Female and Male Differences in Academic Achievement in Individuals With Cleft: A Population-Based Register Study

Screening for Academic Risk Among Students With Cleft Lip and/or Palate: Patterns of Risk and Qualities of Effective Tools

This study evaluated the effectiveness of academic screening measures in relation to parent-reported diagnoses.

Multicenter, retrospective cohort study including structured interviews, questionnaires, and chart reviews.

Six North American cleft centers.

Children (n = 391) with cleft lip and/or palate, ages 8 to 10 years of age (192 male) and their guardians were recruited during regular clinic visits.

Parent and child ratings on the Pediatric Quality of Life Inventory (PedsQL) School Scale, child report on CleftQ School Scale, parent report on the Adaptive Behavior Assessment System-Third Edition Functional Academics (ABAS-FA) Scale and Child Behavior Checklist (CBCL) School Competency Scale, parent interview, and medical chart review.

Risk for concerns ranged from 12% to 41%, with higher risk reflected on the CBCL-SC compared to other measures. Males with cleft palate were consistently at the highest risk. Only 9% of the sample had a parent-reported diagnosis of a learning or language disability. Ratings from the ABAS-FA and CBCL-SC had the highest utility in identifying those with language and/or learning concerns.

As cleft teams work to develop standardized batteries for screening and monitoring of patients, it is important to evaluate the effectiveness of measures in identifying those at highest risk. When screening for language and learning disorders, questions related to potential academic struggles, such as increased school effort or increased school distress, are most useful. Referrals for follow-up evaluation are recommended for those identified at high risk.

Being Normal yet Different: A Qualitative Study on the Dualistic Experience of Living With Unilateral Cleft Lip and Palate

The aim of the present study was to describe the experiences of young adults living with cleft lip and palate (CLP) and to explore potential gender differences.

A descriptive qualitative study was designed involving semi-structured interviews. The interviews were analyzed using qualitative content analysis, as described by Graneheim and Lundman.

A total of 9 women and 8 men, aged 22 to 26 years with UCLP.

The main theme identified was: the duality of living with a cleft-being normal yet different, and 2 subcategories: "My cleft and me" and "My cleft and the World." The participants described themselves as normal yet different, both in relation to themselves and in relation to others. They also stated that gender norms regarding appearance affected their lives and how they saw the cleft.

This study adds to the growing body of qualitative research on CLP. It highlights the dualistic experiences of feeling normal and different at the same time. The interviews indicated that this dualism was based on context and gender, showing the psychological complexity of an individual. The clinical implications of this study emphasizes the need of a person-centered care approach in the cleft care setting where the clinicians are aware of the potential dualistic experience that also may differ over time that individuals with cleft can experience. This can also help clinicians better understand and help patients reduce distress and strengthen positive coping mechanisms.

Isolated oral clefts and school grades: population-based cohort study from Norway

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.

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.

Brain structure and neural activity related to reading in boys with isolated oral clefts

Background: The purpose of this study was to evaluate brain structure and function in participants with iCL/P and unaffected controls. Effects of cleft presence and reading status (average vs impaired) were evaluated.Methods: Males, ages 8-11 years old, including 26 with iCL/P and 57 unaffected peers were recruited and coded for reading status (average vs impaired). All participants underwent a volumetric and task-based functional MRI. Volumes and significant regions of activation during the decoding task were obtained. Main effects of cleft and reading status, and their interaction were evaluated.Results: Participants with iCL/P had significantly increased frontal gray matter volume (associated with average reading) and occipital gray and white matter volume (associated with impaired reading). Impaired readers with iCL/P had a distinctive activation pattern in visual association and motor regions relative to other groups.Conclusions: Findings suggest that increases in frontal gray matter volume may be associated with effective compensation during reading, while posterior increases in occipital volume may be associated with ineffective compensation for participants with iCL/P. These patterns were different from idiopathic dyslexia. Further work in a larger sample is needed to determine if these differences are associated with cleft type and with sex.Abbreviations: iCL/P (isolated cleft lip and/or palate); iCL (isolated cleft lip only); iCLP (isolated cleft lip and palate); iCP (isolated cleft palate only); uAR (unaffected average reader); uIR (unaffected impaired reader); cAR (average reader with iCL/P); cIR (impaired reader with iCL/P).

Retrospective Evaluation of Number of Surgeries and Parent Ratings of Academic and Behavioral Functioning Among Children With Isolated Oral Clefts

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.

Cleft lip and palate: Care configuration, national registration, and research strategies

A child born with a cleft lip and palate will face 20 years or more of hospital care and surgery. This is a global problem with approximately 10 million people affected worldwide. Various models of care exist around the condition, and the best configurations of services within an economy need to be optimized. We provide examples of how centralized care can improve outcomes and provide an opportunity to establish national registries, and then emphasize the opportunities for building research platforms of relevance. The default of any cleft service should be to centralize care and enable cleft teams with a sufficient volume of patients to develop proficiency and measure the quality of outcomes. The latter needs to be benchmarked against the better centers in Europe. Two areas of concern for those with cleft are morbidity/mortality and educational attainment. These two issues are placed in context within the literature and wider approaches using population genetics. Orthodontists have always played a key role in developing these initiatives and are core members of cleft teams with major responsibilities for these children and their families.

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Cleft lip and palate affects about 10 million people worldwide.

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Centralised care can improve outcome and establish national registries.

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Orthodontists have played a key role in developing these initiatives.

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No strong evidence of an association between clefting and cancer.

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Proper care can positively influence lives of children born with a cleft.

Educational Attainment of Children Born with Unilateral Cleft Lip and Palate in the United Kingdom

Objective:

This study evaluated association between functional outcomes in children born with unilateral cleft lip and palate (UCLP) and educational attainment.

Design:

Cleft Care UK (CCUK) was a United Kingdom (UK) wide cross-sectional study.

Setting:

UK Cleft Teams (data collected from all UK sites providing centralized cleft services).

Patients, Participants:

Five-year olds born with nonsyndromic UCLP (n = 268).

Main Outcome Measure(s):

National tests for educational attainment Key Stage 1 (KS1) undertaken by children at age 7 were linked to CCUK data to describe differences in educational attainment. Associations between functional outcomes and KS1 results were evaluated using regression analysis. We adjusted for birth month, gender, and an area-based measure of socioeconomic status.

Results:

Data were available for 205 children with UCLP. These children scored lower than national average (NA) scores across all subject areas, with a 0.62 lower score observed in the Average Point Score (APS; P = .01). There was association between being in a lower category for a cleft related outcomes and poorer KS1 results, with a trend for poorer attainment with higher numbers of poor functional outcomes. Those with 3 or more poor outcomes had a −2.26 (−3.55 to −0.97) lower APS compared to those with 0 to 1 poor outcomes.

Conclusions:

Children born with UCLP have poorer educational attainment at age 7 across all subject areas though differences were modest. Children with poor functional outcomes at age 5 had worse educational outcomes age 7. Improvements in functional outcomes could enhance educational outcomes.

On the role of the frontal projection in videoradiography of velopharynx in decision-making for a velopharyngeal flap plasty in patients with cleft palate

Despite uneventful primary surgery, patients with cleft palate may experience velopharyngeal insufficiency (VPI) and hypernasal speech. Videoradiography of velopharynx is a commonly used method to visualize velopharyngeal function and a velopharyngeal flap is often used to counteract VPI. The aim of this study was to investigate whether the frontal projection on videoradiography plays a role in the decision-making about velopharyngeal flap surgery, or possibly the width and orientation of the flap. A secondary aim was to evaluate the effect of the flap in improving velopharyngeal function. Between 2007 and 2016, 75 patients had received a flap at our department. During the same period of time, 41 patients who had undergone videoradiography did not receive a flap. Medical records, particularly regarding speech assessments, videoradiography statements and operating records, were scrutinised to seek information about the factors leading up to the decision about whether or not to perform a flap. In only one instance, reduced lateral pharyngeal wall movement found on the frontal projection was clearly taken into account when deciding to refrain from performing a velopharyngeal flap. Only a slight agreement was found between pre-operative speech assessment and findings in videoradiography. Hypernasality was reduced by flap surgery in 97% of the patients. We conclude the frontal projection of the videoradiographic examination seems to have no crucial role in the decision-making on performing a velopharyngeal flap or not in patients with cleft palate. Even with reduced lateral pharyngeal wall movement, a velopharyngeal flap effectively reduces hypernasality and VPI.

Are predictors of reading impairment in isolated cleft similar to those in idiopathic dyslexia?

Children with isolated cleft of the lip and/or palate (iCL/P) are at increased risk for reading impairment. The purpose of this study was to evaluate the impact of early risk factors (hearing, speech, and early literacy) on reading performance compared to unaffected participants with average (uAR) and impaired (uIR) reading. Reading achievement and early literacy skills were evaluated across three groups (27 iCL/P, 32 uAR, and 33 uIR). All participants were males, ages 8-11 years old. Those with history of head trauma/injury or major medical/mental health conditions were excluded. Group differences in achievement and early literacy skills were evaluated with ANCOVAs. Participants with impaired reading achievement (at or below 25th Percentile) were identified. Medical record reviews for participates with iCL/P were conducted and audiology and speech ratings recorded. Correlations were calculated between achievement, early literacy, hearing, and speech. Participants with iCL/P had significantly elevated risk for reading impairment (37%); this risk differed by cleft type (0% iCL, 55% iCLP, and 60% iCP). Achievement for participants with iCP was similar to the uIR group. Early literacy risk resulted in lower achievement scores for both iCL/P and unaffected participants. History of inadequate hearing and speech did not significantly impact early literacy or achievement measures. There is a high risk of reading impairment for children with iCL/P-highest for those with iCLP and iCP. Early literacy predictors of reading outcome are similar for iCL/P and idiopathic dyslexia. Current screening and intervention methods are supported.

Associations Between Hypernasality, Intelligibility, and Language and Reading Skills in 10-Year-Old Children With a Palatal Cleft

Background:

This study investigated the associations between hypernasality and intelligibility, and language and reading skills in 10-year old children with a cleft palate ± lip.

Design:

Cross-sectional data collected during routine assessments of speech and language in a centralized treatment setting.

Participants:

Children aged 10, born with cleft palate ± lip from 4 birth cohorts (N = 123).

Outcome Measures:

Hypernasality and intelligibility: Swedish Articulation and Nasality Test-N; language: Language 6-16 (Sentence recall, Serial recall, Vocabulary); reading: word chain test and reading comprehension test.

Results:

A total of 71.3% of the children had no occurrence of hypernasality and 82.8% had intelligibility scores within the normal range. For all children with hypernasality and intelligibility within the normal range, reading and language scores were also within normal ranges. Children with presence of hypernasality had significantly lower language skills, with mean scores within the lower normal range. Children with reduced intelligibility had lower scores on reading comprehension.

Conclusions:

The findings highlight a possible association between hypernasality and language skills, and intelligibility and reading skills. Cleft teams should consider routine assessments of language and reading skills in children with speech impairment, in order to identify potential needs for intervention as early as possible.

Receptive and expressive language characteristics of school-aged children with non-syndromic cleft lip and/or palate

BACKGROUND

Research investigating language skills in school-aged children with non-syndromic cleft lip and/or palate is sparse. Past studies focus on younger populations, lack key comparisons to demographically matched control cohorts or explore language as a component of broader academic skills. Trends of existing studies suggest that affected children may perform at a lower level compared with typically developing peers.

AIMS

To examine the receptive and expressive language skills of middle-school-aged children with non-syndromic cleft lip and palate (CLP) and cleft palate only (CP). Additionally, to explore the language skills of children with clefts compared with a non-cleft control group.

METHODS & PROCEDURES

Thirty-seven participants with orofacial clefts (aged 7;1-14;1 years) participated in the study: 19 with CLP (10 males; 9 females) and 18 with CP (8 males; 10 females). A non-cleft comparison group consisted of 129 individuals matched on age, sex and maternal education level. Participants completed formal language (Clinical Evaluation of Language Fundamentals, Fourth Edition) and non-verbal intellectual measurements (Wechsler Abbreviated Scale of Intelligence-WASI). Demographic and developmental information was obtained via parental interview. Further clinical details (e.g., surgery; hearing status) were extracted from patient medical files. Cleft and non-cleft language and non-verbal IQ outcomes were reported separately. Language outcomes were then compared between groups.

OUTCOMES & RESULTS

Participants with clefts achieved core (mean = 103.31, standard deviation (SD) = 10.31), receptive (mean = 102.51, SD = 11.60) and expressive (mean = 102.89, SD = 12.17) language index scores within the normative average range. A total of 14.1% and 17.8% of the cleft and non-cleft groups respectively had impairment (i.e., ≥ 1.25 SD below the mean) in one or more language domains. No significant differences were found in the three language index scores between cleft and non-cleft groups.

CONCLUSIONS & IMPLICATIONS

This study is the first formally to examine language skills alongside non-verbal IQ in school-aged children with clefts compared with a large matched non-cleft population. Results suggest that health professionals should evaluate each child as they present and not assume that a child with non-syndromic CLP or CP will also have co-occurring language difficulties. Where language falls in the average range, these skills can be harnessed to support areas of difficulty often associated with orofacial clefting, such as speech.