Ventral Frontal Cortex Morphology in Adult Males with Isolated Orofacial Clefts: Relationship to Abnormalities in Social Function

Perceptual Pattern of Cleft-Related Speech: A Task-fMRI Study on Typical Mandarin-Speaking Adults

Congenital cleft lip and palate is one of the common deformities in the craniomaxillofacial region. The current study aimed to explore the perceptual pattern of cleft-related speech produced by Mandarin-speaking patients with repaired cleft palate using the task-based functional magnetic resonance imaging (task-fMRI) technique. Three blocks of speech stimuli, including hypernasal speech, the glottal stop, and typical speech, were played to 30 typical adult listeners with no history of cleft palate speech exploration. Using a randomized block design paradigm, the participants were instructed to assess the intelligibility of the stimuli. Simultaneously, fMRI data were collected. Brain activation was compared among the three types of speech stimuli. Results revealed that greater blood-oxygen-level-dependent (BOLD) responses to the cleft-related glottal stop than to typical speech were localized in the right fusiform gyrus and the left inferior occipital gyrus. The regions responding to the contrast between the glottal stop and cleft-related hypernasal speech were located in the right fusiform gyrus. More significant BOLD responses to hypernasal speech than to the glottal stop were localized in the left orbital part of the inferior frontal gyrus and middle temporal gyrus. More significant BOLD responses to typical speech than to the glottal stop were localized in the left inferior temporal gyrus, left superior temporal gyrus, left medial superior frontal gyrus, and right angular gyrus. Furthermore, there was no significant difference between hypernasal speech and typical speech. In conclusion, the typical listener would initiate different neural processes to perceive cleft-related speech. Our findings lay a foundation for exploring the perceptual pattern of patients with repaired cleft palate.

Articulation-Function-Associated Cortical Developmental Changes in Patients with Cleft Lip and Palate

Cleft lip and palate (CLP) is one of the most common craniofacial malformations. Overall, 40–80% of CLP patients have varying degrees of articulation problems after palatoplasty. Previous studies revealed abnormal articulation-related brain function in CLP patients. However, the association between articulation disorders and cortical structure development in CLP patients remains unclear. Twenty-six CLP adolescents (aged 5–14 years; mean 8.88 years; female/male 8/18), twenty-three CLP adults (aged 18–35 years; mean 23.35 years; female/male 6/17), thirty-seven healthy adolescents (aged 5–16 years; mean 9.89 years; female/male 5/16), and twenty-two healthy adults (aged 19–37 years; mean 24.41 years; female/male 19/37) took part in the experiment. The current study aims to investigate developmental changes in cortical structures in CLP patients with articulation disorders using both structural and functional magnetic resonance imaging (MRI). Our results reveal the distinct distribution of abnormal cortical structures in adolescent and adult CLP patients. We also found that the developmental pattern of cortical structures in CLP patients differed from the pattern in healthy controls (delayed cortical development in the left lingual gyrus (t = 4.02, cluster-wise p < 0.05), inferior temporal cortex (z = −4.36, cluster-wise p < 0.05) and right precentral cortex (t = 4.19, cluster-wise p < 0.05)). Mediation analysis identified the cortical thickness of the left pericalcarine cortex as the mediator between age and articulation function (partial mediation effect (a*b = −0.48), 95% confident interval (−0.75, −0.26)). In conclusion, our results demonstrate an abnormal developmental pattern of cortical structures in CLP patients, which is directly related to their articulation disorders.

Cognitive functioning and clinical characteristics of children with non-syndromic orofacial clefts: A case-control study

Introduction

The higher rate of neuropsychiatric disorders in individuals with non-syndromic orofacial clefts has been well documented by previous studies. Our goal was to identify children with non-syndromic orofacial clefts that are at risk for abnormal neurodevelopment by assessing their developmental history and present cognitive functioning.

Materials and methods

A single-center, case-controlled study was carried out at the Department of Pediatrics of the University of Pécs in Hungary. The study consisted of three phases including questionnaires to collect retrospective clinical data and psychometric tools to assess IQ and executive functioning.

Results

Forty children with non-syndromic oral clefts and 44 age-matched controls participated in the study. Apgar score at 5 min was lower for the cleft group, in addition to delays observed for potty-training and speech development. Psychiatric disorders were more common in the cleft group (15%) than in controls (4.5%), although not statistically significant with small effect size. The cleft group scored lower on the Continuous Performance Test. Subgroup analysis revealed significant associations between higher parental socio-economic status, academic, and cognitive performance in children with non-syndromic orofacial clefts. Analyzes additionally revealed significant associations between early speech and language interventions and higher scores on the Verbal Comprehension Index of the WISC-IV in these children.

Discussion

Children with non-syndromic orofacial clefts seem to be at risk for deficits involving the attention domain of the executive system. These children additionally present with difficulties that affect cognitive and speech development. Children with non-syndromic orofacial clefts show significant skill development and present with similar cognitive strengths as their peers. Longitudinal studies with larger sample sizes are needed to provide more conclusive evidence on cognitive deficits in children with non-syndromic orofacial clefts at risk for neurodevelopmental difficulties.

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.

Brain Developmental Trajectories in Children and Young Adults with Isolated Cleft Lip and/or Cleft Palate

The present study evaluated brain development in persons with isolated cleft lip and/or cleft palate (iCL/P) compared to unaffected controls using an accelerated longitudinal design. A sample of 134 males and females, ages 7-27 years, with iCL/P (184 observations, total) was compared to 144 unaffected controls (208 evaluations, total) on Wechsler Index scores and volumetric data from structural MRI scans. Boys with isolated cleft palate had verbal IQ 15.5 points lower than perceptual IQ; a clinically significant difference. Participants with iCL/P had differential growth trajectories of regional cerebrum matter and consistently lower volumes of cerebellar gray matter and subcortical matter.

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).

Articulation rehabilitation induces cortical plasticity in adults with non-syndromic cleft lip and palate

In this study, we investigated brain morphological changes in adults with non-syndromic cleft lip and palate (NSCLP) after articulation rehabilitation (AR). High-resolution T1 weighted brain magnetic resonance imaging data were analyzed from 45 adults with NSCLP after palatoplasty: 24 subjects were assessed before AR (bNSCLP) and 21 subjects were assessed after AR (aNSCLP). In addition, there were 24 age and sex matched controls. Intergroup differences of grey matter volume were evaluated as a comprehensive measure of the cortex; cortical thickness and cortical complexity (gyrification and fractal dimensions) were also analyzed. As compared to controls, the bNSCLP subjects exhibited altered indexes in frontal, temporal, and parietal lobes; these morphological changes are characteristic for adults with NSCLP. Importantly, as compared to the bNSCLP and control subjects, the aNSCLP subjects exhibited cortical plasticity in the regions involved in language, auditory, pronunciation planning, and execution functions. The AR-mediated cortical plasticity in aNSCLP subjects may be caused by AR-induced cortical neurogenesis, which might reflect the underlying neural mechanism during AR.

[Formula: see text] Neuropsychological functioning and its relationship with brain anatomical measures of children and adolescents with non-syndromic cleft lip and palate

BACKGROUND

Children and adolescents with non-syndromic cleft lip and palate (NSCLP) show cognitive performance below expected. This difficulty can be associated with alterations in the cortical thickness and volume of brain regions. The aim of this study was to investigate anatomical brain characteristics and their relationship with the neuropsychological scores of children and adolescents with NSCLP. Methods: Twenty-four children and adolescents with ages from 10 to 16 years and 11 months (12 with a diagnosis of NSCLP; 12 with typical development) were enrolled. Neuropsychological tests were administered and high-resolution, structural magnetic resonance imaging (MRI) was performed in a 1.5 T scanner. Results: Compared to the control group, NSCLP individuals showed intellectual (p = 0.006) and cognitive (p = 0.003) impairment, as well as deficits in subdomains of executive functions (sustained attention, working memory, and cognitive planning). The morphological analysis showed reduced volumes and cortical thickness in temporal, parietal, and frontal regions, in both hemispheres, of the NSCLP group. Significant, strong associations of structural alterations and cognitive performance were observed. Conclusions: Our study provided strong evidence of the relationship between brain development in children and adolescents with NSCLP, and their neuropsychological profile. This relationship is characterized by a malfunction of associative areas of the brain, such as parieto-temporo-occipital, frontoparietal, and prefrontal regions.

Distinctive Cortical Articulatory Representation in Cleft Lip and Palate: A Preliminary Functional Magnetic Resonance Imaging Study

Objective:

To investigate cortical representation of articulation of the bilabial plosive in patients with cleft lip and palate.

Design:

We examined cortical representation for /pa/-articulation in cleft lip and palate patients using blood oxygenation level–dependent functional magnetic resonance imaging.

Subjects:

Data from four postsurgical adult cleft lip and palate patients were compared with those from six healthy volunteers.

Results:

Activation foci were found in the bilateral primary sensorimotor cortex in all cleft lip and palate patients, as in the controls. The sensorimotor cortex ipsilateral to the side of cleft lip and palate showed greater activation in unilateral cleft lip and palate patients, whereas the sensorimotor cortex contralateral to the side on which cheiloplasty had been performed earlier showed greater activation in a bilateral cleft lip and palate patient.

Conclusions:

The results suggest that there may be an ipsilateral dominance in cortical representation during bilabial articulation to the side of the cleft in the upper lip.

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.

Evidence of olfactory deficits as part of the phenotypic spectrum of nonsyndromic orofacial clefting

Improved understanding of the phenotypic spectrum associated with nonsyndromic orofacial clefting (OFC) has the potential to inform efforts to uncover the etiology of this complex trait. Prior studies report that individuals with OFC are characterized by impaired olfactory ability. In this study, we test whether olfactory dysfunction extends to the unaffected parents of children with OFC. The University of Pennsylvania Smell Identification Test was used to measure olfactory ability in a sample of 60 unaffected mothers and fathers with cleft-affected children. The proportion of deficit was compared with reference data obtained from published sex- and age-specific norms on more than 2700 individuals. The proportion of deficit was significantly higher in unaffected parents compared with baseline control subjects (41.7% vs 12.6%; P < 0.001). Of unaffected fathers, 41.7% displayed evidence of deficit compared with 15.1% of male control subjects (P = 0.001), whereas 41.7% of mothers exhibited deficits compared with 10.4% of female control subjects (P < 0.001). Olfactory deficits are present at a high proportion in the unaffected parents of individuals with OFC. This suggests that the deficits observed in affected cases may not simply be a secondary consequence of surgical repair and may instead be an informative phenotype reflecting underlying etiology.

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.

Regional brain morphometric characteristics of nonsyndromic cleft lip and palate

Nonsyndromic cleft lip and palate (NSCLP) encompasses a group of orofacial abnormalities. Emerging evidence has revealed the presence of structural brain abnormalities in affected individuals. Previous studies have performed structure-based volumetric analysis of the brain assessing gross lobular subdivisions of the cerebral cortex and white matter which may have only vague relationships to the functional subregions implicated in behavioral and cognitive deficits observed in NSCLP patients. High-resolution magnetic resonance imaging structural data were acquired to provide a detailed characterization of the brain with respect to both regional cortical volume and thickness in 26 children with NSCLP and 26 age- and demographically matched typically developing children. Children with NSCLP exhibited abnormally large cerebral cortex grey matter volumes with decreased volumes of subcortical grey matter and cerebral white matter structures. Hemisphere-specific patterns of cortical volume and thickness abnormalities were identified. This study is the first to examine cortical thickness abnormalities in NSCLP. Overall, these findings suggest that the brains of children with NSCLP are less mature than those of their age-matched peers. Gender-specific comparisons reveal that NSCLP females were more immature compared to their typically developing peers compared to NSCLP males.

Reading in subjects with an oral cleft: speech, hearing and neuropsychological skills

OBJECTIVE

To evaluate speech, hearing, and neuropsychological correlates to reading among children, adolescents, and young adults with nonsyndromic cleft of the lip and/or palate (NSCL/P).

METHOD

All testing was completed in a single visit at a Midwestern university hospital. Subjects in both the NSCL/P (n = 80) and the control groups (n = 62) ranged in age from 7-26 years (average age = 17.60 and 17.66, respectively). Subjects completed a battery of standardized tests evaluating intelligence, neuropsychological skills, and word reading. Subjects with NSCL/P also underwent speech assessment, and past audiology records were evaluated.

RESULTS

After controlling for age and socioeconomic status, subjects with cleft performed significantly worse on a test of word reading. For subjects with cleft, word reading deficits were not associated with measures of speech or hearing, but were correlated with impairments in auditory memory.

CONCLUSION

These findings show poorer reading among subjects with NSCL/P compared with those without. Further work needs to focus on correlates of reading among subjects with cleft to allow early identification and appropriate intervention/accommodation for those at risk.

Abnormal cerebellar structure is dependent on phenotype of isolated cleft of the lip and/or palate

Isolated cleft lip and/or palate (ICLP) is one of the most common congenital birth defects in the USA, affecting roughly 1 in 600 births annually. Along with the facial deformity, this population has been found to have abnormal neurodevelopment and gross structural abnormalities in the brain, particularly within the cerebellum. The current study examined cerebellar structure within the two primary subtypes of ICLP: cleft lip with/without cleft palate (CL/P) and cleft palate alone (CPO). A large sample of 107 subjects aged 7 to 27 years with ICLP was compared to 127 healthy controls. Samples were separated by sex. Brain structure was obtained via magnetic resonance imaging. For males, after controlling for intracranial volume, cerebellum volume was significantly lower in the ICLP group (F = 12.351, p = 0.001). Regionally in the cerebellum, males with ICLP had proportionally larger anterior lobes (F = 4.022, p = 0.047) and smaller superior posterior lobes (F = 5.686, p = 0.019). CL/P males showed only a reduction in overall cerebellum volume, with no regional changes. CPO males showed only regional changes, with no reduction in overall volume. Females with ICLP showed no overall or regional cerebellar abnormalities. However, females with CPO did have significantly lower cerebellum volumes than controls. The results reveal both global and regional cerebellar abnormalities within subjects with ICLP. They also establish the existence of abnormal cerebellar morphologies that are dependent on cleft subtype as well as sex. This lends further support to the claim that CL/P and CPO are distinct conditions.

Social motivation in individuals with isolated cleft lip and palate

Social isolation is common among individuals with isolated cleft lip and palate (ICLP), but the available data on why this may be are mixed. We present a novel theory relating to reduced social motivation in ICLP, called the social abulia hypothesis. Based on this hypothesis, we predicted that reduced social motivation would lead to reduced responsiveness to negative social feedback, in terms of both explicit responses and noncontrolled, psychophysiological responses. Twenty males with ICLP and 20 normal comparison males between 13 and 25 years old participated in the study. Social motivation was examined by measuring participants' response to negative social feedback (social exclusion). Additionally, psychophysiological reactivity to positive and negative social stimuli was measured. In order to rule out other potential contributors to social isolation, we tested basic social perception, emotion recognition, and social anxiety. In line with the social abulia hypothesis, we show that negative social feedback had less of an effect on males with ICLP than on healthy male peers, which was evident in explicit responses and noncontrolled, psychophysiological responses to negative social feedback. Our results could not be attributed to problems in social perception, a lack of understanding facial expressions, or increased social anxiety, as groups did not differ on these constructs. This study suggests that current views on social isolation in ICLP may need to be reconsidered to include the possibility that isolation in this population may be the direct result of reduced social motivation.

Corpus callosum shape is altered in individuals with nonsyndromic cleft lip and palate

Individuals with nonsyndromic cleft lip with or without cleft palate (CL/P) have altered brain structure compared with healthy controls. Preliminary evidence suggests that the corpus callosum may be dysmorphic in orofacial clefting; however, this midline brain structure has not been systematically assessed in this population. The goal of the present study was to carry out a morphometric assessment of the corpus callosum and its relationship to cognitive performance in a well-characterized patient cohort with orofacial cleft. Midline brain images were obtained from previously collected MRI scans of 24 CL/P subjects and 40-adult-male controls. Eight landmarks on the corpus callosum were digitized on each image and their x,y coordinate locations saved. A geometric morphometrics analysis was applied to the landmark coordinate data to test for shape differences across groups. The relationship between corpus callosum shape and IQ was explored with nonparametric correlation coefficients. Results revealed significant differences in mean corpus callosum shape between CL/P cases and controls (P = 0.029). The CL/P corpus callosum was characterized by increased overall convexity resulting from a superior and posterior displacement. Within CL/P cases, increased corpus callosum shape dysmorphology was moderately correlated with reduced performance IQ (r = 0.546). These results provide additional evidence that midline brain changes may be an important part of the orofacial cleft phenotype.

Minor physical anomalies in patients with bipolar I disorder and normal controls

BACKGROUND

The neurodevelopmental hypothesis is well established in schizophrenia but has received modest empirical support in bipolar disorder. In schizophrenia it is partly based on the higher prevalence of minor physical anomalies (MPAs), established by many well controlled studies. No studies with comparable designs have been performed in bipolar disorder. The present study aims to establish the rate and topographic distribution of MPAs in bipolar I patients.

METHODS

The subjects were 61 patients (25 men, 36 women) with bipolar I disorder and 103 normal subjects (49 men, 54 women) who were examined for MPAs using a modified version of the Waldrop Physical Anomaly Scale.

RESULTS

The bipolar I patients showed significantly higher regional MPA scores in 3 distinct regions - mouth, feet and head, as well as in the overall scores for the craniofacial complex, the periphery and the total MPA score. Differences were statistically significant for 3 anomalies - high/steepled palate, big gap between I and II toes and furrowed tongue that made significant contribution to the prediction of the patient-control status in a discriminant analysis model.

CONCLUSIONS

Our data suggest that aberrant processes of neurodevelopment may contribute to the etiology of bipolar I disorder. The field is open for further research using modern instruments and designs in order to identify potential biological markers for bipolar disorder.

Psychiatric assessment of children with nonsyndromic cleft lip and palate

OBJECTIVE

The aim of the study was to determine whether children with nonsyndromic cleft lip and palate (NSCLP) are more likely to be diagnosed with psychiatric disorders and whether cleft-related factors are related to psychopathology.

METHOD

Twenty children from 6 to 16 years of age with NSCLP, attending the Plastic, Reconstructive and Aesthetic Surgery Department of Cerrahpasa Medical Faculty between January and October 2010, were included as the case group. Forty healthy children who were matched on age and sex with the case group served as controls. Children were assessed by psychiatric interviews and scales.

RESULTS

Social anxiety disorder (SAD) (P=.003) and major depressive disorder (MDD) (P=.010) were more prevalent in children with NSCLP. The severity of dentofacial (P=.035) and cleft lip nose deformities (P=.002), appearance and competence of the lip (P=.008), dental alignment (P=.002), feeding (P=.044) and articulation problems (P<.001) were associated with clinical global functioning.

CONCLUSIONS

Children with NSCLP are at risk of developing psychopathology, especially SAD and MDD. The above cleft-related factors and articulation problems may be the target of interventions to prevent and treat psychiatric disorders in these children.

Oral clefts and behavioral health of young children

OBJECTIVES

This study examined the behavioral health of young children with oral clefts, and effects of satisfaction with facial appearance, cleft team care, number of cleft-related surgeries, and socioeconomic status (SES).

SUBJECTS AND METHODS

The study included a population-based sample of 104 children aged 2-12 years with isolated oral clefts from the state of Iowa. Behavior was evaluated with the Child Behavior Checklist or the Pediatric Behavior Scale 30, depending on age, compared with normative samples.

RESULTS

Risks of behavioral problems were not significantly different from normative samples except for higher inattention/hyperactivity risks at age 6-12 years. Low satisfaction with facial appearance was associated with behavioral problems in all domains, except aggression. Team-care effects were not associated with behavioral problems. Number of cleft-related surgeries was associated with increased anxiety/depression and somatic symptom risks. Higher SES was associated with reduced inattention/hyperactivity, aggressive/oppositional behavior, and somatic symptoms.

CONCLUSIONS

Most children with oral clefts may have similar behavioral health outcomes to unaffected children, except for increased inattention/hyperactivity risks at older ages. However, low satisfaction with facial appearance, increased exposure to surgeries, and lower SES may significantly increase behavioral problems. Also, the findings emphasize the need to study the representation of behavioral health professionals on cleft teams and access to behavioral health care.

Cerebellum structure differences and relationship to speech in boys and girls with nonsyndromic cleft of the lip and/or palate

OBJECTIVE

To identify regional cerebellar structural differences in boys and girls with nonsyndromic cleft of the lip and/or palate and determine whether these differences are related to speech impairment.

DESIGN

Between 2003 and 2007, measures on cerebellar volume were obtained on 43 children with nonsyndromic cleft of the lip and/or palate and 43 age- and sex-matched, healthy controls. Children with the cleft condition also received speech evaluations. Children with nonsyndromic cleft of the lip and/or palate were recruited from clinic records, and controls (screened for medical, psychiatric, speech/language, and behavioral concerns) were recruited from the local community. All tests were administered at a large midwestern hospital. Boys and girls with nonsyndromic cleft of the lip and/or palate were compared with the healthy controls on global and regional measures of cerebellar volume. Areas of significant difference were then correlated with measures of speech to assess relationships in children with nonsyndromic cleft of the lip and/or palate.

RESULTS

Boys with nonsyndromic cleft of the lip and/or palate had smaller cerebellums than controls (p = .002); whereas, for girls, only regional reductions in size reached significance (corpus medullare, p = .040). Cerebellum size was correlated with articulation for boys (p = .045).

CONCLUSIONS

These findings lend support to previous research documenting abnormal brain structure in children with nonsyndromic cleft of the lip and/or palate and suggest that the cerebellum may play a role in speech deficits along with other structural causes, at least in boys.

Effects of unilateral clefts on brain structure

OBJECTIVE

To evaluate potential abnormalities in brain structure of children and adolescents with unilateral clefts.

DESIGN

Case-control study.

SETTING

Tertiary care center.

PARTICIPANTS

Boys aged 7 to 17 years with right (n=14) and left (n=19) clefts were compared with healthy age-matched boys (n=57).

MAIN EXPOSURES

Structural brain measures were obtained using magnetic resonance imaging.

OUTCOME MEASURE

It was explored whether laterality of clefts had a significant effect on brain structure. To this end, volumes of tissue types and various brain regions were evaluated.

RESULTS

Total white matter was significantly lower in boys with right clefts compared with boys with left clefts and healthy boys. Gross regional analyses demonstrated that reductions in white matter were evident in both the cerebellum and the cerebrum in boys with right clefts. Furthermore, within the cerebrum, white matter volumes were particularly low in the frontal lobes and the occipital lobes.

CONCLUSIONS

These preliminary results suggest that right clefts may be associated with more abnormalities in brain structure. More generally, laterality of a birth defect may have a significant effect on a developing organism.

Visual face perception of adults with unilateral cleft lip and palate in comparison to controls--an eye-tracking study

OBJECTIVE

To assess how faces with a cleft lip and palate are perceived and to study how faces with and without a unilateral cleft lip and palate are viewed by individuals with a unilateral cleft lip and/or palate in comparison to nonaffected controls.

DESIGN

Prospective clinical study.

SETTING

Department of Orthodontics and Department of Psychology, University of Wuerzburg.

PARTICIPANTS

Thirty-three participants (20 men and 13 women; mean age, 25.4 ± 6.6 years) with a unilateral cleft lip and/or palate and a control group of 30 participants (15 men and 15 women; mean age, 26.8 ± 3.4 years) were enrolled in this study.

MAIN OUTCOME MEASURES

Eye movements were analyzed via an eye-tracking camera while all participants looked at pictures of faces with and without a unilateral cleft lip and palate.

RESULTS

The nose and the mouth area of pictures of faces with a unilateral cleft lip and palate were looked at significantly longer by both groups. Additionally, the participants with a unilateral cleft lip and/or palate looked at faces with and without a unilateral cleft lip and palate differently, taking more time to view the nose and less time to view the eyes compared with the participants without a cleft lip and palate.

CONCLUSION

When perceiving a face with a unilateral cleft lip and palate, the observer's gaze is distracted to the nose and mouth area. Moreover, participants with a unilateral cleft lip and/or palate themselves focused greater attention on those features that are anomalous on their own faces in comparison to participants without a cleft lip and palate. Specifically, this different scanpath is reflected in the cumulative duration of the eye movements as well as in the initial facial scan pattern.

Three-dimensional morphometric analysis of brain shape in nonsyndromic orofacial clefting

Previous studies report structural brain differences in individuals with nonsyndromic orofacial clefts (NSOFC) compared with healthy controls. These changes involve non-uniform shifts in tissue volume within the cerebral cortex and cerebellum, suggesting that the shape of the brain may be altered in cleft-affected individuals. To test this hypothesis, a landmark-based morphometric approach was utilized to quantify and compare brain shape in a sample of 31 adult males with cleft lip with or without cleft palate (CL/P), 14 adult males with cleft palate only (CPO) and 41 matched healthy controls. Fifteen midline and surface landmarks were collected from MRI brain scans and the resulting 3D coordinates were subjected to statistical shape analysis. First, a geometric morphometric analysis was performed in three steps: Procrustes superimposition of raw landmark coordinates, omnibus testing for group difference in shape, followed by canonical variates analysis (CVA) of shape coordinates. Secondly, Euclidean distance matrix analysis (EDMA) was carried out on scaled inter-landmark distances to identify localized shape differences throughout the brain. The geometric morphometric analysis revealed significant differences in brain shape among all three groups (P < 0.001). From CVA, the major brain shape changes associated with clefting included selective enlargement of the anterior cerebrum coupled with a relative reduction in posterior and/or inferior cerebral portions, changes in the medio-lateral position of the cerebral poles, posterior displacement of the corpus callosum, and reorientation of the cerebellum. EDMA revealed largely similar brain shape changes. Thus, compared with controls, major brain shape differences were present in adult males with CL/P and CPO. These results both confirm and expand previous findings from traditional volumetric studies of the brain in clefting and provide further evidence that the neuroanatomical phenotype in individuals with NSOFC is a primary manifestation of the defect and not a secondarily acquired characteristic.

The Parental Dentocraniofacial Phenotype—An Orofacial Clefting Microform

Objective

Using the systematic review method, (1) to identify the investigations of the parental dentocraniofacial phenotype in orofacial clefting, (2) synthesize the data to derive a model of the phenotypic features that will assist in the identification of cleft morphogenes, and (3) make recommendations for the future global strategy for researching the parental craniofacial phenotype in orofacial clefting.

Search Strategy

The Cochrane, Medline (via PubMed and OVID platforms [1966 to December 2006]), Embase, CINAHL, and ASKSAM Orthodontic Reference Database (1950–1997) databases were searched using a combination of the following keywords: microform, parent, craniofacial, dental, and cleft. All published articles were reviewed. There were no exclusions of non-English reports. Of the 36 studies identified using this strategy, 26 met the inclusion criteria.

Data Abstraction/Synthesis

The statistically significant data were abstracted using a pro forma, and the methodological quality of the selected studies was evaluated using a checklist. There was considerable heterogeneity among the studies, and therefore it was not possible to synthesize the data. We were, however, able to collate the data.

Results/Conclusions

(1) The craniofacial phenotype possessed by parents of children with orofacial clefting is distinctive when compared with that of the noncleft population. (2) There is insufficient evidence to produce a model of the phenotypic features to assist in the search for orofacial clefting morphogenes. (3) The pattern of expression of the phenotypic features identified to date supports the contention that there are differences in the inheritance of cleft lip with or without cleft palate and isolated cleft palate. Progress in this field is affected by extreme heterogeneity in etiology of cleft lip with or without cleft palate, as well as heterogeneity in study design. (4) Subphenotyping using features such as microforms should be employed to reduce the heterogeneity and to improve the power of future genetic investigations and will also assist in clinical management and genetic counseling for families.

[Cleft lip and palate: indications for radiological postnatal explorations]

AIM

We evaluated the utility of systematic neonatal radiological explorations in 20 instances of isolated cleft lip and palate in 20 cases.

METHODS

This study included 13 infants with prenatal ultrasound diagnosis. The type of cleft and possible associated anomalies were noted. A systematic chromosomal test was done. In 7 cases, the cleft lip was noted at birth. Postnatal outcome was obtained and a clinical examination and radiological explorations were carried out.

RESULTS

For the cases with prenatal diagnosis, the chromosomal test was normal in 11 cases and we noted associated anomalies in three cases. For the cases with neonatal diagnosis, the chromosomal test was normal in 6 cases and 1 infant had associated anomalies.

CONCLUSIONS

The biological and radiological explorations can be numerous. In our study, the systematic neonatal radiological explorations did not find more elements compared with neonatal clinical examinations. The high risk of having a chromosomal anomaly in children with cleft lip requires systematic prenatal chromosomal exploration.

Combined fMRI and MRI movie in the evaluation of articulation in subjects with and without cleft lip and palate

OBJECTIVE

This study was undertaken to explore the application of functional magnetic resonance imaging (fMRI) and MRI movies in the evaluation of articulatory function in subjects with and without cleft lip and palate (CLP).

DESIGN

The authors examined brain activation and the dynamic movement of articulators during bilabial and velar plosives using fMRI and MRI movies.

SUBJECTS

Two subjects, one with unilateral cleft lip and palate (UCLP) and one with bilateral cleft lip and palate (BCLP), and 12 non-CLP volunteers.

RESULTS

Activation foci were found in the precentral gyrus, thalamus, and cerebellum in non-CLP volunteers. In comparison, similar regions were activated in the UCLP subject during both plosives, whereas the regions activated in the BCLP subject were different, particularly during the velar plosive. The dynamic movement of articulators in the UCLP subject was comparable to that in a non-CLP volunteer but different from that in the BCLP subject.

CONCLUSIONS

The results suggest that these two MRI modalities may be a promising evaluation methodology for articulatory function in CLP from central and peripheral perspectives.

Incidence of neurological soft signs in children with isolated cleft of the lip or palate

The purpose of this study was to assess neurological soft signs in children and adolescents with isolated cleft of the lip or palate (iCL/P) compared with healthy controls. Children with iCL/P were recruited through the university cleft clinic. Control subjects were recruited through advertisements. Of the 166 subjects who participated (age range 7 to 17 years, M = 12.5, SD = 3.2), 77 had iCL/P (48 male) and 89 were healthy controls (44 male). All participants took the Physical and Neurological Examination of Subtle Signs and selected tests of motor coordination. A multivariate analysis of variance assessed differences between subjects with and without iCL/P. Also, a Pearson correlation estimated the relationship between the neurological soft signs and age. Subjects with iCL/P scored significantly higher on all neurological soft signs variables. These higher scores were associated with younger age. Findings lend support to the hypothesis of aberrant brain development in children with iCL/P.

Priorities for future public health research in orofacial clefts

The National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention conducted a workshop in January 2006, entitled "Prioritizing a Research Agenda for Orofacial Clefts." The goals of the meeting were to review existing research on orofacial clefts (OFCs), identify gaps in knowledge that need additional public health research, and develop a prioritized research agenda that can help guide future public health research. Experts in the field of epidemiology, public health, genetics, psychology, speech pathology, dentistry, and health economics participated to create the research agenda. Research gaps identified by the participants for additional public health research included: the roles of maternal nutrition, obesity, and diabetes in the etiology of OFCs; psychosocial outcomes for children with OFCs; the quality of life for families and children with OFCs; and the health care costs of OFCs. To create the research agenda, the participants prioritized the research gaps by public health importance, feasibility, and outcomes of interest. This report summarizes the workshop.

Health-related quality of life among preadolescent children with oral clefts: the mother's perspective

OBJECTIVE

The purpose of this study was to evaluate the factors that affect the health-related quality of life of preadolescent children with nonsyndromic oral clefts using the Pediatric Quality of Life Inventory instrument and to evaluate whether there were any differences related to the type of cleft or other factors.

METHODS

Data for this study were derived from telephone interviews with the parents of a statewide population of children who were in the Iowa Registry for Congenital and Inherited Disorders, were aged 2 to 12 years, had nonsyndromic oral clefts, and were born in Iowa between January 1, 1990, and December 31, 2000. Twenty-minute interviews were conducted with mothers of 104 children in the spring and summer of 2003; respondents then completed and mailed back Pediatric Quality of Life Inventory surveys 2 to 3 weeks after the interviews (69% participation rate).

RESULTS

After controlling for demographic characteristics, children with less severe speech problems had higher total Pediatric Quality of Life Inventory scores as well as higher physical and psychosocial health domain scores. Age and cleft type interacted, with younger children (aged 2-7 years) with a cleft lip or cleft lip and palate having higher health-related quality of life scores than children with an isolated cleft palate; however, this pattern was reversed for older children (aged 8-12 years).

CONCLUSIONS

Speech and aesthetic concerns seem to have been important factors affecting the health-related quality of life for children with oral clefts. These factors seem to be more important as children get closer to adolescence (ages 8-12 years) when acceptance by peers becomes more critical.

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

The mental health of children, adolescents, and adults with orofacial clefts has been studied extensively. Outcomes of interest have included parental adaptation, parent-child attachment, child development, intellectual and academic outcomes, behavioral adaptation, and quality of life. The literature sheds light on mental health needs and opportunities in each of these domains at various stages of development. However, this research has been limited in several respects and methodologically rigorous studies are needed to clarify the role of mental health in craniofacial team care. In particular, randomized controlled trials investigating the efficacy of psychosocial interventions tailored for this population are long overdue. Such studies have the potential to advance routine mental health care for individuals with orofacial clefts to the level of 'evidence-based care.'

Abnormal brain structure in adults with Van der Woude syndrome

Van der Woude syndrome (VWS) is an autosomal dominant disorder manifested in cleft lip and/or palate and lip pits. Isolated clefts of the lip and/or palate (ICLP) have both genotype and phenotype overlap with VWS. Subjects with ICLP have abnormalities in brain structure and function. Given the similarities between VWS and ICLP, the current study was designed to evaluate the pattern of brain structure of adults with VWS. Fourteen adults with VWS were compared to age- and gender-matched healthy controls. Brain structure was evaluated using magnetic resonance imaging. All subjects with VWS had enlarged volumes of the anterior regions of the cerebrum. Men with VWS had reduced volumes of the posterior cerebrum. Anterior cerebrum volume was negatively correlated with intelligent quotient in the subjects with VWS indicating that the enlargement of this brain region was 'pathologic.' The pattern of brain structure in VWS is nearly identical to those seen in ICLP. In addition, men are affected more severely. Pathologic enlargement of the tissue and a gender effect with men affected more severely are common features of neurodevelopmental disorders supporting the notion that the brain structure of VWS and ICLP may be because of abnormal brain development.

Social function in boys with cleft lip and palate: relationship to ventral frontal cortex morphology

Isolated clefts of the lip and/or palate (ICLP) are developmental craniofacial abnormalities that have consistently been linked to increased social inhibition or shyness. Two explanations have been proposed: (1) psychosocial factors related to differences in facial appearance may lead to low self-concept and subsequent shyness, or (2) abnormal development of brain structures involved in social function, such as the ventral frontal cortex (VFC), may underlie the difference. To investigate these two possibilities this study was designed to evaluate measures of social function in relation to measures of self-concept and VFC morphology. Subjects included 30 boys (age 7-12) with ICLP and a comparison group of 43 boys without cleft in the same age category. Social function and self-concept were assessed using questionnaires with standardized scoring filled out by subjects and one of their parents. The cortical volume and surface area of the VFC, composed of the orbitofrontal cortex (OFC) and straight gyrus (SG), were evaluated using structural magnetic resonance imaging. The ICLP subjects had significantly impaired social function relative to the comparison group. No difference in self-concept was identified. VFC morphology revealed significant differences between groups, particularly decreased volume and surface area in the left SG of the ICLP group. Moreover, abnormal VFC measures were correlated with social dysfunction but measures of self-concept were not. These results are consistent with the possibility that aberrant VFC development may partially underlie social dysfunction in boys with ICLP.

Neurodevelopment of children with single suture craniosynostosis: a review

INTRODUCTION

Rates of neurocognitive risk range from 35-50% of school-aged children with isolated single suture craniosynostosis (SSC). It has been hypothesized that early surgical intervention to release suture fusion reduces risk for increased intracranial pressure (ICP) and the corresponding risk to neurodevelopment. However, studies assessing children with SSC have been inconsistent in finding an association between neurocognitive development, age of surgery, and ICP.

REVIEW

SSC produces notable distortion of the cranial vault and underlying brain mass. Although a linear relationship between skull distortion, ICP, and neurocognitive deficits has generally been assumed, recent studies have postulated an interactive process between the skull and developing brain that results in neuroanatomical changes that are not limited to areas directly beneath the fused suture. The specific neuropsychological deficits identified in children with SSC including problems with attention and planning, processing speed, visual spatial skills, language, reading, and spelling may be related to the anatomic differences that persist after correction of suture fusion.

CONCLUSIONS

Available literature on neurocognitive development of children with SSC is suggestive of mild but persistent neuropsychological deficits, which become more significant as cognitive demands increase at school age. Anatomical studies of children without SSC are beginning to identify particular groups of brain structures that if disrupted or malformed, may be associated with specific cognitive deficits. Controlled research investigating the relationship between persistent anatomical changes and neurocognitive functioning of school-aged children with SSC is needed.

Type of oral cleft and mothers' perceptions of care, health status, and outcomes for preadolescent children

OBJECTIVE

To evaluate the outcomes of care for children by type of oral cleft.

DESIGN

Data were collected through structured telephone interviews during 2003 in Iowa with mothers of 2- to 12-year-old children with oral clefts. Interviews with mothers of children with clubfoot and statewide data on Iowa children were used for comparison.

PARTICIPANTS

Participants included mothers of children in Iowa born between 1990 and 2000 with nonsyndromic oral clefts. Children were identified by the statewide Iowa Registry for Congenital and Inherited Disorders.

MAIN OUTCOME MEASURES

Rating of cleft care, severity of condition, health status, esthetic outcome, speech, and school performance were evaluated by type of oral cleft.

RESULTS

Children with cleft lip and palate were most likely to have their clefts rated as very severe. Children with palatal involvement were reported to have a lower health status and were almost twice as likely to be identified as having a special health care need compared with either children with cleft lip or children statewide. Children with cleft lip had more esthetic concerns; children with palatal involvement had the most speech concerns.

CONCLUSIONS

Although mothers generally believed their children had received high-quality care, ratings of the children's current health status and outcomes of care varied significantly by type of cleft (cleft lip, cleft palate, and cleft lip and palate). Differences observed in this population-based study support the proposition that cleft type should be considered when examining outcomes of care for children with oral clefts.