Self-perceptions of romantic appeal in adolescents with a cleft lip and/or palate

Establishing an International Interdisciplinary Research Network in Craniofacial Microsomia: The CARE Program

OBJECTIVE

Craniofacial microsomia (CFM) is a broad clinical term used to describe a congenital condition most commonly involving the underdevelopment of the external ear, mandible, soft tissues, and facial nerve. Despite medical advances, understanding of the psychological health and healthcare experiences of individuals with CFM and their caregivers remains limited. This article describes a research program designed to address these knowledge gaps, and identify opportunities for psychosocial intervention and improved healthcare provision.

DESIGN

The Craniofacial microsomia: Accelerating Research and Education (CARE) research program aims to: 1) Conduct up to 160 narrative interviews with individuals and caregivers to validate a conceptual framework; 2) Administer an online international survey of up to 800 individuals with CFM and caregivers to identify predictors of psychological distress; 3) Perform up to 60 semi-structured interviews with healthcare providers and advocacy leaders to examine the extent to which current healthcare provisions address identified patient needs; and 4) Establish a participant registry to build a longitudinal database and develop an international community.

RESULTS

Teams in the USA and UK have been established, alongside an international, interdisciplinary Advisory Committee. Data analysis for Aim 1 is ongoing and informing the delivery of Aims 2-3. Aim 4 is also in development. A dedicated website serves as a recruitment tool, educational resource, and mechanism for engaging with the CFM community.

CONCLUSIONS

The CARE program provides a comprehensive approach to understanding the experiences of individuals with CFM and their caregivers. Challenges encountered and lessons learned are shared for the benefit of the community.

Experiences of appearance conversations among young people living with a visible difference

Stigmatisation surrounding having a visible difference to the face or body may have a marked impact on how young people communicate about appearance. The aim of our study was therefore to explore the experiences of appearance conversations among young people living with a visible difference. Interviews were conducted with 32 young people (mean age 14.1 years; 67.7% girls), with a condition resulting in a visible difference (e.g., craniofacial condition or scarring). Using reflexive thematic analysis, we identified three themes. Importance of Safety and Understanding reflects the importance of feeling safe in order to be able to talk about appearance. Participants described appearance conversations as often originating in their need for emotional support or practical assistance when encountering difficulties (Conversations When in Need of Support), but appearance was also experienced as a sensitive topic that was difficult to talk about (Avoiding Appearance Conversations). Our results highlight the importance of creating spaces where young people with a visible difference feel safe to bring up the topic of appearance when in need of support. Elements that facilitate such conversations include others having knowledge about the condition and having one's feelings and experiences validated instead of minimised.

Is it safe? Exploring positive and negative outcome changes following a web-based intervention for adolescents distressed by a visible difference (YP Face IT)

Despite the importance of making sure that psychological interventions are safe, research including both positive and negative effects of novel internet-delivered support is scarce. The aim of our study was to explore whether, and in what way, a new intervention for adolescents distressed by a visible difference (YP Face IT; YPF, Norwegian version) led to positive and/or negative outcome changes. Participants were 79 adolescents (62.00% girls; M_age = 13.84, SD = 1.73), with a visible difference. All had access to the YPF programme and answered questionnaires assessing social anxiety and body esteem pre- and post-intervention. Analyses included calculations of statistical as well as clinically significant and reliable changes. Results showed that fewer participants reported clinical levels of social anxiety and low body esteem after access to YPF. Results also indicated that participants who had a positive pre- to post-intervention change had lower levels of perceived self-worth pre-intervention, and spent more time on the intervention than those with a negative pre- to post change. Three participants showed a clinically significant negative and reliable change in social anxiety or body esteem from pre- to post-intervention. However, based on an examination of these participants' characteristics, preliminary findings support the safety of YPF.

Cost‐effectiveness analysis of a psychosocial web‐based intervention for adolescents distressed by a visible difference: Results from a randomized controlled trial in Norway

Adolescents with a visible difference to the face or body (e.g., due to a congenital condition, illness, or injury), may be at risk of elevated psychological distress. Young Person's Face IT (YPF), a web-based psychosocial intervention, has displayed effectiveness, but no previous study has specifically evaluated its cost-effectiveness. The aim of our study was to investigate whether YPF could be a cost-effective alternative for psychosocial support to adolescents distressed by a visible difference, relative to care-as-usual (CAU). Within the context of a randomized controlled trial in Norway, 102 participants (43% boys) were allocated to intervention (n = 55) or waiting list control group (n = 47). Mean age was 13.9 years (SD = 1.71; range 11-18), and all self-identified as experiencing distress related to a visible difference. Participants answered questionnaires including measures of health-related quality of life and social anxiety at baseline and 3-month follow-up. A health economic evaluation using the method of cost-utility analysis was performed, including quality-adjusted life-years (QALYs). Results indicated that the incremental cost-effectiveness of YPF was 63,641 Norwegian kroner per QALYs gained, which is well within the acceptability threshold in the Norwegian healthcare sector. Hence, YPF could potentially be considered a cost-effective intervention for adolescents experiencing distress related to a visible difference, but more research is needed that includes comparisons of YPF to other health- and societal resources and long-term follow-ups. Our study also constitutes an addition to research as, compared to interventions for somatic diseases, there is a lack of studies exploring the cost-effectiveness of psychological interventions.

Anxiety in Chinese Patients With Cleft Lip and/or Palate: A Preliminary Study

OBJECTIVES

To preliminarily analyze factors that affected the prevalence of anxiety in Chinese patients with cleft lip and/or palate (CL/P).

METHODS

The Generalized Anxiety Disorder Scale (GAD-7) was used to screen anxiety in Chinese CL/P patients. Non-CL/P individuals were also included as the control group. Sociodemographic and clinical data consisting of diagnosis, gender, only child or not, monthly household income, and current family location were collected to analyze possible factors that could affect the anxiety of this patient population.

RESULTS

One hundred forty-two and 78 valid questionnaires were collected from the study and control groups, respectively. The mean GAD-7 score of the study group (3.092 ± 3.381) was significantly lower than the control (3.987 ± 2.505). Moreover, the proportion of patients presenting with moderate-severe anxiety was larger in the study group than in the control group (6.6 vs. 0.0%). Statistically significant differences in GAD-7 scores were observed between the study and control groups when the patient was the only child, living in an urban area, or the monthly household income was between 1,000 and 5,000 yuan.

CONCLUSION

Although the severity of anxiety in Chinese CL/P patients was not severer than those without CL/P, there was a relatively high incidence of moderate-severe anxiety in CL/P patients, while the only child, current family location and the monthly household income played significant roles in affecting anxiety psychology.

Recruiting hard-to-engage groups to online psychosocial interventions: Experiences from an RCT study targeting adolescents with a visible difference

Online interventions have the potential to reach individuals who are otherwise difficult to engage due to stigma and sensitive topics. However, these individuals also tend to be hard to recruit in clinical trials, a crucial step in order to provide evidence-based interventions. This highlights a need for more information about efficient recruitment strategies for difficult-to-engage groups. The present study aimed to share the systematised experiences of recruiting adolescents with a visible difference to an online psychosocial intervention RCT. With the intention to recruit 160 participants (age 12-17), recruitment efforts were nationwide and included multiple arenas (e.g., hospitals, schools, social media), and methods (e.g., in-consultation, targeted letters, posters). Ultimately, 102 participants were recruited, and results showed that recruitment involving patient organisations, hospital departments, and specialised resource centres were most successful in reaching participants. The most efficient recruitment strategy was targeted letters sent home to eligible patients/members, as 78% of the participants were recruited this way. Media and social media recruitment efforts yielded comparatively few participants. No participants were recruited through schools and educational health care services, primary health care services, or municipal and regional authorities. Our results are discussed in relation to barriers with recruiting difficult-to-engage groups to RCTs, providing useful recruitment tools to future similar studies. For instance, future studies are recommended to utilise targeted approaches over general population approaches. Also, results from recruitment efforts should routinely be reported, as this ultimately will provide more general strategies for effective recruitment and support studies in reaching recruitment goals.

Religiosity, spirituality, and self-esteem in adolescents with cleft lip and palate: a correlational study

OBJECTIVE

To evaluate the correlation between religiosity, spirituality, and self-esteem in adolescents with uni- and bilateral cleft lip and palate.

METHOD

Correlational and cross-sectional study developed in a public and tertiary hospital in Brazil between July 2018 and February 2019. The sample comprised 100 adolescents divided into two groups: G1 (unilateral cleft, 50 participants) and G2 (bilateral cleft, 50 participants). For data collection, three instruments were used: Sociodemographic Questionnaire, DUREL Religion index, Rosenberg self-esteem scale. Statistical analysis was performed with the tests Chi-squared, Mann-Whitney, Pearson Correlation, and analysis of linear correlation strength, with a 5% significance level (p ≥ 0.05).

RESULTS

Only organizational religiosity was higher in G1 when compared with G2 (p = 0.03). The overall self-esteem was satisfactory for both groups; however, there was no significant difference between them (p = 0.34). No correlation between religiosity and spirituality with self-esteem were identified for G1 and G2.

CONCLUSION

The adolescents with uni- or bilateral cleft lip and palate presented high levels of religiosity, spirituality, and self-esteem. However, no correlation between these variables was identified.

Bias in a blink: Shedding light on implicit attitudes toward patients with a cleft lip

INTRODUCTION

Previous studies have shown that patients with cleft lip and/or palate may be stigmatized in society. The objective of this study was to use an implicit association test to evaluate the subconscious biases of non-health care providers and orthodontists against patients with a repaired cleft lip (CL).

METHODS

Respondents participated in an implicit association test. Pictures of patients with CL and controls were shown to participants, along with terms representing positive and negative attributes. Participants were prompted to match pictures to the attributes. The software algorithm detected whether the participants were more likely to associate CL with positive or negative terms than controls. Demographic information was collected to measure the association between some sociodemographic factors and implicit biases.

RESULTS

Of 130 valid participants, 52 were orthodontists and 78 were non-health care providers. The entire sample displayed a significant implicit bias against CL (P <0.001). Overall, orthodontists tended to exhibit slightly higher levels of implicit biases against CL than non-health care providers, but the difference was not significant when controlling for sociodemographic factors (P = 0.34). Females showed significantly lower implicit biases against CL than males (P = 0.046). Spearman correlations showed that older people and those who reported a more conservative political affiliation tended to show slightly higher levels of implicit biases against CL (P <0.007).

CONCLUSIONS

Orthodontists and non-health care providers showed moderate but significant levels of implicit biases against patients with clefts. Males, older age groups, and patients with a more conservative political affiliation tended to exhibit slightly higher levels of biases than females, younger people, and those with a more liberal political affiliation.

Romantic Relationships in Young People with Long-Term Health Conditions: A Scoping Review

OBJECTIVE

Forming and maintaining romantic relationships is an important developmental task in adolescence and young adulthood. This scoping review seeks to explore how young people with long-term physical health conditions understand and experience romantic relationships.

METHODS

Using Arksey and O'Malley's scoping review framework, a systematic search of five databases was conducted (PsychINFO, Cinahl, MEDLINE, Embase, and Web of Science). Studies were eligible for inclusion in the review if they were published in peer-reviewed journals, used primary data collection methods, and adopted quantitative, qualitative, or mixed-methods approaches to study romantic relationships in 11-25 year olds with long-term physical health conditions. Using a data extraction form, data pertaining to demographic characteristics of young people with long-term physical health conditions and relationship engagement were extracted from eligible papers.

RESULTS

Searches returned 4645 papers after duplicate removal, with a two-stage screening process resulting in 111 full-text papers being reviewed. Thirty-three eligible papers were included across a range of long-term physical health conditions. Findings identified that living with a long-term physical health condition impacted young people's perceptions and experiences of romantic relationships across the relationship lifespan, from envisaging future relationships, to forming relationships, and sustaining relationships. Issues around body confidence and self-esteem were identified as challenging in terms of perceptions and experiences of romantic relationships.

CONCLUSIONS

Findings demonstrate that young people wish to engage with romantic relationships, yet many report particular challenges associated with forming and sustaining relationships due to the constraints of their condition and treatment. Future research should consider nonheterosexual relationships.

Interpersonal Relationship Experiences in Adults Born With Cleft Lip and/or Palate: A Whole of Life Survey in the United Kingdom

OBJECTIVES

Previous research has suggested that adults with a cleft lip and/or palate (CL/P) may find their familial, friend, collegial, and/or romantic relationships impacted by their condition. Building on this prior work, this study examined the self-reported interpersonal experiences of a national sample of adults born with CL/P.

DESIGN

An online survey was designed by the Cleft Lip and Palate Association in collaboration with the Centre for Appearance Research. Data from 181 participants were included in the present study, collected between July and October 2018. Qualitative data were analyzed using inductive content analysis, while quantitative data were analyzed using descriptive statistics and independent t tests.

RESULTS

Most participants reported having good relationships with family members and existing friends with similar patterns of marriage as the general population. However, some experienced difficulties initiating new friendships and romantic relationships. Participants described bullying and discrimination in adulthood, most often in public settings and the workplace. Participants reported lower satisfaction with intimate relationships and less secure attachment compared to the general population. Concerns regarding the heritability of CL/P and its impact on the decision to have a family were also reported.

CONCLUSIONS

Individuals with CL/P are at risk of negative social experiences, which if not appropriately addressed may impact psychological well-being in adulthood. The findings illustrate the importance of routine psychosocial support from childhood onward to help individuals with CL/P build social skills, self-esteem, and social confidence and to develop mutually fulfilling friendships and intimate relationships. Additionally, societal campaigns to raise awareness and target discrimination may be helpful.

Appearance and Speech Satisfaction and Their Associations With Psychosocial Difficulties Among Young People With Cleft Lip and/or Palate

OBJECTIVE

Previous research has found lower appearance and speech satisfaction among those with cleft lip and/or palate (CL/P) compared to noncleft control groups. Less research has been conducted into which groups report the lowest satisfaction and how these two factors relate to psychosocial difficulties. This study aimed to investigate (1) differences in appearance and speech satisfaction by diagnosis and age among young people with CL/P and (2) associations between appearance and speech satisfaction and emotional and social difficulties.

DESIGN

Self-report questionnaires that had been collected between June 2016 and August 2018 within routine clinical practice were analyzed.

SETTING

A tertiary pediatric hospital in London.

PATIENTS

A total 130 nonsyndromic 10- and 15-year-old patients with CL/P.

MAIN OUTCOME MEASURES

Cleft Hearing, Appearance and Speech Questionnaire; Strengths and Difficulties Questionnaire.

RESULTS

The CLP group reported significantly lower appearance satisfaction compared to the CP group (P = .005). The 15-year-olds reported significantly lower appearance satisfaction compared to the 10-year-olds (P = .008). No significant differences were found in speech satisfaction by diagnosis (P = .06) or age (P = .064). Significant negative associations were found at 15 years old between appearance satisfaction and emotional difficulties, speech satisfaction and emotional difficulties, appearance satisfaction and social difficulties, and speech satisfaction and social difficulties (P < .05 all correlations). Only the latter two associations were significant at 10 years old (P < .05).

CONCLUSIONS

The findings have important implications as appearance and speech dissatisfaction may be ways in which to identify those at risk of psychosocial difficulties within clinical settings.

Anxiety and depression in adolescents with a visible difference: A systematic review and meta-analysis

Living with a visible difference can entail challenging social situations, associated with psychosocial symptoms. However, it is not clear whether adolescents with a visible difference experience more anxiety and depression than unaffected peers. We aim to determine whether adolescents with a visible difference experience more symptoms of anxiety and depression than unaffected peers. A literature search was conducted in Embase, Medline Ovid, Web of Science, Cochrane CENTRAL, PsycINFO Ovid, and Google Scholar. Meta-analyses were done using random-effects models to calculate a standardised mean difference. Analyses for subgroups were used to study causes of visible difference. Eleven studies were identified (n = 1075, weighted mean age = 15.80). Compared to unaffected peers, adolescents with a visible difference experience more symptoms of anxiety (SMD = 0.253, 95 % CI [0.024, 0.482], p = .030), but not depression (SMD = 0.236, 95 % CI [-0.126, 0.599], p = .202). Adolescents with a skin condition did not experience more symptoms of anxiety (SMD = 0.149, 95 % CI [-0.070, 0.369], p = .182) or depression (SMD = 0.090, 95 % CI [-0.082, 0.262], p = .305) when compared to unaffected peers. Overall, more symptoms of anxiety are found in adolescents with a visible difference compared to peers. No differences in anxiety or depression were found for skin differences. Screening for anxiety is recommended.

Psychological Variables in Children and Adolescents with Cleft Lip and/or Palate

Objective: This review analyzes the psychological variables most frequently studied over the last 10 years in children and adolescents with cleft lip/palate (CL/P). Such variables are assumed to be the keys to these patients' psychosocial adjustment. Study design: Articles published from January 2007 to February 2017 were retrieved from PubMed to identify the psychological variables most commonly studied in children and adolescents with CL/P, irrespective of gender or type of cleft. The search terms were "cleft palate" and "psychology", with the operator AND. Results: Of the 324 articles retrieved, 26 met the criteria for inclusion in the review. The psychological variables most extensively studied over the years were children's social functioning, quality of life and ability to cope. Conclusion: While CL/P patients' quality of life was unanimously agreed to be affected, no consensus was found in the literature on social functioning or coping. In addition to the cleft, patient adjustment was reported to be governed by individual variables and mediators. The range of ages most frequently studied was 7 to 16.

Psychosocial Adjustments Among Adolescents With Craniofacial Conditions and the Influence of Social Factors: A Multi-Informant Study

BACKGROUND

Previous studies have investigated psychosocial adjustments among adolescents with cleft lip and/or palate (CL/P), but our understanding of other craniofacial conditions remains limited. The objective of this study is to compare psychosocial adjustments among 3 groups of adolescents: craniofacial conditions other than cleft lip and/or palate (craniofacial anomaly [CFA]), CL/P, and controls (CON). Our secondary objective is to examine how social factors may predict the adjustments levels.

DESIGN

Cross-sectional, multi-informant, controlled survey study.

PARTICIPANTS

Aged 11- to 17-year olds. Craniofacial anomaly (n = 49), isolated CL/P (n = 42), and 55 CON. Total = 146.

OUTCOME MEASURES

The Strengths and Difficulties Questionnaire (self-report, parent report, and teacher report).

RESULTS

All 3 informant groups displayed similar patterns, where CFA reported the highest difficulties, followed by CL/P, while CON scored the lowest. Parent reports demonstrated significant differences among the 3 groups for most subscales and were emphasized for peer problems. Self-reports showed significant differences between CFA and CON for total scores and peer problems, while teacher reports showed significant differences for peer problems only. Craniofacial anomaly displayed the highest frequency of abnormal psychosocial adjustments, followed by CL/P. Experiencing bullying or teasing predicted increased difficulties, while having a good friend predicted decreased difficulties.

CONCLUSIONS

Adolescents with CFA, and to a lesser extent CL/P, may be at a higher risk of having psychosocial problems. Peer problems may constitute the biggest challenge that CFA and CL/P confront. Social factors, especially being bullied or having a good friend, may predict the psychosocial well-being of adolescents with craniofacial conditions.

Primary Repair in Patients With Unilateral Complete Cleft of Lip and Primary Palate: Assessment of Outcomes

OBJECTIVE

Asymmetry of median facial structures is a major concern for patients with unilateral cleft lip and palate, and the principal goal of its treatment is to restore symmetry. Unilateral complete cleft of lip and primary palate (UCCLPP) is an uncommon subgroup and rarely reported. Patients with UCCLPP have protruding and deviating premaxilla, rendering a primary repair difficult. This study evaluated consecutive patients with UCCLPP and presented their treatment outcome.

METHODS

We assessed 36 patients with UCCLPP and collected clinical information. Surgical repair was performed at 3 months of age by using a modified rotation-advancement method and primary nasal reconstruction. A single surgeon performed all surgical procedures. A postoperative nasal stent was used for 6 months. Follow-up standardized photographs were collected. Landmarks were identified, and nose and lip dimensions measured. The ratios of the corresponding parameters (cleft vs noncleft side) were obtained for evaluating nose and lip symmetry.

RESULTS

No surgical complication was noted in any patient. The overall lip and nose outcome after the primary repair were adequate, and all ratios were close to 1. The nostril width was slightly wider on the cleft side, but the alar width and height were acceptable. The lip heights were balanced between the 2 sides. Patients who received presurgical nasoalveolar molding did not show more favorable lip and nose dimensions, except for the medial philtral height.

CONCLUSION

Even in the presence of protruding and deviating premaxilla, our patients with UCCLPP obtained adequate lip and nose outcome after undergoing primary lip repair and nasal reconstruction.

Assessing Attentional Bias in Secondary Cleft Lip Deformities: An Eye-Tracking Study

OBJECTIVE

Using a well-established measure of attention, we aimed to objectively identify differences in severity between types of simulated secondary cleft lip deformities.

DESIGN

Volunteer participants viewed a series of images of a child digitally modified to simulate different secondary unilateral cleft lip deformities (long lip, short lip, white roll/vermilion disjunction, and vermilion excess), a lip scar with no secondary deformity, or a normal lip. Eye movements were recorded using a table-mounted eye-tracking device. Dwell times for 7 facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face) were compared.

PARTICIPANTS

Forty-six naive adults (25 male; mean age 25.5 years) were recruited from our local university community.

MAIN OUTCOME

The primary outcome of the study was cumulative dwell time between facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face).

RESULTS

Participants spent significantly more time focused on the upper lip regions in patients with simulated secondary deformities relative to those who did not ( P < .01). Severe short lip deformities resulted in longer fixation times than severe long lips ( P < .05). Participants spent less time focused on the eye region in the presence of a secondary lip deformity ( P < .05). When total facial fixation time was assessed, short lip deformities resulted in the greatest duration dwell time ( P < .001).

CONCLUSIONS

This study presents objective data to support the concept that observers show varying degrees of attentional bias to the lip region depending on the type and severity of the simulated secondary cleft lip deformity.

Factors affecting subjective appearance evaluations among patients with congenital craniofacial conditions: An application of Cash's cognitive-behavioural model of body image development

Satisfaction with appearance is of central importance for psychological well-being and health. For individuals with an unusual appearance, such as congenital craniofacial anomalies (CFA), appearance evaluations could be especially important. However, few, if any papers have presented a comprehensive synthesis of the factors found to affect subjective satisfaction with appearance among children, adolescents, and adults born with a CFA. Further, only a handful of craniofacial studies have applied psychological theories or models to their findings, resulting in an overall lack of guidance for researchers in the field. This paper summarises the literature pertaining to satisfaction with appearance among those affected by CFAs, and examines the extent to which Cash's cognitive-behavioural model of body image development (2012) fits with this literature. Given the overlap between factors of interest in the field of CFAs, and in the area of body image more broadly, a closer collaboration between the two research fields is suggested.

Psychological adjustment to craniofacial conditions (excluding oral clefts): A review of the literature

OBJECTIVE

A congenital craniofacial anomaly (CFA) is expected to impact upon several domains of psychological, emotional and social functioning, yet no recent reviews have comprehensively summarised the available literature. Further, existing reviews tend to draw upon literature in the field of cleft lip and palate, and do not give substantive attention to other types of CFAs.

DESIGN

A review of 41 papers published between January 2000 and March 2016 pertaining to psychological adjustment to CFAs.

MAIN OUTCOME MEASURES

Findings are presented according to key psychological domains: General Psychological Well-being, Quality of Life, Behaviour, Emotional Well-being, Social Experiences, Appearance, and Treatment-Related Experiences.

RESULTS

Current literature offers a contradictory picture of adjustment to CFAs. Psychological adjustment appeared to be comparable to norms and reference groups in approximately half of the papers related to non-syndromic CFAs, while more variation was found across domains among samples with syndromic CFAs. Associations were found between adjustment, physical health and cognitive function in several papers. The review identified a number of gaps in the literature, such as the inclusion of a wide range of diagnoses within research samples.

CONCLUSIONS

This review demonstrates the complexity of findings, both within and across domains, and highlights a number of methodological challenges.