radiation exposure ≥ 36 Gy increased risk for head/neck disfigurement (relative risk [RR], 2.42; 95% CI, 2.22 to 2.65) and hair loss (RR, 4.24; 95% CI, 3.63 to 4.95). Adjusting for cranial radiation, age, sex, race, education, and marital status, survivor hair loss increased risk of anxiety (RR, 1.60; 95% CI, 1.23 to 2.07), whereas head/neck disfigurement increased risk of depression (RR, 1.19; 95% CI, 1.01 to 1.41). Limitations due to emotional symptoms were associated with head/neck disfigurement (RR, 1.24; 95% CI, 1.10 to 1.41), arm/leg disfigurement (RR, 1.19; 95% CI, 1.05 to 1.35), and hair loss (RR, 1.26; 95% CI, 1.09 to 1.47).

CONCLUSION

Survivors of childhood cancer are at increased risk for disfigurement and persistent hair loss, which is associated with future emotional distress and reduced quality of life. Future studies are needed to better identify and manage functional outcomes in these patients.

Epidemiology and impact of scarring after burn injury: a systematic review of the literature

The purpose of this study was to perform a systematic review of the existing literature on the incidence of hypertrophic scarring and the psychosocial impact of burn scars. In a comprehensive literature review, the authors identified 48 articles published since 1965 and written in English which reported the incidence and risk factors for hypertrophic scarring or assessed outcomes related to scarring. Most studies had important methodological limitations limiting the generalizability of the findings. In particular, the absence of standardized valid measures of scarring and other outcome variables was a major barrier to drawing strong conclusions. Among studies on hypertrophic scarring, the prevalence rate varied between 32 and 72%. Identified risk factors included dark skin, female gender, young age, burn site on neck and upper limb, multiple surgical procedures, meshed skin graph, time to healing, and burn severity. With regard to psychosocial outcomes, two studies compared pediatric burn survivors with a nonburn comparison group on a body image measure; neither study found differences between groups. Across studies, burn severity and location had a modest relationship with psychosocial outcome variables. Psychosocial variables such as social comfort and perceived stigmatization were more highly associated with body image than burn characteristics. To advance our knowledge of the epidemiology of scars and the burden of scars, future studies need to implement more rigorous methodologies. In particular, standardized valid measures of scarring and other outcomes should be developed. This process could be facilitated by an international collaboration among burn centers.

Parents' emotional and social experiences of caring for a child through cleft treatment

Little is known about the experiences of parents caring for a child through long-term treatment for cleft lip and/or cleft palate. We conducted in-depth interviews with 35 parents with children between the ages of 20 weeks and 21 years to explore experiences across the treatment program. We analyzed the data using a constructivist grounded theory approach and present in detail in this article one subcategory from the analysis: managing emotions. Throughout childhood and adolescence, parents experienced conflicting emotions about their child's impairment, uncertainty about cleft treatment, and stigmatizing attitudes. Although parents attempted to manage emotional tensions by pursuing cleft treatments, the interventions could themselves be a source of conflict for them. We suggest that routine assessment of parents' emotional and social well-being should be included in cleft treatment programs, and access to psychosocial support made available.

Drawing attention to difference: dilemmas in discussing dysmorphism with parents

Dysmorphism is a sensitive topic to discuss with parents. Discussing dysmorphism requires careful thought, awareness of parent reactions, practice and reflection. Clinical practice suggests that barriers exist for both parents and health professionals, which make these discussions challenging. Here, we explored the challenges inherent in dialogue about dysmorphism and offer suggestions for communication strategies that are grounded in both theory and practice.

The experiences of young people with Epidermolysis Bullosa Simplex: a qualitative study

The objective of this study was to explore the experiences of young people with Epidermolysis Bullosa Simplex (EBS). Eleven participants aged 10 -14 years were interviewed and Interpretative Phenomenological Analysis was employed. A key theme was 'self as different'. This related to experiences of negative treatment and exclusion from peers; a lack of understanding of others about the condition; and a sense of the self as 'wrong'. Findings indicate the importance of providing appropriate psychological and peer support, as well as wider community education and intervention, as part of the holistic treatment of young people with this chronic, painful and visible skin condition.

Coping with a Cleft II: Factors Associated with Psychosocial Adjustment of Adolescents with a Cleft Lip and Palate and Their Parents

Objective

To explore the factors that predict psychosocial adjustment in young people with a cleft and their parents.

Design, Participants, Setting

The study used a cross-sectional postal questionnaire design involving young people aged between 11 and 16 and their parents from two cleft services. Data are presented for 91 adolescents and their mothers.

Main Outcome Measures

Participants completed measures of psychological adjustment, coping, social experiences, satisfaction with appearance, stressful life events, cleft-related factors, and demographic information.

Results

Psychosocial adjustment in adolescents was predicted by their social experiences and maternal well-being. Satisfaction with appearance, perceived speech problems, and the use of avoidant coping strategies were also important factors relating to their adjustment. For mothers, adjustment was predicted by use of coping strategies such as self-blame, venting, and acceptance, in addition to perceived problems with their child's hearing and the number of stressful life events experienced.

Conclusions

The findings are discussed in relation to the concepts of adjustment, coping, satisfaction with appearance, and maternal mental health. Directions for future research are outlined, and a number of opportunities and challenges for cleft services regarding the provision of timely interventions for this age group and their families are discussed.

What Difference Can a Minute Make? Social Skills and First Impressions of Youth with Craniofacial Differences

Objective

To determine whether raters' first impressions of youth with craniofacial differences are modifiable.

Design

Observational study of the association between first impressions and social skills as related to youth aged 11 to 18 years with craniofacial differences.

Setting

University research offices and clinics.

Participants

Youth aged 11 to 18 years with (n = 29) and without (n = 31) craniofacial differences; adults (n = 40), dental/medical students (n = 46), and education students (n = 29), all without craniofacial differences. Participants were recruited from medical clinics and through community advertising at all three study sites.

Outcome Measures

The First Impressions Rating Scale.

Results

After viewing 1-minute portrayals of positive social skills by actors with craniofacial differences, raters' perceptions moved significantly in the positive direction for all 26 attributes on the First Impressions Rating Scale; whereas, after viewing negative social skills, ratings moved significantly in the negative direction for 25 of 26 First Impressions Rating Scale attributes.

Conclusions

It appears that first impressions others have of youth with craniofacial differences are significantly affected by how these youth present themselves in social situations, suggesting that positive social skills may help reduce the amount of stigma that youth with craniofacial differences encounter.

Mothers' and fathers' reports of stress in families of infants with and without single-suture craniosynostosis

OBJECTIVE

To compare relative levels of stress reported by mothers and fathers in families containing infants with and without single-suture craniosynostosis.

DESIGN

Case-control study.

PARTICIPANTS

Mothers and fathers of 246 infants with recently diagnosed single-suture craniosynostosis and 253 frequency-matched control infants completed the Parenting Stress Index just prior to their infant's cranioplastic surgery. Family demographic information and mothers' ratings of the severity of their child's single-suture craniosynostosis were obtained.

RESULTS

Average Parent Domain scores for parents of infants with single-suture craniosynostosis differed little from those reported by parents of control infants; however, Child Domain scores among parents of infants with single-suture craniosynostosis were higher on some subscales, primarily related to unexpected infant health and appearance issues. In both groups, fathers reported higher Child Domain stress than mothers, and mothers reported higher Parent Domain stress than fathers. Case mothers reported greater stress if they perceived their child's condition as more noticeable to others.

CONCLUSIONS

Prior to cases' cranioplastic surgery, parents of children with and without single-suture craniosynostosis reported similar levels of stress in relation to their parenting roles and the behavioral characteristics of their infants. Visibility of condition should be considered a risk for increased stress for mothers of infants with single-suture craniosynostosis. Stress differences between mothers and fathers were far more discernible than those associated with the presence or absence of single-suture craniosynostosis.

Development of an illustrated index of tooth appearance-perception-based quantification of tooth discolouration and surface defects

BACKGROUND

Existing indices to quantify tooth discolouration are mostly aetiology-specific. An index of tooth appearance (IOTA), derived from all types of tooth discolouration and surface defects, would allow the quantification of attractiveness for psychological assessment and treatment planning

OBJECTIVE

To develop a perception based IOTA for quantification of all forms of tooth discolouration and surface defects.

METHODS

One hundred images of discoloured teeth were twice ranked by a panel of judges according to perceived attractiveness. Mean image score was then used to arrange the images into a continuum of attractiveness and from these, ten images were selected, to constitute the illustrated IOTA. A second panel of judges assessed 35 clinical pictures using the IOTA, on two occasions.

RESULTS

The first 100 images were assessed with a correlation of 0.79-0.81 between the two ranking sessions and with intra-group reproducibility of 0.8-0.94. The second panel of judges used the developed IOTA quickly, with an intra-judge correlation of 0.87 and inter-judge reliability of 0.72 and 0.74 for two sessions.

CONCLUSIONS

The IOTA could be used by clinicians as a tool for quantifying disfigurement in teeth, irrespective of aetiology or histology.

Appearance is a function of the face

BACKGROUND

Increasingly, third-party insurers deny coverage to patients with posttraumatic and congenital facial deformities because these are not seen as "functional." Recent facial transplants have demonstrated that severely deformed patients are willing to undergo potentially life-threatening surgery in search of a normal physiognomy. Scant quantitative research exists that objectively documents appearance as a primary "function" of the face. This study was designed to establish a population-based definition of the functions of the human face, rank importance of the face among various anatomical areas, and determine the risk value the average person places on a normal appearance.

METHODS

Voluntary adult subjects (n = 210) in three states aged 18 to 75 years were recruited using a quota sampling technique. Subjects completed study questionnaires of demography and bias using the Gamble Chance of Death Questionnaire and the Rosenberg Self-Esteem Scale.

RESULTS

The face ranked as the most important anatomical area for functional reconstruction. Appearance was the fifth most important function of the face, after breathing, sight, speech, and eating. Normal facial appearance was rated as very important for one to be a functioning member of American society (p = 0.01) by 49 percent. One in seven subjects (13 percent) would accept a 30 to 45 percent risk of death to obtain a "normal" face.

CONCLUSIONS

Normal appearance is a primary function of the face, based on a large, culturally diverse population sample across the lifespan. Normal appearance ranks above smell and expression as a function. Restoration of facial appearance is ranked the most important anatomical area for repair. Normal facial appearance is very important for one to be a functional member of American society.