Academic Achievement Among Children With Nonsyndromic Orofacial Clefts : A Population-Based Study

Socioeconomic Deprivation Detrimentally Influences Language Outcomes in Toddlers With Cleft Palate

PURPOSE

The purpose of this study was to examine the influence of socioeconomic deprivation on language and developmental outcomes in toddlers with cleft palate with or without cleft lip (CP ± L). Other factors known to influence language outcomes were also considered, including home language history, history of hearing problems, syndromic diagnoses, and sex.

METHOD

A multicenter, cross-sectional study design was conducted. Data for 566 16-month-old toddlers with CP ± L were collected from 17 outpatient cleft palate clinics located throughout the United States. Outcome measures included the MacArthur-Bates Communicative Development Inventories, LENA Developmental Snapshot, age at first word as reported by the caregiver, and the Ages and Stages Questionnaires-Third Edition (ASQ-3). Multivariable linear or logistic regression was used to determine the influence of socioeconomic deprivation, as measured by the Area Deprivation Index, on language and developmental outcomes.

RESULTS

Greater socioeconomic deprivation significantly predicted poorer language outcomes in toddlers with CP ± L, including receptive vocabulary words (p = .02), expressive vocabulary words (p = .02), and late-developing gestures (p = .02). Additionally, toddlers from less affluent neighborhoods produced their first words significantly later than their counterparts living in more affluent areas (p < .01). Lower maternal education levels predicted significantly increased risk for problem solving delays (p < .01), and patients with subsidized insurance were at significantly increased risk for personal-social delays on the ASQ-3 (p < .01).

CONCLUSIONS

Children with CP ± L are susceptible to developmental delays associated with socioeconomic deprivation. These findings have implications for identifying a child's individual risk factors for developmental language disorders when conducting speech-language assessments. Future study should examine how inequities in care can be mitigated and addressed.

Academic achievement at ages 11 and 16 in children born with congenital anomalies in England: A multi-registry linked cohort study

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.

A protocol for a randomized-controlled trial to investigate the effect of infant sign training on the speech-language development in young children born with cleft palate

BACKGROUND

Children born with a cleft palate with or without cleft lip (CP ± L) are known to be at risk for speech-language disorders that impact educational and social-emotional growth. It is hypothesized that speech-language intervention delivered before the age of 3 years could decrease the impact of CP ± L on speech-language development. Infant sign training in combination with verbal input expands the natural communication of young children including multimodal speech-language input (i.e., verbal and manual input) via caregivers who act as co-therapists.

AIMS

To determine the effectiveness of infant sign training in 1-year-old children with CP ± L by comparing different interventions.

METHODS & PROCEDURES

This is a two-centre, randomized, parallel-group, longitudinal, controlled trial. Children are randomized to either an infant sign training group (IST group), a verbal training group (VT group) or no intervention control group (C group). Caregivers of children who are assigned to the IST group or VT group will participate in three caregiver training meetings to practise knowledge and skills to stimulate speech-language development. Outcome measures include a combination of questionnaires, language tests and observational analyses of communicative acts.

OUTCOMES & RESULTS

It is hypothesized that speech-language development of children with CP ± L will benefit more from IST compared with VT and no intervention. Additionally, the number and quality of communicative acts of both children and caregivers are expected to be higher after IST.

CONCLUSIONS & IMPLICATIONS

This project will contribute to the development of evidence-based clinical practice guidelines regarding early speech-language intervention in children with CP ± L under the age of 3 years.

WHAT THIS PAPER ADDS

What is already known on the subject Children with CP ± L are known to be at risk for speech-language delays that impact educational and social emotional growth. Given the limited scientific prove of the impact of early speech-language intervention, no standardized clinical practice guidelines are available yet for children with CP ± L under the age of 3 years. Early intervention in this population mostly focuses on improving verbal input via caregivers or professionals without including a multimodal language input. A growing scientific interest has been seen in the use of infant signs to support speech-language development and caregiver-child interaction in typically developing children and children with developmental delays. What this study adds to existing knowledge No evidence is yet available for the effectiveness and feasibility of early intervention based on infant sign training in combination with verbal input to improve speech-language skills in young children with CP ± L. The current project will investigate the effect of infant sign training on the speech-language development in this population. Outcome measures are compared with those of two control groups: verbal training only and no intervention. It is hypothesized that infant signs may support the intelligibility of verbal utterances produced by children with CP ± L. Improving children's intelligibility may increase the opportunities for these children to engage in early, frequent and high-quality interactions with their caregivers resulting in a richer social and linguistic environment. As a result, infant sign training may result in better speech-language skills compared with the control interventions. What are the potential or actual clinical implications of this work? If providing early intervention based on infant sign training is effective, there is the potential for improved speech-language outcomes in early childhood, resulting in increased speech intelligibility, increased well-being of the child and family and less need for speech-language therapy on the long-term. This project will contribute to the development of evidence-based clinical practice guidelines regarding early speech-language intervention in children with CP ± L under the age of 3 years.

The Brain in Oral Clefting: A Systematic Review With Meta-Analyses

Background

Neuroimaging of individuals with non-syndromic oral clefts have revealed subtle brain structural differences compared to matched controls. Previous studies strongly suggest a unified primary dysfunction of normal brain and face development which could explain these neuroanatomical differences and the neuropsychiatric issues frequently observed in these individuals. Currently there are no studies that have assessed the overall empirical evidence of the association between oral clefts and brain structure. Our aim was to summarize the available evidence on potential brain structural differences in individuals with non-syndromic oral clefts and their matched controls.

Methods

MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Web of Science and Embase were systematically searched in September 2020 for case-control studies that reported structural brain MRI in individuals with non-syndromic oral clefts and healthy controls. Studies of syndromic oral clefts were excluded. Two review authors independently screened studies for eligibility, extracted data and assessed risk of bias with the Newcastle-Ottawa Scale. Random effects meta-analyses of mean differences (MDs) and their 95% confidence intervals (95% CI) were performed in order to compare global and regional brain MRI volumes.

Results

Ten studies from 18 records were included in the review. A total of 741 participants were analyzed. A moderate to high risk of bias was determined for the included studies. The cerebellum (MD: -12.46 cm3, 95% CI: -18.26, -6.67, n = 3 studies, 354 participants), occipital lobes (MD: -7.39, 95% CI: -12.80, -1.99, n = 2 studies, 120 participants), temporal lobes (MD: -10.53 cm3, 95% CI: -18.23, -2.82, n = 2 studies, 120 participants) and total gray matter (MD: -41.14 cm3; 95% CI: -57.36 to -24.92, n = 2 studies, 172 participants) were significantly smaller in the cleft group compared to controls.

Discussion

There may be structural brain differences between individuals with non-syndromic oral clefts and controls based on the available evidence. Improvement in study design, size, methodology and participant selection could allow a more thorough analysis and decrease study heterogeneity.

Academic achievement and needs of school-aged children born with selected congenital anomalies: A systematic review and meta-analysis

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.

Exploratory Qualitative Analysis of Early Literacy Engagement in Latinx Parents of a Child With a Cleft

ABSTRACT

Literacy interventions are needed for children born with orofacial clefts, particularly for Latinx children who may experience multiple risk factors. To collect formative data for intervention design, focus groups and interviews were completed with 18 Latinx parents of children ages 13 to 49 months with orofacial clefts. Interviews focused on literacy experiences and practices. Six themes were identified through inductive qualitative analysis: child reading skills were highly valued; parents were motivated to improve on their childhood reading experiences; bilingualism was a goal for all parents; parents noted challenges in building child reading skills; reading engagement was broadly defined; and impact of cleft diagnosis was wide-reaching. Implications for intervention include a bilingual strength-based approach incorporating cleft-specific speech concerns, play, parallel online programming, behavioral strategies, and social support options. Use of telephone and online intervention with mailed materials can also help address family resource and time limitations.

Prevalence of Reading Difficulties in 9- to 10-Year Old Children in Sweden Born With Cleft Palate

OBJECTIVE

To investigate the prevalence of reading difficulties in children born with cleft palate at ages 9 and 10 in Sweden.

DESIGN

Using a cross-sectional design, a parental questionnaire assessing dyslexia-like reading difficulties (Short Dyslexia Scale, SDS) was administered together with separate questions regarding background data.

PARTICIPANTS

Families with a child born with overt cleft palate with or without cleft lip in 4 regions of Sweden. A total of 245 families were approached of which 138 families responded. Data from 136 (56%) were complete with information on cleft type and could be analyzed.

RESULTS

Twenty-two percent (95% CI, 15-30) of the whole study group displayed risk for dyslexic reading difficulties on the SDS corresponding to the 7th to 10th percentiles in the population. Children with cleft palate only had a significantly higher prevalence of reading difficulties (37%) compared to children with unilateral cleft palate (19%) and bilateral cleft palate (10%). The frequency of reading difficulties in participants with comorbidity was 32%. Among a subgroup with reported comorbidity in areas of attention, language, and learning problems, there was a 2.5 times higher risk of reading disability compared to participants without this reported comorbidity.

CONCLUSION

The prevalence of reading difficulties in the cleft palate population was higher than in the general population. Results showed that co-occurring difficulties were common in the cleft group and that reading difficulties often appear together with other, co-occurring neurodevelopmental difficulties.

Home Language Environment of Children With Orofacial Clefts as a Target for Intervention

OBJECTIVE

To evaluate the home language environment (HLE) in children with orofacial clefts as a potential modifiable target for language and literacy intervention.

DESIGN

Feasibility study examining longitudinal trends in HLE and responses to parent-focused literacy intervention.

SETTING

Tertiary care children's hospital.

PARTICIPANTS

HLE data were collected for 38 children with orofacial clefts between ages 7 and 23 months. Twenty-seven participants received parent-focused literacy intervention.

INTERVENTIONS

Reach Out and Read, a literacy intervention, was introduced during a clinic visit. To assess response, participants were randomized to age at intervention (9, 18, or 24 months).

MAIN OUTCOME MEASURES

Primary outcome measures included measurements from recordings in the home language environment of adult word count, child vocalizations, and conversational turns.

RESULTS

Baseline (preintervention) results showed lower adult word count and conversational turns for caregivers and children with cleft lip and palate, as well as for those from lower socioeconomic groups. After the literacy intervention was introduced, this cohort showed increasing measures of child and caregiver vocalizations, particularly when introduced at 18 months.

CONCLUSIONS

Although these results are preliminary, findings suggest that HLE characteristics vary as a function of children's cleft type as well as family socioeconomic status. Further, our caregiver-focused literacy intervention was feasible and resulted in short-term improvements in HLE. This is the first study to document HLE as a target for intervention in children with oral clefts. These findings support further research on HLE and caregiver-focused intervention to improve language/literacy outcomes for children with oral clefts.

Mothers' Reactions to Seeing Their Children With Cleft for the First Time: A Qualitative Study in Ghana

OBJECTIVE

Studies on the etiology, treatment, and psychosocial effects of clefts among children born with the condition abound. Limited studies, however, have focused on the mothers of these children. This study aimed to explore the immediate reaction of mothers to seeing their children born with a cleft for the first time. Mothers' knowledge of cleft and the support systems available to them were also explored.

DESIGN

Employing a qualitative description approach, data were collected through face-to-face individual in-depth interviews using a semistructured interview guide.

PARTICIPANTS AND RESEARCH CONTEXT

Using the purposive and snowballing sampling techniques, 12 mothers who sought treatment for their children with cleft at a Tertiary health facility in Ghana were selected. The ethical principles outlined in the Declaration of Helsinki were followed during data collection. The data obtained were analyzed applying the technique of thematic analysis.

RESULTS

Mothers' first time reaction to seeing their child born with a cleft was that of sadness, worry, and disappointment. Knowledge of cleft among the mothers was low with most of them knowing more about the condition only after the delivery of their child with a cleft. Mothers received support from family members, health care practitioners, nongovernmental organizations, and their partners.

CONCLUSION

To reduce the psychosocial and emotional effects resulting from mothers giving birth to a child with a cleft, information on the condition should be made available to mothers and primary caregivers early enough.

Linguistic and auditory processing skills in non-syndromic children with cleft palate: A scoping review

BACKGROUND

Cleft lip and/or palate (CL/P) is the most common congenital craniofacial condition. Children born with CL/P are at increased risk of persistent speech difficulties related to velopharyngeal incompetence (VPI) and compensatory articulation problems. It has also been reported that they achieve poorer results academically than their peers. There is a further body of evidence to suggest delayed language skills. These potentially related outcomes are often reported separately.

AIM

To review published and unpublished research into the nature of difficulties related to spoken and written language across all non-syndromic cleft diagnoses. To review any evidence of associations between comorbidities.

METHOD

A scoping review was carried out in October 2016 and updated in June 2019 following published methodology (Arksey & O'Malley, 2005; Levac et al. 2010).

RESULTS

A search of the literature over the two time points found 38 papers in total. Three main themes were found: oral language skills, reading and auditory processing difficulties.

CONCLUSIONS

There is evidence of early language delay in children born with CL/P. Evidence of persistent oral language problems is less conclusive. Many studies have reported scores within the average range for language, auditory processing and reading but poorer outcomes when compared to non-cleft control groups. However, studies have used a range of outcome measures, making comparisons difficult. Moreover there is no clear evidence how these difficulties might relate to speech outcomes or educational achievement and no comparison to other populations with speech, language and communication needs (SLCN).

Word Reading in Boys With Isolated Oral Clefts: Comparison to Unaffected Average and Dyslexic Readers Using the Dual-Route Model

OBJECTIVE

To examine word reading performance between boys with isolated cleft lip and/or palate (iCL/P), unaffected average reading (uAR), and unaffected impaired reading (uIR), using the dual-route model.

DESIGN

Case/control study.

SETTING

University children's hospital.

PARTICIPANTS

Males, between the ages of 8 to 11 years, with iCL/P (n = 26), uIR (n = 33), or uAR (n = 28).

METHODS

Single word reading and achievement were evaluated. Analyses of variance and analyses of covariance evaluated group differences in achievement. Medical records were reviewed for iCL/P participants for audiology and speech history. Spearman ρ correlations were calculated between hearing, speech, and reading achievement for the iCL/P group.

MAIN OUTCOME MEASURE(S)

Reading performance was evaluated using select subscales from the Woodcock Johnson Reading Mastery Test, 3rd Edition and the Test of Orthographic Competence.

RESULTS

Participants with iCL/P had higher than expected rates of reading impairment, differing across cleft type (0% iCL, 50% isolated cleft lip and palate [iCLP], 71.4% isolated cleft palate only [iCP]). On measures of word reading accuracy, iCL/P participants outscored uIR participants, with uAR participants scoring the highest. This pattern was specific to nonlexical reading tasks. Participants in the uAR and iCL/P groups outscored uIR participants on lexical tasks, with no significant differences between uAR and iCL/P. Evaluation of speech and hearing revealed no significant relationship to single word reading or achievement measures in the iCL/P group.

CONCLUSIONS

Boys with iCL/P are at a higher risk of reading impairments, particularly within the iCP subset. Regular screening should be encouraged, with skills from both lexical and nonlexical routes assessed.

Early Speech and Language Development in Children With Nonsyndromic Cleft Lip and/or Palate: A Meta-Analysis

Objective The aim of the study was to conduct a meta-analysis of research examining the early speech and language functioning of young children, birth to age 8;11 (years;months), with nonsyndromic cleft lip and/or palate (NSCL/P) compared to their peers without NSCL/P. Method We conducted a random-effects metaregression using 241 effect sizes from 31 studies comparing 955 young children with NSCL/P to 938 typically developing peers on measures of speech and language functioning. Moderators were sample characteristics (i.e., age, cleft type, publication year, and study location) and measurement characteristics (i.e., speech sample material, language modality and domain, and assessment type). Results Young children with NSCL/P scored significantly lower on measures of speech and language compared to children without NSCL/P. Children with NSCL/P had smaller consonant inventories (standardized mean difference effect size [ESg] = -1.24), less accurate articulation (ESg = -1.13), and more speech errors (ESg = 0.93) than their peers. Additionally, children with NSCL/P had poorer expressive (ESg = -0.57) and receptive (ESg = -0.59) language skills than their peers. Age and assessment type moderated effect sizes for expressive language. As children with NSCL/P aged, their expressive language performance became more similar to their peers. Expressive language effect sizes from parent reports and observational language measures (estimated effect size = -0.74) were significantly lower than those from standardized norm-referenced tests (estimated effect size = -0.45). Conclusions These findings suggest that young children with NSCL/P experience delays relative to their peers across multiple speech and language constructs. Differences between children with NSCL/P and their typically developing peers appear to decrease with age. Supplemental Material https://doi.org/10.23641/asha.11356904.

Neurodevelopmental and Academic Outcomes in Children With Orofacial Clefts: A Systematic Review

CONTEXT

Children with orofacial clefts (OFCs) are reported to have worse neurodevelopmental outcomes than unaffected peers, although study methodologies and findings are highly variable and trends in outcomes by age remain unexplored.

OBJECTIVE

To examine the strength of the evidence and explore trends in neurodevelopment by age.

DATA SOURCES

A systematic review was conducted of studies published from January 1, 1980, through November 3, 2017.

STUDY SELECTION

Studies were independently screened by the authors and included in the review if they met predetermined eligibility criteria: (1) children and/or youth (<25 years) with OFCs were studied, and (2) neurodevelopmental or academic outcomes were included.

DATA EXTRACTION

The authors independently evaluated study quality and extracted outcome data.

RESULTS

Thirty-one studies involving 10 143 patients with OFCs and 2 017 360 controls met eligibility criteria. Although the quality of the studies varied, patients with OFCs consistently performed worse than their peers on neurodevelopmental and academic measures. In infancy, differences were observed on multiple developmental outcomes (eg, cognition, motor skills, and language), and in later childhood and adolescence, differences were manifest on several indicators of academic achievement (eg, use of special education services, grades, and scores on standardized measures).

LIMITATIONS

Heterogeneity in study designs, methods, and outcomes prevented statistical pooling and modeling for meta-analysis.

CONCLUSIONS

Children with OFCs exhibit neurodevelopmental and academic deficits compared with their unaffected peers. Although the nature of these deficits changes with development, differences are observed from infancy through adolescence. Clinicians should monitor neurodevelopment in children with OFCs and support them appropriately.

Special education use in elementary school by children with nonsyndromic orofacial clefts

BACKGROUND

Children with nonsyndromic orofacial clefts (NS OFCs) may require exceptional children's (EC) services for academic delays. We examined EC service use of children with and without NS OFCs in NC in elementary school.

METHODS

We included 559 children with NS OFCs and 6,822 children without birth defects who had NC educational records. We estimated prevalence ratios, trends in enrollment, and characteristics of eligibility classification using descriptive statistics and logistic regression by cleft subtype and race/ethnicity. We estimated the odds of third grade retention by EC enrollment using logistic regression with inverse probability of treatment weights.

RESULTS

Children with NS OFCs were 3.02 (95% CI: 2.50, 3.64) times as likely to receive third grade special education (SE) services compared to unaffected peers. The prevalence odds was highest among children with CL+P (OR: 4.61, 95% CI: 3.49, 6.09) declining by 54% by fifth grade. The prevalence odds of SE for white children was approximately 1.50 times that for African American children in fourth and fifth grades. Approximately 33% of children with NS OFCs within each racial/ethnic group received SE in third grade. African American children were twice as likely to receive services under specific learning disability. Children with NS OFCs receiving EC services were 44% (OR: 0.56; 95% CI: 0.13, 2.38) less likely to be retained in third grade compared to children with NS OFCs who were not receiving services.

CONCLUSIONS

Children with NS OFCs are more likely to receive SE services in elementary school compared to their unaffected peers. The eligibility category differed by racial/ethnic group.