Neuropsychological, behavioral, and academic sequelae of cleft: early developmental, school age, and adolescent/young adult outcomes

Intelligence among ear deformities and cleft lip and/or alveolus and/or cleft palate patients during 50 years in Israel

PURPOSE

We evaluated hearing loss and general intelligence among persons with auricle anomalies and cleft lip and/or alveolus and/or cleft palate (CLAP).

METHODS

A nationwide cross-sectional study of data recorded during 1966-2019, as mandatory pre-military recruitment of individuals.

RESULTS

Of 3 182 892 adolescents, 548 were diagnosed with auricle anomalies and 2072 with CLAP. For the latter, the adjusted odds ratios for the low, low to medium and medium general intelligence categories compared to the highest category were 1.4 [95% CI 1.5-1.2], 1.2 [95% CI 1.4-1.1] and 1.1 [95% CI 1.2-0.9] respectively. The corresponding values for the auricle anomalies were not significant.

CONCLUSIONS

General intelligence was impaired among individuals with CLAP, but no significant correlation was found among individuals suffering from auricle anomalies.

White matter tract integrity in isolated oral clefts: relationship to cognition and reading skills

Children with isolated cleft of the lip and/or palate (iCL/P) have been shown to be at risk for impaired reading ability. Structural and functional neuroimaging studies have revealed subtle morphological and functional abnormalities correlated to cognition and reading ability. However, the integrity of white matter tracts and their potential relationship to reading performance in iCL/P is under-studied. The purpose of the present study was to evaluate white matter integrity related to cognition and reading skills among participants with and without iCL/P. Data from two cross-sectional, case/control studies with similar neuropsychological batteries and diffusion tensor imaging (DTI) protocols were combined. The final sample included 210 participants (ages 7 to 27 years). Group and sex differences in fractional anisotropy (FA) values were examined between participants with (n = 105) and without (n = 105) iCL/P. Potential associations between FA values and age, cognition, and reading skills were also evaluated separately by group and sex. Sex effects were prominent in association and projection fibers, and effects of cleft status were found in association fibers and cerebellar regions, with isolated associations to reading skills. Findings provide preliminary understanding of microstructural associations to cognitive and reading performance among children, adolescents, and young adults with iCL/P.

The Association of Speech/Language Risk With Phonological Awareness, Rapid Naming, and Reading Ability in Children With Cleft Lip and/or Palate

Children with cleft lip and/or palate were assessed for speech, language, phonological awareness (PA), rapid naming (RN) and reading ability using standardized instruments at baseline (T1; N = 142, Mage = 6.14 years, 51% males) and 2-year follow-up (T2; 89% retention, Mage = 8.38). Children with no speech or language risk scored higher for T1 and T2 PA, RN, and reading than children with both speech and language risk [Adjusted Mean Difference (AMD) ranged from 11.79 to 21.25]; language risk (AMD 8.37 to 13.58); and speech risk (0.51 to 6.87). No significant differences by cleft type or child sex.

Comparison of intelligent development (IQ & EQ) of children with cleft lip and palate

Background

Attention to the issue of intelligence and its promotion in children with cleft lip and cleft palate (CL and CP) is necessary to reduce their injuries in life. This study aimed to determine the intelligence quotient (IQ) and emotional intelligence (EQ) in children with CL and CP in comparison to healthy children.

Materials and Methods

In this descriptive study, 140 children, including 70 children with CL and CP, were selected from the Children treated in Craniofacial and Cleft Research Center, Spearman correlation, ANOVA and 70 healthy children were selected from the Pediatric Dentistry Department of Isfahan University, in the age range of 5-9 years. After obtaining the consent of the children's parents, the Raven IQ questionnaire and the Mayer and Salovey EQ questionnaire were given to the children. Data were analyzed by the Pearson correlation coefficient tests (α =0.05).

Results

EQ score in healthy children was significantly higher than in children with CL and CP (P < 0.001). The percentage of IQ cognitive intelligence in healthy children and children with CL and CP was not significantly different (P = 0.641). In healthy children, no significant relationship was observed between cognitive intelligence IQ and EQ (r = 0.018, P = 0.882). However, among children with CL and CP, there was a significant inverse relationship between cognitive intelligence IQ and EQ (P < 0.001, r = -0.526).

Conclusion

CL and CP have no effect on IQ in children, but it does affect EQ.

Feasibility of using ultrasound visual biofeedback to treat persistent speech sound disorders in children with cleft palate- a case series

The current study aimed to assess the effectiveness of incorporating ultrasound visual biofeedback (UVB) into a treatment programme addressing persistent speech sound disorders linked to cleft palate in children who have been unresponsive to traditional therapy approaches. Materials and Methods. A single-subject multiple baseline experiment was conducted with five children aged 6:5-13:5 over a period of 16 therapy sessions. Treatment focused on providing cues from real-time ultrasound images to assist children in modifying their tongue movements. Probe data were collected before, mid, and post-treatment to assess target consonant accuracy for 50 untreated words. The results of the statistical analysis suggested participants showed a significant increase in percent target consonant accuracy as a result of intervention using UVB. Although most of the participants exhibited progress in generalising learned phonemes to untreated words, some did not show improvement in gaining generalisation from treated phonemic contexts to those untreated ones. When traditional methods fail to yield significant progress, incorporating ultrasound biofeedback into the treatment programme emerges as a viable option to enhance sound accuracy in children with persistent speech sound disorders resulting from cleft palate.

Developmental Risk for Infants with Cleft Lip with or Without Cleft Palate Based on Caregiver-Proxy Reports

OBJECTIVES

(1) Assess caregiver-reported development in infants born with cleft lip ± alveolus (CL ± A) and cleft lip and palate (CLP); (2) determine factors associated with increased developmental risk; and (3) determine consistency of developmental risk before and after surgery for cleft lip.

DESIGN

Prospective, longitudinal assessment of development. Time (T) 1, prior to lip closure; T2, 2 months post lip closure.

SETTING

Three US craniofacial teams and online parent support groups.

PARTICIPANTS

123 total caregivers (96% mothers); 100 at T1, 92 at T2, and 69 at both T1 and T2.

MEASURE

Ages and Stages Questionnaire-3 (ASQ-3): Communication, Gross Motor, Fine Motor, Problem Solving, Personal Social Domains.

RESULTS

At T1 47%; at T2 42% passed all 5 Domains; 36% of infants pass all 5 Domains at both T1 and T2. Infants with CLP were at greatest risk on Communication [B = 1.449 (CI = .149-20.079), p = .038; Odds Ratio (OR) = 4.3 (CI = .923-19.650)] and Gross Motor Domains [B = 1.753 (CI = .316-20.605), p = .034; OR = 5.8 (CI = 1.162-28.671)]. Male infants were at greatest risk on Fine Motor [B = 1.542 (CI = .495-20.005), p = .009; OR = 4.7 (CI = 1.278-17.101)] and Problem Solving Domains [B = 1.200 (CI = .118-19.708), p = .044; OR = 3.3 (CI = .896-12.285)].

CONCLUSIONS

Based on caregiver report, infants with CL ± A and CLP meet referral criteria at a high rate. Infants with CLP and male infants were at greatest risk. Regular developmental screening is recommended.

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.

Quality of Life in Adolescents and Young Adults with Cleft Lip and Palate with and Without Speech Therapy During COVID-19

OBJECTIVE

Cleft-related speech concerns can affect the quality of life (QOL) in patients with cleft lip and palate (CLP). During the coronavirus disease 2019 (COVID-19), in-person speech therapy (ST) was restricted due to fear of getting infected. This study aimed to compare QOL in patients with CLP with and without ST during the pandemic.

DESIGN

Cross-sectional Study.

SETTING

CLP team at Tehran University of Medical Sciences (TUMS).

PATIENTS/PARTICIPANTS

Thirty-six CLP subjects with a mean age of 17.33 ± 4 years participated in two groups, including with and without ST. Fifteen subjects had cleft palate only (CPO) and others had CLP.

INTERVENTIONS

ST group received at least 10 ST sessions, and group without ST didn't receive ST during COVID-19.

MAIN OUTCOME MEASURE(S)

A virtual link of demographic and QOL adolescent cleft (QoLAdoCleft) questionnaires were sent to fill out. Results were extracted and transferred to SPSS.

RESULTS

Total and subscales' scores of QoLAdoCleft were lower in ST group than without ST but differences between them weren't statistically significant (P > .05). Furthermore, according to cleft type, there weren't any statistically significant differences in total, physical, and social subscales of QoLAdoCleft (P > .05); however, psychological subscale in CLP had a higher significant score than CPO (P < .05).

CONCLUSIONS

QOL was weak in all patients with CLP, and receiving/not receiving ST couldn't make noticeable differences between them. It seems; COVID-19 pandemic can have an adverse effect on these results. Also, subjects with CLP had weaker psychological than CPO due to negative psychosocial feedback related to Orofacial deformities received from society.

Psychosocial Outcomes in Children with Cleft Lip and/or Palate: Associations of Demographic, Cleft Morphologic, and Treatment-Related Variables

OBJECTIVE

To determine associations of demographic, morphologic, and treatment protocol parameters with quality of life (QoL), appearance/speech satisfaction, and psychological adjustment.

DESIGN

Observational study utilizing retrospective report of protocol variables and current outcome variables.

SETTING

Six North American cleft treatment clinics.

PARTICIPANTS

Children, ages 8.0-10.99 years, with Cleft Lip ± Alveolus, Cleft Palate, Cleft Lip and Palate, and parents (N = 284).

OUTCOME MEASURES

Pediatric QoL Inventory (PedsQL): Parent, Child, Family Impact Module (FIM); Patient Reported Outcome Measurement Information System (PROMIS); Child Behavior Checklist (CBCL); CLEFT-Q.

RESULTS

Outcome scores were average with few differences by cleft type. Multiple regression analyses yielded significant associations (Ps < .05) between socioeconomic status, race, and age at assessment and parent- and self-reported measures. Females had higher PROMIS Depression (β=.20) but lower CBCL Affective (β = -.16) and PROMIS Stigma scores (β= -.24). Incomplete cleft lip was associated with lower PROMIS Depression, and more positive ratings of CLEFT-Q: Nose, Nostril, Lip Scar; CBCL Competence scores, (βs = -.17 to .17). Younger Age at Lip Closure was associated with higher CBCL School Competence (β= -.18). Younger Age at Palate Closure was associated with higher Child PedsQL Total, Physical, Psychosocial QoL, and better CLEFT-Q Speech Function (βs = -.18 to -.15). Furlow Palatoplasty was associated with more CBCL Externalizing Problems (β = .17) higher CBCL Activities (β = .16). For all diagnoses, fewer Total Cleft-Related Surgeries was associated with lower PROMIS Stigma and higher CBCL Total Competence and Activities (βs = -.16 to .15).

CONCLUSIONS

Demographic characteristics, lip morphology, and treatment variables are related to later psychological functioning.

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.

[Study on brain mechanism of rehabilitation training of articulation disorder in cleft lip and palate patients based on functional magnetic resonance imaging]

The cleft lip and palate (CLP) is one of the most common craniofacial malformations in humans. We collected functional magnetic resonance data of 23 CLP patients before rehabilitation training (Bclp) and 23 CLP patients after rehabilitation training (Aclp), who were performing Chinese character pronunciation tasks, and performed brain activation analysis to explore the changes of brain mechanism in CLP patients after articulation disorder rehabilitation training. The study found that Aclp group had significant activation in the motor cortex, Broca area, Wernicke area and cerebellum. While the Bclp group had weak activation in the motor cortex with a small activation range. By comparing the differences and co-activated brain regions between the two groups, we found that rehabilitation training increased the activity level of negatively activated brain areas (cerebellum, left motor area, Wernicke area, etc.) to a positive level. At the same time, the activity level of weakly activated brain areas (right motor area, Broca area, etc.) was also increased. Rehabilitation training promoted the activity level of articulation-related brain regions. So that the activation intensity of articulation-related brain regions can be used as a quantifiable objective evaluation index to evaluate the effect of rehabilitation training, which is of great significance for the formulation of rehabilitation training programs.

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.

Influence of Cleft Lip and Palate on Oral Health-Related Quality of Life in Northern Italy: Exploring Both the Children's and Caregivers' Perspectives

The aim of this cross-sectional study was to examine whether parents/caregivers' perceptions of oral health-related quality of life (OHRQoL) differ from that of their cleft children, exploring the impact of demographic variables and cleft type on their agreement. Fifty-three primary and secondary schoolchildren, with non-syndromic orofacial cleft, and their parents answered the Child Oral Health Impact Profile (COHIP) questionnaire. Concordance between caregivers' and children's reports was low to moderate. Parents/caregivers had worse perceptions of OHRQoL compared to that of their children, peer interaction and functional well-being domains being statistically significantly different (p = 0.033 and p = 0.005, respectively). Cleft type, gender and parents' country of origin seemed to be potential contributing factors of disagreement. Parents overestimated the impact of unilateral (p = 0.047) and bilateral cleft lip and palate (p = 0.021) on OHRQoL, and they rated more poorly than their male children did. Italian parents were more concerned about the functional well-being of their children (p = 0.014), and foreign parents about peer interaction (p = 0.010) and school environment (p = 0.012) dimensions. These findings suggest that parental assessment of OHRQoL cannot replace that of school-aged children, but they are complementary as they cover different, but equally relevant perspectives.

A preliminary examination of expressive writing in boys with isolated orofacial clefts

BACKGROUND

Children with isolated cleft of the lip and/or palate (iCL/P) are at a higher risk for language and reading issues. The current pilot study evaluated concurrent writing skills of children with iCL/P compared to unaffected participants with average (uAR) and impaired (uIR) reading. It was hypothesized that children with iCL/P would perform lower than age-expectations.

METHODS

Twenty-three males, aged 8-11 years old, were recruited through clinics, local advertisements, and state dyslexia groups (iCL/P = 7, uAR = 8, uIR = 8). Group differences on measures of cognitive processes and writing were evaluated using ANCOVA. Relationships between these measures were compared for each group through Pearson correlations.

RESULTS

Participants with iCL/P performed within the average range across all measures; group differences were only found for the uIR group. For those with iCL/P, writing was correlated to global cognitive skills rather than more specific skills.

CONCLUSIONS

While this small sample of children with iCL/P demonstrated average writing skills, patterns suggest performance is related to global cognitive reasoning rather than specific cognitive processes as found in unaffected children with impaired reading. Further research is needed to better understand writing in iCL/P and the relationship to reading and cognitive processes.

IMPACT

Research in children with isolated cleft of the lip and/or palate (iCL/P) has demonstrated higher rates of language and reading disorders. No work has assessed written expression in children with iCL/P in over 40 years. This study is the first to evaluate elements of written expression and associated cognitive processes among children with iCL/P in comparison to unaffected children with either average or impaired reading skills. Measures of writing were within the average range for children with iCL/P and demonstrated correlation to global cognitive reasoning rather than to specific cognitive processes as found in unaffected children with impaired reading.

Association between craniofacial anomalies, intellectual disability and autism spectrum disorder: Western Australian population-based study

BACKGROUND

Accurate knowledge of the relationship between craniofacial anomalies (CFA), intellectual disability (ID) and autism spectrum disorder (ASD) is essential to improve services and outcomes. The aim is to describe the association between CFA, ID and ASD using linked population data.

METHODS

All births (1983-2005; n = 566,225) including CFA births (comprising orofacial clefts, craniosynostosis, craniofacial microsomia and mandibulofacial dysostosis) surviving to 5 years were identified from the birth, death, birth defects and midwives population data sets. Linked data from these data sets were followed for a minimum of 5 years from birth until 2010 in the intellectual disability database to identify ID and ASD. These associations were examined using a modified Poisson regression.

RESULTS

Prevalence of ID and ASD was higher among CFA (especially with additional anomalies) than those without [prevalence ratio 5.27, 95% CI 4.44, 6.25]. It was higher among CFA than those with other gastrointestinal and urogenital anomalies but lower than nervous system and chromosomal anomalies. Children with CFA and severe ID had a higher proportion of nervous system anomalies.

CONCLUSIONS

Findings indicate increased ID and ASD among CFA but lower than nervous system and chromosomal anomalies. This population evidence can improve early identification of ID/ASD among CFA and support service planning.

IMPACT

Our study found about one in ten children born with craniofacial anomalies (CFA) are later identified with intellectual disability (ID). Prevalence of ID among CFA was higher than those with other gastrointestinal, urogenital, and musculoskeletal birth defects but lower than those with the nervous system and chromosomal abnormalities. Most children with craniofacial anomalies have a mild-to-moderate intellectual disability with an unknown aetiology. On average, intellectual disability is identified 2 years later for children born with non-syndromic craniofacial anomalies than those with syndromic conditions. Our findings can improve the early identification of ID/ASD among CFA and support service planning.

Phonological Profile of Patients With Velopharyngeal Dysfunction and Palatal Anomalies

PURPOSE

This purpose of this study was to assess the frequency and types of phonological process errors in patients with velopharyngeal dysfunction (VPD) and the different types of palatal anomalies.

METHOD

A total of 808 nonsyndromic patients with VPD, who underwent follow-up at the Center for Cleft Palate and Craniofacial Anomalies, from 2000 to 2016 were included. Patients were stratified into four age groups and five subphenotypes of palatal anomalies: cleft lip and palate (CLP), cleft palate (CP), submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), and non-CP. Phonological processes were compared among groups.

RESULTS

The 808 patients ranged in age from 3 to 29 years, and 439 (54.3%) were male. Overall, 262/808 patients (32.4%) had phonological process errors; 80 (59.7%) ages 3-4 years, 98 (40, 0%) ages 4.1-6 years, 48 (24.7%) 6.1-9 years, and 36 (15.3%) 9.1-29 years. Devoicing was the most prevalent phonological process error, found in 97 patients (12%), followed by cluster reduction in 82 (10.1%), fronting in 66 (8.2%), stopping in 45 (5.6%), final consonant deletion in 43 (5.3%), backing in 30 (3.7%), and syllable deletion and onset deletion in 13 (1.6%) patients. No differences were found in devoicing errors between palatal anomalies, even with increasing age. Phonological processes were found in 61/138 (44.20%) with CP, 46/118 (38.1%) with SMCP, 61/188 (32.4%) with non-CP, 70/268 (26.1%) with OSMCP, and 25/96 (26.2%) with CLP. Phonological process errors were most frequent with CP and least with OSMCP (p = .001).

CONCLUSIONS

Phonological process errors in nonsyndromic VPD patients remained relatively high in all age groups up to adulthood, regardless of the type of palatal anomaly. Our findings regarding the phonological skills of patients with palatal anomalies can help clarify the etiology of speech and sound disorders in VPD patients, and contribute to general phonetic and phonological studies.

Psychosocial Experiences That Support Positive Self-Concept in Children with Cleft Lip and Palate Adopted From China

Objective

Existing psychosocial research offers little information on the unique challenges and strengths of children adopted from China with cleft lip and/or palate (CL/P). The present study aimed to understand biopsychosocial factors that support positive self-concept in this population.

Design

Qualitative, semistructured interviews were conducted with children and their parents. Interpretive phenomenological analysis of transcribed interviews was utilized for data analysis.

Setting

Participants were recruited in an outpatient, pediatric multidisciplinary cleft clinic during a standard team visit.

Patients, Participants

Participants were ages 8 to 12 years with a diagnosis of isolated cleft lip-palate who were internationally adopted from China before the age of 2 years and English-speaking. Participants also included English-speaking parents.

Results

Themes reflecting data from the child and parent subsamples include: (1) child's characteristics, (2) family strengths, (3) adoption identity, (4) cultural identity, (5) coping with a cleft, and (6) social factors. Additional 2 to 3 subthemes were identified for the parent and child subsamples within each broader theme.

Conclusions

Findings from this sample suggested factors supporting positive self-concept included pride and self-efficacy in activities, family support, instilment of family values, strategies for coping with a cleft, family belonging, cultural exposure, and normalization of differences. Medical providers can support patients and families by providing education on surgeries, CL/P sequelae and outcomes, and pediatric medical stress. Mental health providers can screen for social and emotional challenges and provide psychoeducation on racial/ethnic socialization, identity development, and coping.

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.

Aesthetic and psychosocial impact of dentofacial appearance after primary rhinoplasty for cleft lip and palate

The primary aim of this study was to demonstrate whether primary rhinoplasty shows aesthetic and psychosocial advantages for children with a complete unilateral cleft lip and palate. The second aim was to determine the satisfaction levels concerning the dentofacial appearance. Group A corresponded to patients from a center specialised in primary cheilo-rhinoplasty with 20 years' experience and Group B to patients who did not benefit from primary rhinoplasty. Children and their parents filled in a custom-designed satisfaction questionnaire on dentofacial appearance and its psychosocial impact. The variables studied were the main criterion (the nose) and secondary criteria (the upper lip, the smile, the profile and the face as a whole). 56 families consented to be involved in the study. The children did not rate statistically differently their social relationships if they had primary rhinoplasty or not. Parents however expressed very different views. They considered the nasal appearance of the children who had primary rhinoplasty as statistically more attractive and evaluated their psychosocial experience as significantly better. For the other parts of the face, in both groups, satisfaction levels of dentofacial appearance and psychosocial comfort were good (scores above 80/100). Yet, 44% of the families would go for further interventions, especially concerning the nose (13% of whom were in Group A and 42% in Group B). Within the limitations of this study, primary rhinoplasty seems to improve the patient's well-being and social life and, therefore, should be considered whenever appropriate.

Good Outcome for an Individual with Severe Facial Anomalies and Hypogonadotropic Hypogonadism: A Consequence of His Cognitive Function, Pragmatic Approach, and Temperament

The multiple factors that determine outcomes for individuals with visible developmental errors and/or atypical development of the reproductive system are not fully understood. This case report of an individual with Bosma arhinia microphthalmia syndrome causing severe facial anomalies and hypogonadotropic hypogonadism is used to highlight factors that impacted his adjustment from childhood through adulthood. Key factors include his temperament, intact cognitive ability, and pragmatic approach for controlling his physical and social environment. His successful adjustment even in the face of significant early life challenges demonstrates that positive outcomes are attainable for individuals with significant developmental errors. His story and experiences with the health-care system offer insight into some factors that may be pertinent to resilience and lifelong adjustment for patients with similar conditions and the importance of continually seeking the patient's perspective to tailor treatment across the lifespan.

Birth Defect Co-Occurrence Patterns Among Infants With Cleft Lip and/or Palate

OBJECTIVE

To investigate 2- to 5-way patterns of defects co-occurring with orofacial clefts using data from a population-based registry.

DESIGN

We used data from the Texas Birth Defects Registry for deliveries between 1999 and 2014 to Texas residents, including 1884 cases with cleft palate (CP) and 5289 cases with cleft lip with or without cleft palate (CL±P) without a known syndrome. We identified patterns of defects co-occurring with CP and with CL±P observed more frequently than would be expected if these defects occurred independently. We calculated adjusted observed-to-expected (O/E) ratios to account for the known tendency of birth defects to cluster nonspecifically.

RESULTS

Among infants without a syndrome, 23% with CP and 21% with CL±P had at least 1 additional congenital anomaly. Several combinations of defects were observed much more often than expected. For example, the combination of CL±P, congenital hydrocephaly, anophthalmia, and other nose anomalies had an O/E ratio of 605. For both CP and CL±P, co-occurrence patterns with the highest O/E ratios involved craniofacial and brain abnormalities, and many included the skeletal, cardiovascular, and renal systems.

CONCLUSIONS

The patterns of defects we observed co-occurring with clefts more often than expected may help improve our understanding of the relationships between multiple defects. Further work to better understand some of the top defect combinations could reveal new phenotypic subgroups and increase our knowledge of the developmental mechanisms that underlie the respective defects.

Cleft lip/palate and educational attainment: cause, consequence or correlation? A Mendelian randomization study

BACKGROUND

Previous studies have found that children born with a non-syndromic orofacial cleft have lower-than-average educational attainment. Differences could be due to a genetic predisposition to low intelligence and academic performance, factors arising due to the cleft phenotype (such as social stigmatization, impaired speech/language development) or confounding by the prenatal environment. A clearer understanding of this mechanism will inform interventions to improve educational attainment in individuals born with a cleft, which could substantially improve their quality of life. We assessed evidence for the hypothesis that common variant genetic liability to non-syndromic cleft lip with or without cleft palate (nsCL/P) influences educational attainment.

METHODS

We performed a genome-wide association study (GWAS) meta-analysis of nsCL/P with 1692 nsCL/P cases and 4259 parental and unrelated controls. Using GWAS summary statistics, we performed Linkage Disequilibrium (LD)-score regression to estimate the genetic correlation between nsCL/P, educational attainment (GWAS n = 766 345) and intelligence (GWAS n = 257 828). We used two-sample Mendelian randomization to evaluate the causal effects of genetic liability to nsCL/P on educational attainment and intelligence.

RESULTS

There was limited evidence for shared genetic aetiology or causal relationships between nsCL/P and educational attainment [genetic correlation (rg) -0.05, 95% confidence interval (CI) -0.12 to 0.01, P 0.13; MR estimate (βMR) -0.002, 95% CI -0.009 to 0.006, P 0.679) or intelligence (rg -0.04, 95% CI -0.13 to 0.04, P 0.34; βMR -0.009, 95% CI -0.02 to 0.002, P 0.11).

CONCLUSIONS

Common variants are unlikely to predispose individuals born with nsCL/P to low educational attainment or intelligence. This is an important first step towards understanding the aetiology of low educational attainment in this group.

Parent-reported socioemotional and cognitive development in children with a cleft lip and/or palate at 18 months: Findings from a UK birth cohort

BACKGROUND

One of the most common congenital conditions in the world, cleft lip and/or palate (CL/P) has been shown to potentially impact long-term physical and developmental outcomes in affected children. However, little is known about the factors that contribute to such outcomes, and there is a lack of consensus about which screening tools may be most effective. The aims of the current study were (a) to assess parent-reported socioemotional and cognitive development in children born with CL/P at 18 months of age; (b) to identify factors associated with the incidence of developmental concerns; and (c) to assess the utility of the widely recommended Ages and Stages Questionnaires (ASQs) in identifying developmental concerns from an early age in the CL/P population.

METHODS

Parent-reported questionnaire data were extracted from The Cleft Collective Cohort Study for 322 mothers of children with CL/P aged 18 months.

RESULTS

Mean scores across both ASQ measures indicated typical development in the study sample overall. However, 31.1% of children met a referral criterion on at least one domain. Child-related risk factors included problems with physical development and feeding method. Parent-related risk factors included the mother's levels of anxiety and depression and mother's marital status. Additional developmental concerns extracted from mothers' qualitative data included feeding difficulties, speech development, sleep patterns, aggressive behaviours, vision, oral health, hearing, breathing and motor skills.

CONCLUSIONS

The majority of children in this study were developing as expected at 18 months of age. However, parent-reported developmental concerns were identified in a minority of children, suggesting a need to screen for potential risk factors in routine practice. Further, the ASQ appears to offer a viable option in the early identification of developmental concerns in children with CL/P. A combined medical and systemic approach to healthcare is recommended to support the prevention of long-term developmental concerns in the child and poor psychological adjustment in parents.

Behavioral Outcomes in Children With an Orofacial Cleft in a National Study in New Zealand

OBJECTIVE

To determine whether children with an orofacial cleft have higher levels of behavioral problems than the general population and whether this differs by cleft phenotype.

DESIGN

A cohort of children with cleft lip and/or palate (CL/P) born in New Zealand from January 1, 2000.

SETTING

Cleft clinics in New Zealand participating in a larger outcomes study between 2014 and 2017.

PARTICIPANTS

Children (N = 378) aged 5 to 12 years of age and their parents.

MAIN OUTCOMES

The Strengths and Difficulties Questionnaire (SDQ) and Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales 4.0 and Family Impact Module 2.0.

RESULTS

Compared to standardized norms, children with a cleft had higher than expected (defined as 20%) levels of abnormal/borderline SDQ scores for conduct problems (27.4%, P = .0003) and peer relationship problems (31.6%, P < .0001) but lower than expected levels of problems with pro-social skills (6.3%, P < .0001). There were no significant differences by age-group and or cleft phenotype other than an increased risk of hyperactivity in children with CP compared to children with CL. Total difficulties SDQ scores had moderate correlations with the PedsQL.

CONCLUSIONS

While over 90% of children with CL/P had normal prosocial skills, they may not be easily accepted by their peers which may result in behavioral problems. These concerns were moderately related to lower quality of life. Support for establishment and maintenance of peer relationships is important to address externalizing and peer difficulties in children with CL/P. Community knowledge and understanding of CL/P needs to continue to be promoted.

An Exploratory Study of Speech and Language Therapy Intervention for Children Born With Cleft Palate ± Lip

INTRODUCTION

Children born with a cleft palate ± lip are at risk of developing speech and language difficulties, which may require intervention from a speech and language therapist (SLT). To date, there is no strong evidence to support one approach to intervention over another, neither is it clear which approaches or methods of provision are commonly used.

OBJECTIVES

To describe the range of speech and language therapy interventions being used with children born with cleft palate in the United Kingdom up to 5 years of age. To explore the different ways, interventions are being delivered.

DESIGN

A prospective study to conduct 9 semi-structured focus groups. Iterative content analysis was completed.

SETTING

Regional Cleft Lip and Palate Centers in the United Kingdom.

PARTICIPANTS

Sixty-two speech and language therapy professionals from specialist cleft teams and community services.

RESULTS

Four main codes were identified: "intervention approaches," "service delivery models," "decision-making and rationale," and "patient-centered care." Participants frequently discussed how they adopt an eclectic style when delivering intervention, the importance of an individualized approach for each child and service delivery constraints, such as a lack of resources.

CONCLUSION

Insight into the multitude of intervention approaches used by SLTs, aspects which influence their decision-making and the variability of service delivery models were gained. Uncertainty regarding which intervention approaches and methods for delivery are most effective provides rationale for future research, to improve the effectiveness of speech and language intervention for children with cleft palate ± lip.

Randomized controlled trial comparing Parent Led Therapist Supervised Articulation Therapy (PLAT) with routine intervention for children with speech disorders associated with cleft palate

BACKGROUND

A total of 68% of pre-school children with cleft palate have speech problems requiring speech therapy. There is a lack of access to regular targeted therapy. Parent training leads to positive outcomes in early communication skills in cleft palate and non-cleft speech disorders. Connected health has been used to address inadequate access to therapy, providing intervention to those who would not otherwise receive therapy.

AIMS

To evaluate the speech, activity and participation outcomes of Parent Led, Therapist Supervised, Articulation Therapy (PLAT) compared with routine speech therapy intervention in parent-child dyads.

METHODS & PROCEDURES

A total of 44 children, aged 2.9-7.5 years, were included in a two-centre, two-phase randomized controlled trial. Informed consent and assent were obtained. Participants and speech and language therapists (SLTs) were unblinded to the groups. Parents, in the parent-trained group (n = 23), attended 2 days' training, received a detailed speech therapy programme, and undertook intervention over 12 weeks supported by the cleft specialist SLT using FaceTime and one face-to-face session. In the control arm (n = 21), parent-child dyads received six therapy sessions over 12 weeks with a research SLT, comparable with usual care. Speech recordings were undertaken pre- and post-intervention. Percent consonant correct (PCC) was analysed by external SLTs blinded to the time and group. Activity and participation were measured using the Intelligibility in Context Scale (ICS) and Focus on Outcomes for Children Under Six (FOCUS) questionnaire.

OUTCOMES & RESULTS

There was no evidence of an interaction between Time and Group or an overall statistical difference between groups for PCC scores. There was a statistically significant difference over time for both groups (words: p < 0.002; confidence interval (CI) = 9.38-16.27; d = 0.57; sentences: p < 0.002; CI = 16.04-25.97; d = 0.23). Effect sizes were medium for words and small for sentences. For intelligibility and participation, there was no evidence of an interaction between Time and Group or an overall statistical difference between groups. A statistically significant difference over time was found for intelligibility (F = 29.97, d.f. = 1, 42, p < 0.001, 95 % CI = 1.45-3.15 d = 0.46) and for participation (F = 14.19, d.f. = 1, 41, p < 0.001 95% CI = 7.63-25.03; d = 0.36) with FOCUS results indicating clinically meaningful (parent-led group) and significant (control group) change in participation.

CONCLUSIONS & IMPLICATIONS

PLAT can be as effective as routine care in changing speech, activity and participation outcomes for children with cleft palate, when supported by a specialist cleft SLT using connected health. What this paper adds What is already known on this subject Over 50% of children with cleft palate require speech therapy. However, there is a lack of timely, accessible speech therapy services in the UK and Ireland. Previous studies have shown that parents can deliver therapy effectively, and that connected health can support the delivery of speech therapy. This study aims to provide evidence that parent-led therapy with the supervision of a specialist cleft therapist using FaceTime is effective. What this paper adds to existing knowledge This randomized controlled trial indicates that parents can be trained to deliver therapy for children with cleft palate speech disorders, under the supervision of an SLT. This approach results in improved speech, activity and participation outcomes similar to routine care. What are the potential or actual clinical implications of this work? This study indicates that both parent-led articulation therapy and routine care showed meaningful gains in speech, activity and participation, and that parent-led articulation therapy when supported by a cleft SLT using connected health could be an additional service delivery model for children with cleft palate speech disorders.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Care of the Asian American Child With Cleft Lip or Palate

Orofacial clefts are one of the most common global birth defects. Orofacial clefts may be part of a syndrome or an isolated birth defect, and affect approximately 1-1.5 per 1,000 live births worldwide with noted inequalities across geographical areas and cultures. In the United States, Asian American populations have a substantially higher incidence of cleft lip with or without cleft palate (2/1,000 live births). Orofacial clefts are a key health issue with substantial health care costs, and associated medical, psychological, and social ramifications. It has been estimated that the health care costs within the United States are approximately $697 million over a child's lifetime. In disorders like orofacial clefts, because of the complexity of the condition and subsequent medical interventions, as well as the cultural intricacies of the Asian culture, it requires significant knowledge and understanding by the health care providers. In order to provide optimal and safe cleft care, reduce health care costs, and improve the outcomes for the Asian American population, a culturally sensitive, multidisciplinary, and coordinated approach is needed. Increased culturally specific education, early access to prenatal care, and ongoing infant and pediatric health care are essential.

Psychological Variables in Children and Adolescents with Cleft Lip and/or Palate

Objective: This review analyzes the psychological variables most frequently studied over the last 10 years in children and adolescents with cleft lip/palate (CL/P). Such variables are assumed to be the keys to these patients' psychosocial adjustment. Study design: Articles published from January 2007 to February 2017 were retrieved from PubMed to identify the psychological variables most commonly studied in children and adolescents with CL/P, irrespective of gender or type of cleft. The search terms were "cleft palate" and "psychology", with the operator AND. Results: Of the 324 articles retrieved, 26 met the criteria for inclusion in the review. The psychological variables most extensively studied over the years were children's social functioning, quality of life and ability to cope. Conclusion: While CL/P patients' quality of life was unanimously agreed to be affected, no consensus was found in the literature on social functioning or coping. In addition to the cleft, patient adjustment was reported to be governed by individual variables and mediators. The range of ages most frequently studied was 7 to 16.

Facilitating Positive Psychosocial Outcomes in Craniofacial Team Care: Strategies for Medical Providers

Objective:

Psychosocial issues associated with craniofacial diagnoses and the ongoing burden of care can impact the quality of life of patients and families, as well as treatment adherence and outcomes. Utilizing available literature and clinical expertise across 6 centers, the present article summarizes key psychosocial issues for the benefit of nonmental health medical providers and offers suggestions as to how all members of craniofacial teams can promote positive psychosocial outcomes.

Results:

Family adjustment across developmental phases is outlined, with strategies to support adaptive parental coping. Teasing is a common concern in craniofacial populations and medical providers can promote coping and social skills, as well as link families to mental health services when needed. Academic issues are described, alongside suggestions for medical providers to assist families with school advocacy and ensure access to appropriate services within the school setting. Medical providers are key in preparing patients and families for surgery, including consideration of medical, social, and logistical supports and barriers. As craniofacial care spans infancy to adulthood, medical providers are instrumental in assisting patients and families to navigate treatment transition periods. In addition to ongoing clinical team assessments, medical providers may utilize screening measures to identify and track patient and family adjustment in multiple areas of team care.

Conclusions:

Multidisciplinary providers play an important role in supporting positive adjustment in patients affected by craniofacial conditions and their families.

Adherence to Orthodontic Treatment in Youth With Cleft Lip and/or Palate

OBJECTIVE

To identify rates of nonadherence to orthodontic treatment among youth with cleft lip and/or palate (CL/P) and to compare demographic and clinical characteristics of patients categorized as adherent or nonadherent.

DESIGN

Retrospective chart review.

SETTING

Orthodontic treatment program affiliated with a US pediatric hospital-based craniofacial team.

PARTICIPANTS

Medical charts of 54 patients with CL/P beginning phase I or phase II orthodontics between 2011 and 2014 (54% male; mean age: 11.7 ± 3.2 years) were reviewed.

MAIN OUTCOME MEASURE(S)

Data abstracted included demographic and clinical characteristics. Patients were classified as nonadherent based upon treatment termination due to nonadherence, treatment courses extending beyond 3 years, and information about missed appointments, poor oral hygiene, and broken appliances.

RESULTS

In all, 24% had treatment terminated due to nonadherence and were significantly more likely to have behavioral health diagnoses (P = .01) or visits (P = .02) and social work consults (P = .01) than patients without termination. Thirty-seven percent had treatment courses beyond 3 years; youth with longer courses were significantly more likely to have cleft lip and palate versus cleft palate only or cleft lip (P = .03). Patients who missed more than 4 appointments were less likely to have behavioral health diagnoses (P < .01) compared to those with fewer missed appointments. Poor hygiene and broken appliance notations were common. Youth with poor hygiene notations were significantly older (P < .01) at treatment initiation than those without notations.

CONCLUSIONS

Nonadherence was associated with diagnosis, age, and history of behavioral health or social work involvement. An understanding of adherence and relationships with clinical and demographic factors can inform clinical care and support intervention development to improve outcomes.

Care of the Asian American Child With Cleft Lip or Palate

Orofacial clefts are one of the most common global birth defects. Orofacial clefts may be part of a syndrome or an isolated birth defect, and affect approximately 1-1.5 per 1,000 live births worldwide with noted inequalities across geographical areas and cultures. In the United States, Asian American populations have a substantially higher incidence of cleft lip with or without cleft palate (2/1,000 live births). Orofacial clefts are a key health issue with substantial health care costs, and associated medical, psychological, and social ramifications. It has been estimated that the health care costs within the United States are approximately $697 million over a child's lifetime. In disorders like orofacial clefts, because of the complexity of the condition and subsequent medical interventions, as well as the cultural intricacies of the Asian culture, it requires significant knowledge and understanding by the health care providers. In order to provide optimal and safe cleft care, reduce health care costs, and improve the outcomes for the Asian American population, a culturally sensitive, multidisciplinary, and coordinated approach is needed. Increased culturally specific education, early access to prenatal care, and ongoing infant and pediatric health care are essential.

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.

Identifying Three-Dimensional Facial Fluctuating Asymmetry in Normal Pediatric Individuals: A Panel Assessment Outcome Study of Clinicians and Observers

This study measured three-dimensional facial fluctuating asymmetry in 600 normal and healthy Taiwanese individuals (6 to 12 years old) and assessed the perceptions of increasing levels of facial fluctuating asymmetric severity by using a panel composed of 20 clinicians (surgical professionals), as well as 20 adult and 40 pre-adolescent observers. On average, this normal cohort presented a facial fluctuating asymmetry of 0.96 ± 0.52 mm, with 0.52 ± 0.05, 0.67 ± 0.09, 1.01 ± 0.10, and 1.71 ± 0.36 mm for levels I, II, III, and IV of severity, respectively. For all categories of raters, significant differences in the average symmetry-asymmetry scale values were observed, with level I < level II < level III = level IV (all p < 0.01, except for level III vs. IV comparisons with p > 0.05). For level I, pre-adolescent observers presented a significantly (p < 0.05) higher symmetry-asymmetry scale value than adult observers, with no significant (all p > 0.05) differences for other comparisons. For overall facial asymmetry and levels II, III, and IV, no significant (all p > 0.05) differences were observed. This study reveals that the normal pediatric face is asymmetric and the panel assessment of facial fluctuating asymmetry was influenced by the level of severity and the category of raters and contributes to the literature by revealing that pre-adolescent raters present a similar or higher perception of facial asymmetry than adult raters.

Increased Risk for Neurodevelopmental Disorders in Children With Orofacial Clefts

OBJECTIVE

Children with orofacial clefts (OFC) may have an increased risk of poor mental health. This study aimed to investigate the risk of psychiatric diagnoses in individuals with OFC, stratified by cleft type.

METHOD

A nationwide register-based cohort of all individuals born with nonsyndromic OFC in Sweden between 1973 and 2012 (n = 7,842) was compared to a matched cohort (n = 78,409) as well as to their unaffected siblings (n = 9,637). The risk of psychiatric diagnoses, suicide attempts, and suicides was examined by crude and adjusted Cox regression models. Effect modification by sex was investigated with interaction terms in the models.

RESULTS

Children with cleft lip (CL) had a significantly higher risk of any psychiatric disorder, intellectual disability, and language disorders; children with cleft lip and palate (CLP) had, in addition, an increased risk of autism spectrum disorder (ASD). Children with cleft palate only (CPO) had risk increases for the same diagnoses as children with CL and CLP, but with higher hazard ratios, and also for psychotic disorders, attention-deficit/hyperactivity disorder (ADHD), and other behavioral or emotional disorders in childhood. Sex stratification indicated higher risk increases among females in CL and CLP but not in CPO. Siblings without OFC were less likely to be diagnosed with any psychiatric disorder, intellectual disability, language disorder, ASD, or ADHD compared to their siblings with OFC.

CONCLUSION

Children with nonsyndromic clefts had a significantly higher risk of neurodevelopmental disorders. This risk is unlikely to be explained by familial influences such as inherited genetic or shared environmental factors.

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.

Associations Between Parenting Stress at School Entry and Later Psychosocial Adjustment: A Longitudinal Study of Children With Congenital Craniofacial Anomalies

OBJECTIVE

To examine the reciprocal relationships between parenting stress and psychosocial adjustment of children with congenital craniofacial anomalies (CFAs) at 2 time points: school entry and approximately 2.5 years later, after children had time to adjust to school.

DESIGN

Retrospective review of medical charts of children with CFAs.

SETTING

Department of reconstructive plastic surgery at an urban medical center.

PARTICIPANTS

Parents of 42 children aged 3.9 to 6.5 years at time 1 and 6.5 and 9.8 years at time 2.

MAIN OUTCOME MEASURES

Parenting Stress Index/Short Form and Child Behavior Checklist (CBCL), both completed by parents at time 1 and time 2.

RESULTS

Compared to norms, more parents scored in the clinical range on parenting stress both at time 1 and time 2. Parenting stress remained stable across the 2 time points. Although rates of psychosocial problems for boys were comparable to those of the CBCL normative sample, higher-than-expected rates of clinically significant internalizing and externalizing were found for girls at time 2. Parenting stress at time 1 was associated with child internalizing and externalizing problems at time 2. Whereas child externalizing problems at time 1 predicted parenting stress at time 2, child internalizing at time 1 showed trivial effects on time 2 parenting stress.

CONCLUSIONS

Early school years may be a period that is particularly stressful for parents of children with CFAs. There appears to be a transactional relationship between parenting stress and child psychosocial adjustment during the early school years.

Short- and Long-Term Effects of Late Maxillary Advancement With the Liou-Alt-RAMEC Protocol in Unilateral Cleft Lip and Palate

Objective:

The objective of this retrospective longitudinal study was to evaluate short- and long-term results of the application of the Liou Alt-RAMEC (alternate rapid maxillary expansion and constriction) technique, a late orthopedic maxillary protraction technique, with intraoral anchorage, in patients with cleft.

Materials and Methods:

Twenty-six patients with unilateral cleft lip and palate (UCLP) were consecutively treated with the Alt-RAMEC technique. The average age of the patients was 11.7 years (10.3-13.2 years) before protraction and 18.3 years (17.4-21.1 years) at long-term follow-up. A sample of nontreated patients with UCLP was used as a control group. It was matched for sex, skeletal class III, and age (11.3 years). The control sample had records at the end of growth (18.7 years).

Results:

The sagittal advancement of A-point, after the application of the technique, was 5.7 (2.17) mm. Some mandibular dentoalveolar and positional adaptation was noted. The position of the maxilla was stable in the long term. On the other hand, the UCLP control group showed hardly any growth at the maxillary level during the long-term follow-up period.

Conclusion:

Our results showed that the Alt-RAMEC technique, performed at the correct time, with a double-hinged expander, followed by class III spring or elastic traction, 24 hours per day, allows for satisfactory maxillary protraction, with, at this stage, apparently stable long-term results. Nevertheless, as only 50% of the patients had long-term follow-up data, we are still unable to predict the percentage of patients which will not eventually need orthognathic surgery.

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

Background:

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

Design:

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

Results:

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

Conclusions:

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

Adult Narratives of the Psychosocial Impact of Cleft in a Western Australian Cohort

BACKGROUND

Living with a cleft condition involves many years of multidisciplinary therapy, treatment, and surgical intervention. This complex process may have both physical and psychosocial long-term impacts. There is limited evidence of the psychosocial impact of cleft on individuals in Australia.

AIM

To obtain an understanding of the adult patient perception of having a cleft and explore the impact of the condition on their lives.

DESIGN

Qualitative methodologies at one case study site in Western Australia.

POPULATION OF INTEREST

Adults with a cleft lip and/or palate (CL/P) who had received treatment at Princess Margaret Hospital, the only treatment center for cleft in Western Australia.

METHODOLOGY

Individual in-depth semi-structured qualitative interviews were conducted and recorded and transcribed for analysis.

RESULTS

Fifteen adults with a CL/P. Two main themes were identified: lived experience (with 3 subthemes: normality, support networks, and impacts in later life) and advice to others. The majority of participants reported social rejection and isolation, which occurred mostly at school and in some instances at home, but did not often last into adulthood. The greatest protective factor was the support of family and friends, which if missing during their childhood, was desired and appreciated in adulthood.

CONCLUSION

Adults with CL/P may require psychosocial support from their cleft team including referral to clinicians in adult services. There is also the need for earlier psychological interventions and social programs to support those with appearance-related social difficulties.

Early academic achievement in children with isolated clefts: a population-based study in England

OBJECTIVES

We used national data to study differences in academic achievement between 5-year-old children with an isolated oral cleft and the general population. We also assessed differences by cleft type.

METHODS

Children born in England with an oral cleft were identified in a national cleft registry. Their records were linked to databases of hospital admissions (to identify additional anomalies) and educational outcomes. Z-scores (signed number of SD actual score is above national average) were calculated to make outcome scores comparable across school years and across six assessed areas (personal development, communication and language, maths, knowledge of world, physical development andcreative development).

RESULTS

2802 children without additional anomalies, 5 years old between 2006 and 2012, were included. Academic achievement was significantly below national average for all six assessed areas with z-scores ranging from -0.24 (95% CI -0.32 to -0.16) for knowledge of world to -0.31 (-0.38 to -0.23) for personal development. Differences were small with only a cleft lip but considerably larger with clefts involving the palate. 29.4% of children were documented as having special education needs (national rate 9.7%), which varied according to cleft type from 13.2% with cleft lip to 47.6% with bilateral cleft lip and palate.

CONCLUSIONS

Compared with national average, 5-year-old children with an isolated oral cleft, especially those involving the palate, have significantly poorer academic achievement across all areas of learning. These outcomes reflect results of modern surgical techniques and multidisciplinary approach. Children with a cleft may benefit from extra academic support when starting school.

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

OBJECTIVE

The focus of this study was to determine if there is any significant difference in academic achievement for girls and boys with a cleft compared to the general population of Swedish students at graduation from compulsory school.

DESIGN

A retrospective population-based study using data obtained from the Swedish Medical Birth Register that was linked to the Swedish School-Grade Register.

PARTICIPANTS

Two hundred seventy girls and 241 boys with cleft palate (CP), 222 girls and 429 boys with cleft lip (CL), and 299 girls and 531 boys with cleft lip and palate (CLP) were compared with the compulsory school population comprising 609,397 girls and 640,007 boys.

MAIN OUTCOME MEASURES

(1) Odds of receiving the lowest grade and reduced odds in receiving high grades in Mathematics, English, and Swedish. (2) grade point average (GPA).

RESULTS

In all 3 subject grades, for boys with cleft there was no difference when compared to the male population. Girls with cleft were similar to their peers with a few exceptions. Girls with CLP had lower Math grades, and girls with CP had lower Math, English, and Swedish grades. Girls with CP and CLP achieved a significantly lower GPA in comparison to the female population and boys with CP and CL achieved lower GPAs in comparison to the male population.

CONCLUSIONS

This study indicates that educational outcomes for girls with cleft are more negatively affected than for boys with cleft.

Early Reading Abilities of Bilingual Children With Nonsyndromic Orofacial Clefts

OBJECTIVE

To investigate the early reading abilities, and related cognitive-linguistic processes, in bilingual children with nonsyndromic cleft lip and/or palate (CL/P), and to identify deficits that might be amenable to intervention.

DESIGN AND PARTICIPANTS

Bilingual participants with CL/P aged 5 to 6 years who were English-dominant ( n=17) or Mandarin-dominant ( n=18) were recruited using consecutive sampling from a national cleft treatment center and matched pairwise to a sample of typically developing (TD) children on language dominance, age, and socioeconomic status. All participants were assessed in English on single-word reading accuracy using the Wide Range Achievement Test (4th Ed), and key cognitive-linguistic factors associated with reading development: phonological awareness, rapid automatized naming (RAN), receptive and expressive vocabulary, and verbal short-term and working memory.

RESULTS

CL/P and TD groups were compared within language dominance group (Mandarin or English) for all measures. The Mandarin-dominant CL/P group had significantly poorer reading accuracy and phonological awareness than their TD peers. Additionally, regardless of language dominance, faster RAN correlated significantly with better reading accuracy in both the CL/P groups but not the TD groups.

CONCLUSIONS

Children with CL/P who are learning English as a second language are at greater risk of reading difficulties. Furthermore, the cognitive-linguistic processes underlying early reading in bilingual children with CL/P differ from those of their TD peers. Routine screening and tailored intervention is advisable.

Common basis for orofacial clefting and cortical interneuronopathy

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