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Glinianaia SV, Tan J, Morris JK, Brigden J, Evans HER, Loane M, Neville AJ, Rankin J. Academic achievement at ages 11 and 16 in children born with congenital anomalies in England: A multi-registry linked cohort study. Paediatr Perinat Epidemiol 2024; 38:411-425. [PMID: 38318667 DOI: 10.1111/ppe.13049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 01/15/2024] [Accepted: 01/21/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Children born with major congenital anomalies (CAs) have lower academic achievement compared with their peers, but the existing evidence is restricted to a number of specific CAs. OBJECTIVES To investigate academic outcomes at ages 11 and 16 in children with major isolated structural CAs and children with Down or Turner syndromes. METHODS This population-based cohort study linked data on approximately 11,000 school-aged children born with major CAs in 1994-2004 registered by four regional CA registries in England with education data from the National Pupil Database (NPD). The comparison group was a random sample of children without major CAs from the background population recorded in the NPD that were frequency matched (5:1) to children with CAs by birth year, sex and geographical area. RESULTS Overall, 71.9%, 73.0% and 80.9% of children with isolated structural CAs achieved the expected attainment level at age 11 compared to 78.3%, 80.6% and 86.7% of the comparison group in English language, Mathematics and Science, respectively. Children with nervous system CAs as a whole had the lowest proportion who achieved the expected attainment at age 11. At age 16, 46.9% of children with CAs achieved the expected level compared to 52.5% of their peers. Major CAs were associated with being up to 9% (95% confidence interval [CI] 8%, 11%) and 12% (95% CI 9%, 14%) less likely to achieve expected levels at ages 11 and 16, respectively, after adjustment for socioeconomic deprivation. CONCLUSIONS Although many children with isolated CAs achieved the expected academic level at ages 11 and 16, they were at higher risk of underachievement compared to their peers. These stark yet cautiously encouraging results are important for counselling parents of children with specific CAs and also highlight the possible need for special education support to reduce potential academic difficulties.
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Affiliation(s)
- Svetlana V Glinianaia
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Joachim Tan
- Population Health Research Institute, St George's, University of London, London, UK
- NIHR GOSH Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Joan K Morris
- Population Health Research Institute, St George's, University of London, London, UK
| | - Jo Brigden
- Population Health Research Institute, St George's, University of London, London, UK
| | - Hannah E R Evans
- Population Health Research Institute, St George's, University of London, London, UK
| | - Maria Loane
- Faculty of Life and Health Sciences, Ulster University, Belfast, UK
| | - Amanda J Neville
- Center for Clinical and Epidemiological Research, University of Ferrara, Ferrara, Emilia-Romagna, Italy
| | - Judith Rankin
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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Roustaei Z, Heino A, Kiuru-Kuhlefelt S, Morris JK, Glinianaia SV, Garne E, Loane M, Rankin J, Gissler M. Educational achievement of children with selected major congenital anomalies and associated factors: a Finnish registry-based study. Eur J Public Health 2023; 33:1027-1034. [PMID: 37594898 PMCID: PMC10710322 DOI: 10.1093/eurpub/ckad149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Children with major congenital anomalies may be at risk of poor educational outcomes. We aimed to evaluate the educational achievement of children born with major congenital anomalies compared with children without major congenital anomalies in relation to sociodemographic factors. METHODS We performed a registry-based study including 401 544 children in Finland, graduates of the compulsory school who applied to secondary education. We used health data from the Finnish Register of Congenital Malformations for children born from 1995 to 2002 linked with education data from the Finnish Ministry of Education and Culture. We used generalized linear regression to compare the mean grade differences of children with specific major congenital anomalies and 'All anomalies' subgroup (major congenital anomalies, chromosomal syndromes, and multiple anomalies) with reference children. RESULTS Children with major congenital anomalies were less likely to apply for further education than reference children (88.0% vs. 96.8%; odds ratio = 4.13; 95% confidence interval, 3.92-4.36). For most non-chromosomal congenital anomalies, children born with congenital anomalies had similar educational achievement to the reference children. For the 'All anomalies' subgroup, children with congenital anomalies had lower educational achievement than reference children. Among children with congenital anomalies, male sex, lower maternal educational levels and younger maternal age were associated with lower educational achievement. CONCLUSIONS For children applying to further education, most non-chromosomal congenital anomalies were not associated with lower educational achievement. Nevertheless, efforts are needed to improve educational achievement in children with major congenital anomalies associated with maternal sociodemographic background.
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Affiliation(s)
- Zahra Roustaei
- Department of Health Sciences, University of Helsinki, Helsinki, Finland
| | - Anna Heino
- Department of Knowledge Brokers, THL Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Sonja Kiuru-Kuhlefelt
- Department of Knowledge Brokers, THL Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Joan K Morris
- Population Health Research Institute, St George's, University of London, London, UK
| | | | - Ester Garne
- Paediatric Department, Hospital Lillebælt, Kolding, Denmark
| | - Maria Loane
- Faculty of Life and Health Sciences, Ulster University, Belfast, UK
| | - Judith Rankin
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Mika Gissler
- Department of Knowledge Brokers, THL Finnish Institute for Health and Welfare, Helsinki, Finland
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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Etoori D, Park MH, Blackburn RM, Fitzsimons KJ, Butterworth S, Medina J, Mc Grath-Lone L, Russell C, van der Meulen J. Number and timing of primary cleft lip and palate repair surgeries in England: whole nation study of electronic health records before and during the COVID-19 pandemic. BMJ Open 2023; 13:e071973. [PMID: 37311637 DOI: 10.1136/bmjopen-2023-071973] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
OBJECTIVE To quantify differences in number and timing of first primary cleft lip and palate (CLP) repair procedures during the first year of the COVID-19 pandemic (1 April 2020 to 31 March 2021; 2020/2021) compared with the preceding year (1 April 2019 to 31 March 2020; 2019/2021). DESIGN National observational study of administrative hospital data. SETTING National Health Service hospitals in England. STUDY POPULATION Children <5 years undergoing primary repair for an orofacial cleft Population Consensus and Surveys Classification of Interventions and Procedures-fourth revisions (OPCS-4) codes F031, F291). MAIN EXPOSURE Procedure date (2020/2021 vs 2019/2020). MAIN OUTCOMES Numbers and timing (age in months) of first primary CLP procedures. RESULTS 1716 CLP primary repair procedures were included in the analysis. In 2020/2021, 774 CLP procedures were carried out compared with 942 in 2019/2020, a reduction of 17.8% (95% CI 9.5% to 25.4%). The reduction varied over time in 2020/2021, with no surgeries at all during the first 2 months (April and May 2020). Compared with 2019/2020, first primary lip repair procedures performed in 2020/2021 were delayed by 1.6 months on average (95% CI 0.9 to 2.2 months). Delays in primary palate repairs were smaller on average but varied across the nine geographical regions. CONCLUSION There were significant reductions in the number and delays in timing of first primary CLP repair procedures in England during the first year of the pandemic, which may affect long-term outcomes.
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Affiliation(s)
- David Etoori
- Institute of Health Informatics, University College London, London, UK
| | - Min Hae Park
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | | | - Kate J Fitzsimons
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Sophie Butterworth
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Jibby Medina
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | | | - Craig Russell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- National Cleft Surgical Service for Scotland, Royal Hospital for Children, Glasgow, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
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Jay MA, Sanders-Ellis D, Blackburn R, Deighton J, Gilbert R. Umbrella systematic review finds limited evidence that school absence explains the association between chronic health conditions and lower academic attainment. Front Public Health 2023; 11:1122769. [PMID: 37361156 PMCID: PMC10288991 DOI: 10.3389/fpubh.2023.1122769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/12/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction Absence from school is more frequent for children with chronic health conditions (CHCs) than their peers and may be one reason why average academic attainment scores are lower among children with CHCs. Methods We determined whether school absence explains the association between CHCs and academic attainment through a systematic review of systematic reviews of comparative studies involving children with or without CHCs and academic attainment. We extracted results from any studies that tested whether school absence mediated the association between CHCs and academic attainment. Results We identified 27 systematic reviews which included 441 unique studies of 7, 549, 267 children from 47 jurisdictions. Reviews either covered CHCs generally or were condition-specific (e.g., chronic pain, depression, or asthma). Whereas reviews found an association between a range of CHCs (CHCs generally, cystic fibrosis, hemophilia A, end-stage renal disease (pre-transplant), end-stage kidney disease (pre-transplant), spina bifida, congenital heart disease, orofacial clefts, mental disorders, depression, and chronic pain) and academic attainment, and though it was widely hypothesized that absence was a mediator in these associations, only 7 of 441 studies tested this, and all findings show no evidence of absence mediation. Conclusion CHCs are associated with lower academic attainment, but we found limited evidence of whether school absence mediates this association. Policies that focus solely on reducing school absence, without adequate additional support, are unlikely to benefit children with CHCs. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285031, identifier: CRD42021285031.
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Affiliation(s)
- Matthew A. Jay
- UCL GOS Institute of Child Health, Population, Policy and Practice Research and Teaching Department, University College London, London, United Kingdom
| | - David Sanders-Ellis
- UCL Institute of Education, Social Research Institute, University College London, London, United Kingdom
| | - Ruth Blackburn
- UCL Institute of Health Informatics, University College London, London, United Kingdom
| | - Jessica Deighton
- The Evidence Based Practice Unit, University College London and Anna Freud Centre for Children and Families, London, United Kingdom
| | - Ruth Gilbert
- UCL GOS Institute of Child Health, Population, Policy and Practice Research and Teaching Department, University College London, London, United Kingdom
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Ruiz Nishiki M, Cabecinha M, Knowles R, Peters C, Aitkenhead H, Ifederu A, Schoenmakers N, Sebire NJ, Walker E, Hardelid P. Establishing risk factors and outcomes for congenital hypothyroidism with gland in situ using population-based data linkage methods: study protocol. BMJ Paediatr Open 2022; 6:e001341. [PMID: 36053651 PMCID: PMC8969044 DOI: 10.1136/bmjpo-2021-001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/05/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION There has been an increase in the birth prevalence of congenital hypothyroidism (CH) since the introduction of newborn screening, both globally and in the UK. This increase can be accounted for by an increase in CH with gland in situ (CH-GIS). It is not known why CH-GIS is becoming more common, nor how it affects the health, development and learning of children over the long term. Our study will use linked administrative health, education and clinical data to determine risk factors for CH-GIS and describe long-term health and education outcomes for affected children. METHODS AND ANALYSIS We will construct a birth cohort study based on linked, administrative data to determine what factors have contributed to the increase in the birth prevalence of CH-GIS in the UK. We will also set up a follow-up study of cases and controls to determine the health and education outcomes of children with and without CH-GIS. We will use logistic/multinomial regression models to establish risk factors for CH-GIS. Changes in the prevalence of risk factors over time will help to explain the increase in birth prevalence of CH-GIS. Multivariable generalised linear models or Cox proportional hazards regression models will be used to assess the association between type of CH and school performance or health outcomes. ETHICS AND DISSEMINATION This study has been approved by the London Queen Square Research Ethics Committee and the Health Research Authority's Confidentiality Advisory Group CAG. Approvals are also being sought from each data provider. Obtaining approvals from CAG, data providers and information governance bodies have caused considerable delays to the project. Our methods and findings will be published in peer-reviewed journals and presented at academic conferences.
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Affiliation(s)
- Milagros Ruiz Nishiki
- UCL Great Ormond Street Institute of Child Health Population Policy and Practice, London, UK
| | - Melissa Cabecinha
- Institute of Child Health, UCL, London, UK
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Rachel Knowles
- Life Course Epidemiology and Biostatistics, University College London, London, UK
| | - Catherine Peters
- Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Helen Aitkenhead
- Department of Chemical Pathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Adeboye Ifederu
- Department of Chemical Pathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Nadia Schoenmakers
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| | - Neil J Sebire
- Paediatric Pathology, Great Ormond Street Hospital for Children, London, UK
| | | | - Pia Hardelid
- UCL Great Ormond Street Institute of Child Health Population Policy and Practice, London, UK
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Glinianaia SV, McLean A, Moffat M, Shenfine R, Armaroli A, Rankin J. Academic achievement and needs of school-aged children born with selected congenital anomalies: A systematic review and meta-analysis. Birth Defects Res 2021; 113:1431-1462. [PMID: 34672115 PMCID: PMC9298217 DOI: 10.1002/bdr2.1961] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/21/2021] [Indexed: 11/09/2022]
Abstract
Children with congenital anomalies have poorer intellectual and cognitive development compared to their peers, but evidence for academic achievement using objective measures is lacking. We aimed to summarize and synthesize evidence on academic outcomes and special education needs (SEN) of school‐aged children born with selected major structural congenital anomalies. Electronic databases (MEDLINE, EMBASE, Scopus, PsycINFO, CINAHL, ProQuest Natural Science and Education Collections), reference lists and citations for 1990–2020 were systematically searched. We included original‐research articles on academic achievement in children with non‐syndromic congenital anomalies that involved school test results, standardized tests and/or SEN data. Random‐effects meta‐analyses were performed to estimate pooled mean test scores in mathematics and/or reading where possible and pooled odds ratios (ORs) for SEN in children with severe congenital heart defects (CHDs) and children with orofacial clefts (OFCs). Thirty‐nine eligible studies (n = 21,066 children) were synthesized narratively. Sixteen studies were included in meta‐analyses. Children with non‐syndromic congenital anomalies were at a higher risk of academic underachievement than controls across school levels. Children with severe CHD (pooled OR = 2.32, 95% CI: 1.90, 2.82), and children with OFC (OR = 1.38 (95% CI: 1.20, 1.57), OR = 3.07 (95% CI: 2.65, 3.56), and OR = 3.96 (95% CI: 3.31, 4.72) for children with cleft lip, cleft palate and cleft lip/palate, respectively) had significantly higher ORs for SEN than controls. Children with non‐syndromic congenital anomalies underperform academically and have higher SEN rates compared to their peers. Early monitoring and development of differential SEN are important to promote academic progress in these children.
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Affiliation(s)
- Svetlana V Glinianaia
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ashleigh McLean
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Malcolm Moffat
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rebekka Shenfine
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Annarita Armaroli
- Center for Clinical and Epidemiological Research, University of Ferrara, Ferrara, Emilia-Romagna, Italy
| | - Judith Rankin
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
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Gjerdevik M, Lie RT, Haaland ØA, Berg E, Feragen KB, Sivertsen Å. Isolated oral clefts and school grades: population-based cohort study from Norway. BMJ Open 2021; 11:e046944. [PMID: 34610928 PMCID: PMC8493916 DOI: 10.1136/bmjopen-2020-046944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To compare school grades of adolescents in Norway born with isolated cleft with those of their unaffected peers. DESIGN Population-based cohort study. SETTING Norway. PATIENTS A total of 347 419 individuals born in Norway between 1986 and 1992, including 523 isolated cleft cases which were identified using data from Norway's two treatment centres. Individuals were followed from birth through compulsory school. MAIN OUTCOME MEASURES Grade point average (GPA) from middle school graduation (around the age of 16). Specific subject grades were also investigated. RESULTS Using a grade scale from 1-6, the observed mean GPA for the reference group was 3.99. Both cleft lip only (CLO) and cleft lip with cleft palate (CLP) had a mean GPA similar to the reference group (adjusted GPA differences from the reference with 95% CIs of 0.06 (-0.04 to 0.16) and -0.08 (-0.19 to 0.03), respectively). Cleft palate only (CPO) had a marginally lower GPA (adjusted GPA difference: -0.18 (-0.28 to -0.08)). These comparisons were consistent across specific subjects. Overall, the evidence suggests a larger difference in GPA between cases and controls in males compared with females. Females with CLO even had a higher estimated GPA than females in the reference group (adjusted GPA difference: 0.19 (0.013 to 0.36)). Grades were similar regardless of laterality of cleft lip (CLO or CLP). CONCLUSION In Norway, individuals born with isolated CLO or CLP did not have lower average school grades when graduating from middle school. Individuals born with isolated CPO had marginally lower grades.
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Affiliation(s)
- Miriam Gjerdevik
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Hordaland, Norway
| | - Rolv Terje Lie
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Hordaland, Norway
| | - Øystein Ariansen Haaland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Hordaland, Norway
| | - Erik Berg
- Department of Plastic and Reconstructive Surgery, Southern Norway Hospital, Arendal, Norway
| | | | - Åse Sivertsen
- Department of Plastic Surgery and Norwegian Quality Registry of Cleft Lip and Palate, Haukeland University Hospital, Bergen, Norway
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Conrad AL, Albert M, Crerand CE, Crilly Bellucci C, Heppner CE, Sheikh F, Woodard S, Kapp-Simon KA. Retrospective Evaluation of Number of Surgeries and Parent Ratings of Academic and Behavioral Functioning Among Children With Isolated Oral Clefts. Cleft Palate Craniofac J 2020; 58:1294-1303. [PMID: 33380226 DOI: 10.1177/1055665620982807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate possible relationships between number of surgeries and parent ratings of academic functioning among children with isolated oral clefts. DESIGN Multicenter, retrospective cohort study including structured interviews, questionnaires, and chart reviews. SETTING Completion of questionnaires occurred during clinical visits at 6 different cleft centers across North America. PARTICIPANTS Parents of 285 children with isolated clefts of the lip and/or palate, aged 8 to 10 years old, participated in structured interviews and completed questionnaires regarding the academic and behavioral functioning of their children. MAIN OUTCOME MEASURES Parent interview and medical chart review of number of surgeries to date and parent ratings on the Adaptive Behavior Assessment System, Third Edition-Functional Academics Scale (ABAS-FA) and Child Behavior Checklist (CBCL) Total Competency Scale. RESULTS Parent ratings of ABAS-FA were at or above normative expectations, while ratings across CBCL Competency Scales were lower than normative expectations. Socioeconomic status (SES), age, and race were consistent predictors of parent ratings (higher SES, older age, and Caucasian race were associated with better functioning). Number of surgeries did not add significantly to academic ratings but did significantly contribute to ratings of social and activity participation. Patients with more surgeries were rated with lower functioning in these domains. CONCLUSIONS Findings do not support a connection between number of surgeries and later ratings of academic functioning but do support a connection to social and activity involvement. Recommendations for conducting direct studies of the connection between surgeries and academic functioning as well as clinical considerations for surgeries and impact on social and activity involvement are discussed.
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Affiliation(s)
- Amy L Conrad
- Division of Developmental and Behavioral Pediatrics, The Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Meredith Albert
- Cleft-Craniofacial Clinic, Departments of Psychology and Pediatric Plastic Surgery, Shriners Hospitals for Children-Chicago, IL, USA.,Craniofacial Center, Department of Surgery, University of Illinois at Chicago, IL,USA
| | - Canice E Crerand
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Departments of Pediatrics and Plastic Surgery, The Ohio State University College of Medicine, OH, USA
| | - Claudia Crilly Bellucci
- Cleft-Craniofacial Clinic, Departments of Psychology and Pediatric Plastic Surgery, Shriners Hospitals for Children-Chicago, IL, USA
| | - Celia E Heppner
- Fogelson Plastic and Craniofacial Surgery Center, Children's Health/Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Farah Sheikh
- Division of Plastic and Reconstructive Surgery, the Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Kathleen A Kapp-Simon
- Cleft-Craniofacial Clinic, Departments of Psychology and Pediatric Plastic Surgery, Shriners Hospitals for Children-Chicago, IL, USA.,Craniofacial Center, Department of Surgery, University of Illinois at Chicago, IL, USA
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