A developmental approach to mental health for children and adolescents with orofacial clefts

Body Dysmorphic Disorder in Adult Patients With an Orofacial Cleft: An Unseen Psychological Burden

OBJECTIVES

Facial dysmorphic disorder (FDD), a variant of body dysmorphic disorder, occurs when individuals are preoccupied with perceived defects in their facial appearance. Cleft lip and/or palate (CL/P) requires many clinical interventions and has significant psychological impacts on a patient's perception of appearance. This study identified psychological burdens related to living as an adult with CL/P and characterizes the degree of FDD symptoms in an adult craniofacial population.

METHODS

This was a prospective, single-center, cross-sectional case-control study using semi-structured interviews and symptom assessments at a university-based craniofacial center. Patients without CL/P undergoing non-cosmetic facial surgery were recruited as controls (n = 20). Patients with an orofacial cleft (n = 30) were recruited from medical and dental providers at the University of North Carolina. Body Dysmorphic Disorder-Yale Brown Obsessive Compulsive Scale (BBD-YBOCS) scores were collected from a control population and patients with CL/P to assess FDD severity.

RESULTS

Demographic factors such age, biological sex, and ethnicity had no significant impact on FDD symptom scores. Patient with CL/P were more likely to have significant FDD symptoms (BDD-YBOCS greater than 16) than patients without CL/P (OR 10.5, CI₉₅ 2.7-41.1), and had a mean difference in FDD symptoms scores of 10.04 (p < 0.0001; CI₉₅ 5.5-14.6). Patients with CL/P seen by a mental health provider in the past 3 months had 3-fold lower overall FDD symptom scores (OR 0.081; CI₉₅ 0.0085-0.77).

CONCLUSIONS

Adults with CL/P would benefit from treatment for cleft-specific needs and psychological support as they face unique stressors related to their appearance, including an increase in FDD-associated symptoms. This study emphasizes the importance of recognizing psychological symptoms and providing ongoing multidisciplinary care to adults with CL/P.

LEVEL OF EVIDENCE

3; Individual case-control study Laryngoscope, 133:818-821, 2023.

Immediate effects of voice focus adjustments on hypernasal speakers' nasalance scores

OBJECTIVES

To explore the immediate effects of voice focus adjustments on the oral-nasal balance of hypernasal speakers, measured with nasalance scores.

METHODS

Five hypernasal speakers (2 M, 3 F) aged 5-12 (SD 2.7) learned to speak with extreme forward and backward voice focus. Speakers repeated oral, nasal, and phonetically balanced stimuli. Nasalance scores were collected with the Nasometer 6450.

RESULTS

From the average baseline of 34.27% for the oral stimulus, nasalance increased to 46.07% in forward and decreased to 30.2% in backward focus. From the average baseline of 64.53% for the nasal stimulus, nasalance decreased to 64.13% in forward and decreased to 51.73% in backward focus. From the average baseline of 51.33% for the phonetically balanced stimulus, nasalance increased to 58.87% in forward and decreased to 46.2% in backward focus.

CONCLUSIONS

Forward voice focus resulted in higher and backward voice focus resulted in lower nasalance scores during speech for a group of hypernasal speakers. However, there was an exception: One male speaker showed decreased nasalance in forward voice focus. Future research should investigate the longer-term effectiveness of the intervention.

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.

The Contribution of a Charitable Organization to Regional Cleft Lip and Palate Services in England and Scotland

BACKGROUND

From diagnosis through to adulthood, a cleft lip and/or palate (CL/P) poses a number of challenges for those affected. Alongside the care provided by clinical teams, complementary information and support is offered by charitable organizations. In 2011, the Cleft Lip and Palate Association received funding to implement a new regional service across England and Scotland, with the aim of increasing support at a local level. The Centre for Appearance Research at the University of the West of England were commissioned to conduct an independent evaluation of the service over 7 years.

METHODS

A pragmatic, mixed-methods approach was utilized to assess the impact of the service from the perspective of charity volunteers; children, young people, and adults with CL/P; caregivers; and clinicians. Feedback forms were distributed to stakeholders at a variety of events, and qualitative feedback was collected via focus groups and an online survey.

RESULTS

The majority of participants indicated they had gained access to a local support network, felt more able to cope with CL/P-related challenges, and felt more confident in themselves. Qualitative investigation provided further support for these findings and highlighted additional benefits of the regional service for clinical teams.

CONCLUSIONS

The evaluation provides encouraging evidence toward the contribution of a relatively small charitable organization in the context of cleft care. The importance of a pragmatic approach to community-based evaluation and the benefits of collaborative working between researchers and the charitable sector were also highlighted.

Do Cleft Lip and Palate Types Affect Health-Related Quality of Life of Adolescents?

The adolescent with oral cleft must deal with the process of body changing and the psychological implications caused by morphological, functional, and esthetic impairments of the cleft itself. This study aimed to evaluate whether the cleft lip and palate types affects health-related quality of life of adolescents through Short-form Health Survey (SF-36) questionnaire. Fifty-seven adolescents (29 males and 28 females; mean age 15 years and 11 months ± 1 year and 2 months) were divided into 2 groups: Group 1-single cleft-unilateral or bilateral CL or CP; Group 2-complex cleft-unilateral or bilateral cleft lip and palate. The participants filled in SF-36 questionnaire to verify their functional, physical, and mental well-being profile. Spearman test assessed SF-36 scores correlation with age. Mann-Whitney U test verified the differences between genders and cleft types. Linear regression models were used to analyze confounding factors (age and gender). P was set at <0.05. The different SF-36 domains weakly correlated with age, ranging from -0.07 (P = 0.60) for the social aspects and 0.31 (P = 0.02) for general health. Females had statistically lower SF-36 scores than males in the domains Bodily pain (P = 0.02), Vitality (P < 0.001), and Mental Health (P < 0.001). G1 showed lower scores in the domains Limitations due to Emotional Problems (P = 0.008) and Mental Health (P = 0.036). However, when the confounding factors (age and gender) were analyzed, the oral cleft type did not affect health-related quality of life (P > 0.05). Considering the age and gender, the cleft lip and palate types did not affect the health-related quality of life of adolescents.

Epidemiology, prevention, diagnosis, treatment, and outcomes for psychosocial problems in patients and families affected by non-intellectually impairing craniofacial malformation conditions: a systematic review protocol of qualitative data

BACKGROUND

Physical attractiveness or unattractiveness wields a tremendous impact on the social and psychological components of life. Many individuals with facial deformities are treated more negatively than normal individuals, which may affect their self-image, quality of life, self-esteem, interpersonal encounters, and ultimately, success in life. Malformations that do not create physiological problems and whose major health impact is to degrade physical attractiveness and engender psychosocial consequences are insufficiently understood and not considered functional problems by medical insurance companies.

METHODS/DESIGN

As part of a clinical practice guideline development process for psychosocial concerns in Freeman-Burian syndrome, manuscripts describing psychosocial considerations related to the presence of non-intellectually impairing craniofacial malformation conditions or associated clinical activities are sought, especially focusing on epidemiology, prevention, symptoms, diagnoses, severity, timing, treatment, consequences, and outcomes. All published papers on this topic are considered in searching PubMed, OVID MEDLINE, and CINAHL Complete and again before final analyses. The results will be written descriptively to be practically useful and structured around the type or timing of psychosocial problems or consequences described or target population characteristics. No meta-analysis is planned.

DISCUSSION

Because the quality of research on psychosocial problems in craniofacial malformation conditions is known to be fraught with methodological problems, inconsistencies, and considerable knowledge gaps, we anticipate difficulties, which may limit the review questions able to be answered. We hope to produce a survey relevant to all non-intellectually impaired craniofacially deformed patients and their families and outline knowledge gaps and prioritise areas for clinical investigation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018093021: UNIVERSAL TRIAL NUMBER: U1111-1211-8153.

Quality of Life and Patient Satisfaction in Adults Treated for a Cleft Lip and Palate: A Qualitative Analysis

Objective:

Long-term outcomes of patients born with a cleft lip and palate (CLP) are scarcely investigated. Yet, this patient group is of particular interest, as they can provide a valuable retrospective view upon their treatment experiences and psychological adjustment. Qualitative accounts may be especially useful in understanding the patient journey.

Design:

The present study set out to evaluate quality of life and satisfaction with treatment in adult patients previously treated for CLP at the Wilhelmina Children’s Hospital. Semistructured interviews were performed.

Patients:

A total of 22 patients aged 17 to 35 years (mean: 25 years) were interviewed about their experiences of growing up with CLP and of the treatment they received. Interviews were audio-recorded and factors thought to influence psychological adjustment were identified.

Results:

Four main themes were identified: background factors, support systems, treatment factors, and coping/internal factors. Each theme was described with illustrative quotes.

Conclusion:

This study underlines that psychological adjustment can fluctuate over time and greatly differs between individuals, even during adulthood. Psychological support should therefore be available beyond the finalization of the treatment course. Furthermore, the majority of participants stated they had wanted more psychological support as a child to facilitate resilience and to help them cope with challenges.

Assessing Psychological Adjustment to Congenital Craniofacial Anomalies: An Illustration of Methodological Challenges

Background:

Recognition of the challenges inherent in psychology research related to cleft lip and/or palate (CL/P) and other craniofacial anomalies (CFAs) is far from novel; yet these challenges continue to limit progress within the field. The aim of the present article was to illustrate these challenges by utilizing data extracted from 2 recent literature reviews pertaining to psychological adjustment within CL/P and CFA research.

Design:

Data relating to 148 CL/P and 41 CFA studies were extracted, summarized, and compared, using percentages, figures, and χ2 calculations.

Results:

Comparable patterns were observed in both populations in relation to small sample sizes, wide age ranges, a reliance on data collection from single sites, and limited global coverage. Similarly, only one-third of all studies had used a comparison group, 42% of studies did not include the patient perspective, and fewer than 10% of studies had collected data longitudinally. Qualitative research was lacking across both populations, but particularly in relation to CFA. A higher proportion of CFA studies utilized validated measures and were less likely to exclude patients with additional anomalies. CFA studies most frequently focused on behavior and overall quality of life, while CL/P studies tended to investigate emotional well-being and social experiences.

Conclusions:

Findings illustrate the variability in research approaches, sampling, measurement, and analysis across both populations. There is a pressing need to address key methodological issues within craniofacial research and to examine the possible similarities and condition-specific differences between CL/P and other congenital craniofacial anomalies.

ATTACHMENT IN INFANTS WITH CLEFT LIP AND/OR PALATE: MARGINAL SECURITY AND ITS CHANGES OVER TIME

This study examines the attachment quality and how this changed over time among infants who had cleft lip and palate (CLP), by conducting a prospective longitudinal study addressing the effects of this type of perinatal event on the parent-infant relationship and the emotional development of the infants. At 12 months of age, the Strange Situation Paradigm (SSP; M. Ainsworth, M.C. Blehar, E. Waters, & T. Wall, 1978) was administered to a sample of 38 CLP infants (born between 2003 and 2010) and 17 healthy controls. At 4 years of age, the Attachment Story Completion Task (ASCT; I. Bretherton, D. Ridgeway, & J. Cassidy, 1990) was administered to 32 individuals from the CLP sample and 14 from the control group. As reported in the literature, CLP infants display secure attachment behaviors as frequently as do control infants (55%). However, a more detailed analysis of the attachment scales revealed that CLP infants show more avoidance and less proximity seeking. In addition, a closer examination of the subcategories of attachment styles revealed that most CLP infants (71%) displayed distal attachment strategies such as the B1/B2 or A1/A2 subcategories. At 4 years old, CLP infants clearly displayed more deactivation and less security than did the control sample. Moreover, when detailing the evolution of attachment individually, almost 60% of the CLP children showing distal strategies at 12 months became deactivated or disorganized when they reached 4 years. Indeed, subtle differences in attachment behaviors at 12 months old-which can be considered marginally secure at that age-may reveal attachment vulnerabilities, which seem to be more apparent over the course of development.

Common basis for orofacial clefting and cortical interneuronopathy

Orofacial clefts (OFCs) of the lip and/or palate are among the most common human birth defects. Current treatment strategies focus on functional and cosmetic repair but even when this care is available, individuals born with OFCs are at high risk for persistent neurobehavioral problems. In addition to learning disabilities and reduced academic achievement, recent evidence associates OFCs with elevated risk for a constellation of psychiatric outcomes including anxiety disorders, autism spectrum disorder, and schizophrenia. The relationship between these outcomes and OFCs is poorly understood and controversial. Recent neuroimaging studies in humans and mice demonstrate subtle morphological brain abnormalities that co-occur with OFCs but specific molecular and cellular mechanisms have not been investigated. Here, we provide the first evidence directly linking OFC pathogenesis to abnormal development of GABAergic cortical interneurons (cINs). Lineage tracing revealed that the structures that form the upper lip and palate develop in molecular synchrony and spatiotemporal proximity to cINs, suggesting these populations may have shared sensitivity to genetic and/or teratogenic insult. Examination of cIN development in a mouse model of nonsyndromic OFCs revealed significant disruptions in cIN proliferation and migration, culminating in misspecification of the somatostatin-expressing subgroup. These findings reveal a unified developmental basis for orofacial clefting and disrupted cIN development, and may explain the significant overlap in neurobehavioral and psychiatric outcomes associated with OFCs and cIN dysfunction. This emerging mechanistic understanding for increased prevalence of adverse neurobehavioral outcomes in OFC patients is the entry-point for developing evidence-based therapies to improve patient outcomes.

Adults’ Narratives of Growing up with a Cleft Lip and/or Palate: Factors Associated with Psychological Adjustment

Background

Growing up with a cleft lip and/or palate presents a number of challenges for those affected and their families. Understanding why some individuals cope well while others struggle is key to psychological research in this field. A better appreciation of the factors and processes that contribute to psychological adjustment to cleft lip and/or palate (CL/P) from the patient perspective would be of value to both researchers and clinicians.

Design

Qualitative data elicited from individual interviews with 52 adults born with CL/P.

Result

Inductive thematic analysis identified three main themes: “background” factors (age, gender, sexual orientation, culture, additional conditions, socioeconomic status, and adoption), “external” factors (treatment autonomy, familial coping and support, salience, public understanding, psychological input, and peer support), and “internal” psychological factors (perceptions of difference, noticeability and teasing, social confidence, internalization of beauty ideals, valence, expectations of treatment, responding to challenges, social comparisons, acceptance, faith, dispositional style, and recognition of strengths and positive growth).

Conclusions

The number and breadth of factors identified in this study are testament to the importance of psychology in the field of CL/P and may offer guidance in relation to developing and assessing the value of psychological interventions. There is a clear role for psychologists in tackling appearance-related concerns, designing materials, supporting patient decision making, and improving social interaction, as well as providing specialist psychological support. The findings illustrate the potential degree of individual variation in perspectives and offer insight into the conflicting results found within current literature.

Toward a Conceptual and Methodological Shift in Craniofacial Research

Objective:

To date, research investigating the psychological impact of craniofacial conditions has produced variability across outcomes. The aims of this article were to summarize the challenges that may contribute to this variability, and to offer alternative perspectives and approaches to guide future research and practice.

Design:

A comprehensive evaluation of papers exploring adjustment to congenital craniofacial conditions was conducted. Methodological approaches and underlying conceptual issues were identified and summarized.

Results:

The conceptual limitations identified include inherent challenges pertaining to the multifactorial and fluctuating nature of adjustment, a lack of consensus regarding the primary constituents of a positive outcome, scant use of appropriate models and theories, and a predominant focus on “deficits” over “strengths.” The methodological shortcomings identified include a lack of representative samples, biomedical inclusion/exclusion criteria, inconsistency in measurement, a relative absence of the patient perspective, variability in approaches to data analysis and interpretation, and the failure to draw on knowledge from other disciplines and related fields of health research. Findings are believed to be relevant to all disciplines involved in craniofacial research and practice.

Conclusions:

Existing literature remains markedly affected by a range of conceptual and methodological challenges, despite these challenges being identified 25 years ago. The present article proposes that a shift in the way we conceptualize and study craniofacial conditions is needed, in order to construct a comprehensive understanding of adjustment to craniofacial conditions, and to address the key unanswered questions important to all stakeholders.

Stress in Parents of a Child with Hemifacial Microsomia: The Role of Child Characteristics and Parental Coping Strategies

OBJECTIVE

Examine stress levels of parents of children with hemifacial microsomia (HFM) and the relationship of parental stress to child characteristics and cognitive coping strategies.

DESIGN

Prospective cross-sectional study.

PARTICIPANTS AND SETTING

Parents with a child (age 3-19 years) with HFM (N = 31) were recruited through the Department of Orthodontics and the Craniofacial Center, Sophia-Erasmus Medical Center, Rotterdam, The Netherlands. Intervention and Outcome Measures: The adapted and shortened Dutch version of the parental stress index (NOSI-K) was used to measure parental stress, and the cognitive emotion-regulation questionnaire was used to measure cognitive coping strategies. Pearson correlations and a multiple regression analysis were performed.

RESULTS

The hierarchical multiple regression analysis showed associations between increased parental stress and learning difficulties and use of acceptance as a coping strategy. This suggests that problems other than the characteristic visual appearance of the child's face in HFM have a greater influence on parental stress.

CONCLUSIONS

Learning difficulties of the child with HFM and parental acceptance affect stress in parents with a child with HFM the most and are important in the search for a targeted tailoring of intervention for parents with high levels of parental stress.

Parent-Reported Family Functioning Among Children With Cleft Lip/Palate

OBJECTIVE

To examine family functioning related to sociodemographic and clinical characteristics in youth with cleft lip and/or palate (CL/P).

DESIGN

Cross-sectional, multi-site investigation.

SETTING

Six U.S. cleft centers.

PATIENTS/PARTICIPANTS

A diverse sample of 1200 children with CL/P and their parents.

MAIN OUTCOME MEASURE

Parents completed the Family Environment Scale (FES), which assesses three domains of family functioning: cohesion (or closeness), expressiveness (open expression of feelings), and conflict. Demographic and clinical characteristics were also assessed including race, ethnicity, type of insurance, and surgical recommendations.

RESULTS

The FES scores for families seeking team evaluations for their youth with CL/P (mean age = 11.6 years) fall within the average range compared with normative samples. Families receiving surgical recommendations for their youth also had FES scores in the average range, yet families of children recommended for functional surgery reported greater cohesion, expressiveness, and less conflict compared with those recommended for aesthetic surgery (P < .05). For cohesion and expressiveness, significant main effects for race (P = .012, P < .0001, respectively) and ethnicity (P = .004, P < .0001, respectively) were found but not for their interaction. No significant differences were found on the conflict domain. Families with private insurance reported significantly greater cohesion (P < .001) and expressiveness (P < .001) than did families with public insurance.

CONCLUSIONS

Family functioning across domains was in the average range. However, observed differences by race, ethnicity, type of insurance, and surgical recommendation may warrant consideration in clinical management for patients and families.

Risk and Protective Factors at Age 16: Psychological Adjustment in Children with a Cleft Lip and/or Palate

Objective

Explore psychological functioning in adolescents with a cleft at age 16 from a broad perspective, including cognitive, emotional, behavioral, appearance-related, and psychosocial adjustment. High-risk groups were identified within each area of adjustment to investigate whether vulnerable adolescents were found across domains or whether risk was limited to specific areas of adjustment.

Methods

Cross-sectional data based on psychological assessments at age 16 (N = 857). The effect of gender, cleft visibility, and the presence of an additional condition were investigated on all outcome variables. Results were compared with large national samples.

Measures

Hopkins Symptom Checklist, Harter Self-Perception Scale for Adolescents, Child Experience Questionnaire, and Satisfaction With Appearance scale.

Results

The main factor influencing psychological adjustment across domains was gender, with girls in general reporting more psychological problems, as seen in reference groups. The presence of an additional condition also negatively affected some of the measures. No support was found for cleft visibility as a risk factor except for dissatisfaction with appearance. Correlation analyses of risk groups seem to point to an association between social and emotional risk and between social risk and dissatisfaction with appearance. Associations between other domains were found to be weak.

Conclusions

The results point to areas of both risk and strength in adolescents born with a cleft lip and/or palate. Future research should investigate how protective factors could counteract potential risk in adolescents with a cleft.

Toward a Reconsideration of Inclusion and Exclusion Criteria in Cleft Lip and Palate: Implications for Psychological Research

Background

This article investigates the prevalence of conditions that affect cognitive and/or psychosocial functioning in 10-year-old children born with a cleft lip and/or palate (CL/P) and explores how the presence of such additional difficulties may affect the reporting of outcomes in psychological research.

Design

Cross-sectional data derived from routine psychological assessments.

Setting

Centralized treatment, Norway.

Participants

Data on cleft type and additional conditions were collected for 754 children with CL/P from 11 consecutive birth cohorts. Data on psychological adjustment were collected for three consecutive birth cohorts (n = 169).

Main Outcome Measures

The Strengths and Difficulties Questionnaire (SDQ), completed by children and parents.

Results

A total of 240 children (32%) in the sample had an additional condition, such as developmental delay, attention deficit/hyperactivity disorder, or a specific language impairment or dyslexia. Analysis of SDQ scores using conventional exclusion criteria (approach 1) was compared with a second method (approach 2), which included all children and categorized them according to the presence or absence of additional conditions. Significant variation in profiles of psychosocial adjustment was found depending on the approach to exclusion.

Conclusions

The presence of additional conditions in a sample may affect results and subsequently the conclusions drawn in relation to the psychosocial adjustment of children born with CL/P. The present study emphasizes the importance of careful assessments and reporting of all associated conditions, in order to improve the understanding of the impact of a cleft and the consequences of associated conditions in this population.

Characterization of subtle brain abnormalities in a mouse model of Hedgehog pathway antagonist-induced cleft lip and palate

Subtle behavioral and cognitive deficits have been documented in patient cohorts with orofacial clefts (OFCs). Recent neuroimaging studies argue that these traits are associated with structural brain abnormalities but have been limited to adolescent and adult populations where brain plasticity during infancy and childhood may be a confounding factor. Here, we employed high resolution magnetic resonance microscopy to examine primary brain morphology in a mouse model of OFCs. Transient in utero exposure to the Hedgehog (Hh) signaling pathway antagonist cyclopamine resulted in a spectrum of facial dysmorphology, including unilateral and bilateral cleft lip and palate, cleft of the secondary palate only, and a non-cleft phenotype marked by midfacial hypoplasia. Relative to controls, cyclopamine-exposed fetuses exhibited volumetric differences in several brain regions, including hypoplasia of the pituitary gland and olfactory bulbs, hyperplasia of the forebrain septal region, and expansion of the third ventricle. However, in affected fetuses the corpus callosum was intact and normal division of the forebrain was observed. This argues that temporally-specific Hh signaling perturbation can result in typical appearing OFCs in the absence of holoprosencephaly--a condition classically associated with Hh pathway inhibition and frequently co-occurring with OFCs. Supporting the premise that some forms of OFCs co-occur with subtle brain malformations, these results provide a possible ontological basis for traits identified in clinical populations. They also argue in favor of future investigations into genetic and/or environmental modulation of the Hh pathway in the etiopathogenesis of orofacial clefting.

Academic achievement of children and adolescents with oral clefts

BACKGROUND AND OBJECTIVE

Previous studies of academic achievement of children with oral clefts have mostly relied on small, clinic-based samples prone to ascertainment bias. In the first study in the United States to use a population-based sample with direct assessment, we evaluated the academic achievement of children with oral clefts relative to their classmates.

METHODS

Children born with isolated oral clefts in Iowa from 1983 to 2003 were identified from the Iowa Registry for Congenital and Inherited Disorders and matched to unaffected classmates by gender, school/school district, and month and year of birth. Academic achievement was assessed by using standardized tests of academic progress developed by the Iowa Testing Programs. Iowa Testing Programs data were linked to birth certificates for all children. Regression models controlled for household demographic and socioeconomic factors. The analytical sample included 588 children with clefts contributing 3735 child-grade observations and 1874 classmates contributing 13 159 child-grade observations.

RESULTS

Children with oral clefts had lower scores than their classmates across all domains and school levels, with a 5-percentile difference in the overall composite score. Children with clefts were approximately one-half grade level behind their classmates and had higher rates of academic underachievement and use of special education services by 8 percentage points. Group differences were slightly lower but remained large and significant after adjusting for many background characteristics.

CONCLUSIONS

Children with oral clefts underperformed across all academic areas and grade levels compared with their classmates. The results support a model of early testing and intervention among affected children to identify and reduce academic deficits.

A comprehensive description of functioning and disability in children with velopharyngeal insufficiency

Children with velopharyngeal insufficiency (VPI) experience functional impairments in a variety of areas that extend beyond the primary physical impairment associated with this disorder. At present, the physical deficits associated with VPI have been studied extensively; however, a comprehensive description of social and communicative participation in this population is needed. Therefore, a biopsychosocial framework such as the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY), may offer an enhanced understanding of the daily experiences of children with VPI. Specifically, the ICF-CY framework is intended to model complex nonlinear systems, and as such, to describe functioning as the interaction of multiple components from which a limitation in communicative participation may emerge. This paper describes how the ICF-CY framework can be utilized to comprehensively describe functioning and disability in children with VPI by describing the interaction of components of this framework.

LEARNING OUTCOMES

As a result of this activity, the reader will be able to: (1) discuss the utility of the ICF-CY in describing the multi-dimensional nature of velopharyngeal insufficiency (VPI); (2) describe interrelationships between functioning and disability in children with VPI; and (3) identify how limitations in communicative participation may emerge from the interaction of components of the ICF-CY in children with VPI.

Relational development in children with cleft lip and palate: influence of the waiting period prior to the first surgical intervention and parental psychological perceptions of the abnormality

Background

The birth of a child with a cleft lip, whether or not in association with a cleft palate, is a traumatic event for parents. This prospective, multidisciplinary and multi-centre study aims to explore the perceptions and feelings of parents in the year following the birth of their child, and to analyse parent–child relationships. Four inclusion centres have been selected, differing as to the date of the first surgical intervention, between birth and six months. The aim is to compare results, also distinguishing the subgroups of parents who were given the diagnosis in utero and those who were not.

Methods/Design

The main hypothesis is that the longer the time-lapse before the first surgical

intervention, the more likely are the psychological perceptions of the parents to affect the harmonious development of their child. Parents and children are seen twice, when the child is 4 months (T0) and when the child is one year old (T1). At these two times, the psychological state of the child and his/her relational abilities are assessed by a specially trained professional, and self-administered questionnaires measuring factors liable to affect child–parent relationships are issued to the parents. The Alarme Détresse BéBé score for the child and the Parenting Stress Index score for the parents, measured when the child reaches one year, will be used as the main criteria to compare children with early surgery to children with late surgery, and those where the diagnosis was obtained prior to birth with those receiving it at birth.

Discussion

The mental and psychological dimensions relating to the abnormality and its correction will be analysed for the parents (the importance of prenatal diagnosis, relational development with the child, self-image, quality of life) and also, for the first time, for the child (distress, withdrawal). In an ethical perspective, the different time lapses until surgery in the different protocols and their effects will be analysed, so as to serve as a reference for improving the quality of information during the waiting period, and the quality of support provided for parents and children by the healthcare team before the first surgical intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT00993993.

Social life aspects of young adults with cleft lip and palate: grounded theory approach

OBJECTIVES

The findings of many questionnaire and inventory studies suggest that people with cleft lip and/or palate report a decreased quality of life. Common problems include dissatisfaction with the external appearance of the lips and nose, speech problems, depression, and anxiety. This qualitative study aimed to explore the subjective perceptions and values of young adults with clefts, particularly with regard to their social lives.

MATERIAL AND METHODS

Twelve persons participated in an in-depth interview. Among those, seven had a repaired isolated cleft palate involving only the hard/soft palate. Five had a repaired bilateral cleft lip and palate that had been a continuous lesion of the lip, the alveolar process, and the palate. A grounded theory approach was used to conduct and analyze the interviews.

RESULTS

The study revealed seven important categories--hoping to be like other people, being treated differently from others, experiencing deviation from others, regarding oneself as being different from others, lack of recognition, low self-esteem, and receiving recognition from significant others--with hoping to be like other people as the core category.

CONCLUSION

Young adults with either cleft lip and palate or isolated cleft palate who received recognition from significant others reported increased self-esteem and greater ability to cope with their social lives.