Toward a Reconsideration of Inclusion and Exclusion Criteria in Cleft Lip and Palate: Implications for Psychological Research

Establishing an International Interdisciplinary Research Network in Craniofacial Microsomia: The CARE Program

OBJECTIVE

Craniofacial microsomia (CFM) is a broad clinical term used to describe a congenital condition most commonly involving the underdevelopment of the external ear, mandible, soft tissues, and facial nerve. Despite medical advances, understanding of the psychological health and healthcare experiences of individuals with CFM and their caregivers remains limited. This article describes a research program designed to address these knowledge gaps, and identify opportunities for psychosocial intervention and improved healthcare provision.

DESIGN

The Craniofacial microsomia: Accelerating Research and Education (CARE) research program aims to: 1) Conduct up to 160 narrative interviews with individuals and caregivers to validate a conceptual framework; 2) Administer an online international survey of up to 800 individuals with CFM and caregivers to identify predictors of psychological distress; 3) Perform up to 60 semi-structured interviews with healthcare providers and advocacy leaders to examine the extent to which current healthcare provisions address identified patient needs; and 4) Establish a participant registry to build a longitudinal database and develop an international community.

RESULTS

Teams in the USA and UK have been established, alongside an international, interdisciplinary Advisory Committee. Data analysis for Aim 1 is ongoing and informing the delivery of Aims 2-3. Aim 4 is also in development. A dedicated website serves as a recruitment tool, educational resource, and mechanism for engaging with the CFM community.

CONCLUSIONS

The CARE program provides a comprehensive approach to understanding the experiences of individuals with CFM and their caregivers. Challenges encountered and lessons learned are shared for the benefit of the community.

Psychological and Peer Difficulties of Children with Cleft Lip and/or Palate: A Systematic Review and Meta-Analysis

OBJECTIVES

A systematic review and meta-analysis were conducted to determine if children born with cleft lip and/or palate are at increased risk of psychological and peer difficulties, and if so, which difficulties they develop.

METHODS

EMBASE, MEDLINE, and PsycINFO were searched for English language studies published between January 2005 and January 2022 which investigated the psychological outcomes and peer function of children with nonsyndromic cleft lip and palate. Outcomes included internalizing problems, such as anxiety and depression, externalizing problems, such as hyperactivity, conduct disorders, self-concept including self-image and self-esteem, peer problems, resilience, coping, and overall psychological function. A risk of bias assessment was performed using the Newcastle-Ottawa Scale. Random effects models were used in the meta-analysis to compare the outcomes for children born with a cleft and those without.

RESULTS

In total 41 studies met inclusion criteria, with 9 included in the meta-analysis. Children born with a cleft appear to have similar psychological outcomes compared to normative controls when using the strengths and difficulties questionnaire. There are some minor differences between self-report and parent report, with parents generally reporting that their child with a cleft has increased emotional, conduct, and hyperactivity problems. The small differences between the study cohort and control cohorts are unlikely to imply any differences on a clinical level.

CONCLUSIONS

Overall psychological outcomes appear to be similar between children born with a cleft and the nonaffected population, however, some symptoms such as anxiety and depression appear higher in children with cleft lip and/or palate.

Psychological and Physical Health Outcomes in Adults With Craniosynostosis

OBJECTIVES

Within current research, little is known about the long-term outcomes of craniosynostosis. A priority-setting exercise by UK charity Headlines Craniofacial Support identified 2 key questions in this area: (1) What are the long-term physical and psychological effects for individuals with syndromic and non-syndromic craniosynostosis? and (2) Are individuals with craniosynostosis likely to suffer from mental health difficulties, or are they more resilient? The aim of the current study was to conduct an initial investigation of these priority questions.

METHODS

A comprehensive UK-wide survey consisting of 9 standardized psychological outcome measures and open-ended questions was distributed online. Thirty-six eligible adults (69.4% female) with a mean age of 30.8 years responded to the survey. Participants reported having single suture craniosynostosis (27.8%) or syndromic craniosynostosis (52.8%), with 19.4% being unsure of their diagnosis. Sample means were compared to published norms using independent samples t tests. Qualitative responses were analysed using inductive content analysis.

RESULTS

Compared to the general population, participants reported significantly less favorable scores related to appearance concerns, attachment in adult relationships, anxiety, optimism, and resilience. Self-worth, depression, and social anxiety scores were similar to norms. Qualitative responses provided additional insight into participants' satisfaction with appearance, physical health, medical treatment, employment, relationships, and recurrence risks. Few participants had accessed psychological support.

DISCUSSION

This preliminary study illustrates the potential long-term implications for individuals with craniosynostosis. Improved treatment protocols are needed to address physical health concerns in adulthood, while dedicated psychological resources are necessary to promote emotional well-being, social confidence, and resilience.

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.

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.

Physical Health in Adults Born With Cleft Lip and/or Palate: A Whole of Life Survey in the United Kingdom

Objectives:

Previous research in the field of cleft lip and/or palate (CL/P) has indicated a high prevalence of common health concerns, functional difficulties, and additional conditions known to affect long-term physical health, cognitive development, and psychological well-being. The aim of the present study was to examine the self-reported physical health of a national sample of adults born with CL/P.

Design:

Drawing upon previous literature, an online, mixed-methods survey was designed by the Cleft Lip and Palate Association in collaboration with the Centre for Appearance Research at the University of the West of England. A total of 207 eligible responses were received between July and October 2018. Qualitative data were analyzed using inductive content analysis, while quantitative data were analyzed using descriptive statistics.

Results:

A considerable proportion of participants reported one or more comorbid conditions, including common health concerns, difficulties related to language and/or learning, unresolved speech and/or hearing issues, problems with vision, breathing difficulties, and concerns related to eating and drinking. Many participants were unaware of their entitlement to specialist treatment, and some had experienced difficulties accessing specialist services through their general practitioner (GP).

Conclusions:

Individuals with CL/P may be at risk of physical health issues persisting into adulthood. The monitoring of physical symptoms from an early age is recommended, as is a routine physical assessment for adults returning to the CL/P service later in life. Education for both GPs and adults is warranted. Future studies could investigate the wider prevalence of comorbid conditions in CL/P, in order to better understand the longer-term health burden.

Psychosocial Adjustments Among Adolescents With Craniofacial Conditions and the Influence of Social Factors: A Multi-Informant Study

BACKGROUND

Previous studies have investigated psychosocial adjustments among adolescents with cleft lip and/or palate (CL/P), but our understanding of other craniofacial conditions remains limited. The objective of this study is to compare psychosocial adjustments among 3 groups of adolescents: craniofacial conditions other than cleft lip and/or palate (craniofacial anomaly [CFA]), CL/P, and controls (CON). Our secondary objective is to examine how social factors may predict the adjustments levels.

DESIGN

Cross-sectional, multi-informant, controlled survey study.

PARTICIPANTS

Aged 11- to 17-year olds. Craniofacial anomaly (n = 49), isolated CL/P (n = 42), and 55 CON. Total = 146.

OUTCOME MEASURES

The Strengths and Difficulties Questionnaire (self-report, parent report, and teacher report).

RESULTS

All 3 informant groups displayed similar patterns, where CFA reported the highest difficulties, followed by CL/P, while CON scored the lowest. Parent reports demonstrated significant differences among the 3 groups for most subscales and were emphasized for peer problems. Self-reports showed significant differences between CFA and CON for total scores and peer problems, while teacher reports showed significant differences for peer problems only. Craniofacial anomaly displayed the highest frequency of abnormal psychosocial adjustments, followed by CL/P. Experiencing bullying or teasing predicted increased difficulties, while having a good friend predicted decreased difficulties.

CONCLUSIONS

Adolescents with CFA, and to a lesser extent CL/P, may be at a higher risk of having psychosocial problems. Peer problems may constitute the biggest challenge that CFA and CL/P confront. Social factors, especially being bullied or having a good friend, may predict the psychosocial well-being of adolescents with craniofacial conditions.

Health-related quality of life in patients with cleft palate: Reproducibility, responsiveness and construct validity of the Dutch version of the VELO questionnaire

OBJECTIVES

Recently, the Velopharyngeal Insufficiency (VPI) Effects on Life Outcomes (VELO) questionnaire, which evaluates the impact of speech and swallowing difficulties on health-related quality of life (HRQoL) in patients with VPI (Skirko et al., 2012), was translated to Dutch (Bruneel et al., 2017). The purpose of this study was to evaluate the reproducibility, responsiveness and construct validity of this Dutch version of the questionnaire.

METHODS

To evaluate the reproducibility, 50 parents and 14 children with cleft palate re-completed the questionnaire after two weeks. Thirty-five parents and 8 children with cleft palate completed the VELO questionnaire after one year for the evaluation of the responsiveness. The correlation between age and the VELO questionnaire (construct validity), and the internal consistency (Cronbach's α) were re-determined based on the responses of 73 parents and 24 children.

RESULTS

Based on descriptive statistics, results of the Wilcoxon signed rank-test, and the absolute (SEM) and relative (ICC) consistency, the questionnaire showed good reproducibility. VELO scores did not significantly differ after one year, neither when performing separate analyses for the intervention (speech therapy) and the non-intervention group. Correlations indicated higher HRQoL, as perceived by the parents, with increasing age. The reverse was the case for the youth report. Cronbach's α showed excellent internal consistency for both reports.

CONCLUSIONS

The VELO questionnaire showed good reproducibility and internal consistency. Moreover, results reconfirmed the age effect on VELO scores. To understand the implications of the results regarding the questionnaire's responsiveness, future research should focus on the identification of factors influencing the patient's evolution in HRQoL.

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

Background:

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

Design:

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

Participants:

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

Outcome Measures:

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

Results:

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

Conclusions:

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

Effects of cleft lip and palate on children's psychological health: A systematic review

OBJECTIVES

This study aimed to evaluate the psychological effects of cleft lip and palate (CLP) on children and their parents and to determine any relationship between social support and timing of surgical repairs for these defects.

METHODS

A systematic review that followed the problem, intervention, comparison, outcome and setting (PICOS) method was used. The participants were children with CLP, interventions were surgical corrections and/or social support, comparison occurred with children with neither surgical corrections nor social support, outcomes were psychological effects and the study design was a systematic review. Four electronic databases, EBSCO, ProQuest, Science Direct, and PsycInfo were used to search for studies over the period of ten years (January 2007 until January 2017). The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2009 guidelines on systematic review reporting were used for this study.

RESULTS

Searching through four databases revealed 53,346 articles; however, only 26 articles that met the inclusion criteria were included. There were few articles about children.

CONCLUSIONS

CLP is not only connected to psychological effects which distress children's self-esteem and psychological functions, it also extends to their parents, particularly their mothers. However, parental and social support seem to have positive influences by reducing these psychological effects.

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.

Risk factors and comorbidities in Brazilian patients with orofacial clefts

Considering that environmental risk factors substantially contribute to the etiology of orofacial clefts and that knowledge about the characteristics and comorbidities associated with oral clefts is fundamental to promoting better quality of life, this study aimed to describe the risk factors, main characteristics, and comorbidities of a group of patients with cleft lip and/or cleft palate (CL/P) from Rio Grande do Norte (RN), Brazil. Data were obtained from 173 patients with CL/P using a form from the Brazilian database on Orofacial Clefts. Most patients were male with cleft lip and palate and had a normal size and weight at birth; presented few neonatal intercurrent events; and had anemia and respiratory and cardiovascular diseases as main associated comorbidities. They also required timely surgical rehabilitation and multidisciplinary care to stimulate their neuropsychomotor development. In addition, a high frequency of familial recurrence and of parental consanguinity was evidenced in the studied population, especially for the cleft lip and cleft palate type. Other relevant findings were the considerable maternal exposure to alcohol, infections, smoking, and hypertension, as well as low supplementation with vitamins and minerals and deliberate consumption of analgesics, antibiotics, and antihypertensives during pregnancy. Characterization of the CL/P patient profile is essential for the planning of health services and integration among the health professionals involved in the diagnosis and treatment of these malformations. Our results reinforce the need for additional research to confirm the association between environmental factors and the development of orofacial clefts.

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.

Identifying Psychosocial Risk Factors Among Families of Children With Craniofacial Conditions: Validation of the Psychosocial Assessment Tool-Craniofacial Version

OBJECTIVE

To evaluate the psychometric properties of the Psychosocial Assessment Tool-Craniofacial Version (PAT-CV), a screening instrument for psychosocial risk in families of children with craniofacial conditions, and to examine risk classification of patients in a craniofacial population.

DESIGN

Prospective, cross-sectional, single-center study.

SETTING

Interdisciplinary cleft lip and palate/craniofacial center at a US children's hospital.

PARTICIPANTS

Parents/caregivers (n = 242) of 217 children ages 1 month to 17 years being treated for a congenital syndromic or nonsyndromic craniofacial condition completed the PAT-CV and validating measures from July 2015 to July 2016. The PAT-CV was completed by 121 caregivers a second time to assess test-retest reliability.

MAIN OUTCOME MEASURES

PAT-CV, Child Behavior Checklist, Adult Self-Report, Pediatric Quality of Life Inventory, Craniofacial Experiences Questionnaire, and Family Environment Scale.

RESULTS

Construct validity of the PAT-CV was supported by significant correlations ( P < .001) between PAT-CV total and subscale scores and the validated measures. PAT-CV total scores categorized 59.9% of families within the universal risk group, 32.3% within the targeted risk group, and 7.8% within the clinical range. Good criterion validity was indicated by significantly higher scores ( P < .0001) obtained on the validated measures for those in the targeted and clinical risk groups. Internal consistency (Cronbach's α = 0.86) and test-retest reliability for the PAT-CV total score ( r = 0.77, P < .0001) were acceptable.

CONCLUSIONS

The PAT-CV appears to be a reliable and valid screening instrument for psychosocial risk. Accurate identification of risk and implementation of appropriate interventions may contribute to improvements in medical and psychosocial outcomes.

Adults’ Narratives of Growing up with a Cleft Lip and/or Palate: Factors Associated with Psychological Adjustment

Background

Growing up with a cleft lip and/or palate presents a number of challenges for those affected and their families. Understanding why some individuals cope well while others struggle is key to psychological research in this field. A better appreciation of the factors and processes that contribute to psychological adjustment to cleft lip and/or palate (CL/P) from the patient perspective would be of value to both researchers and clinicians.

Design

Qualitative data elicited from individual interviews with 52 adults born with CL/P.

Result

Inductive thematic analysis identified three main themes: “background” factors (age, gender, sexual orientation, culture, additional conditions, socioeconomic status, and adoption), “external” factors (treatment autonomy, familial coping and support, salience, public understanding, psychological input, and peer support), and “internal” psychological factors (perceptions of difference, noticeability and teasing, social confidence, internalization of beauty ideals, valence, expectations of treatment, responding to challenges, social comparisons, acceptance, faith, dispositional style, and recognition of strengths and positive growth).

Conclusions

The number and breadth of factors identified in this study are testament to the importance of psychology in the field of CL/P and may offer guidance in relation to developing and assessing the value of psychological interventions. There is a clear role for psychologists in tackling appearance-related concerns, designing materials, supporting patient decision making, and improving social interaction, as well as providing specialist psychological support. The findings illustrate the potential degree of individual variation in perspectives and offer insight into the conflicting results found within current literature.

Risk and Protective Factors at Age 10: Psychological Adjustment in Children with a Cleft Lip and/or Palate

Objective

To explore psychological functioning in children with a cleft at age 10 from a broad perspective, including cognitive, emotional, behavioral, appearance-related, and social adjustment. High-risk groups were identified within each area of adjustment to investigate whether vulnerable children were found across domains or whether risk was limited to specific areas of adjustment.

Methods

Retrospective chart review from psychological assessments at age 10 (N – 845). The effects of gender, cleft visibility, and the presence of an additional condition were investigated. Results were compared with large national samples.

Measures

Personality Inventory for Children, Child Experience Questionnaire, Strengths and Difficulties Questionnaire, Satisfaction With Appearance scale.

Result

The factor affecting psychological adjustment on most domains was the presence of an associated condition in addition to the cleft. As expected, no support was found for cleft visibility as a risk factor, while there were some gender differences related to emotional difficulties and attention. Correlation analyses of risk groups pointed to an association between social experiences and emotional adjustment and between social and behavioral adjustment; whereas, dissatisfaction with appearance was not related to any other domains of risk at age 10.

Conclusions

The results point to the importance of early screening and assessment of children born with a cleft to identify possible associated conditions and offer adapted and appropriate treatment and care. Future research should investigate how protective factors could counteract potential risk in children with a cleft.

Multidisciplinary Aspects of 104 Patients with Pierre Robin Sequence

Objective

To describe Pierre Robin sequence patients with a cleft palate from a multidisciplinary perspective.

Patients

A total of 104 individuals with Pierre Robin sequence and cleft palate, born between 1980 and 2010.

Method

Data were collected retrospectively and compared with large control groups.

Results

Of 104 patients, 19 (18.3%) were treated with a nasopharyngeal or oropharyngeal tube, continuous positive airway pressure, and/or a tracheotomy. The mean weight percentile for newborns with Pierre Robin sequence was 30.9. It decreased to 29.9 at the time of cleft palate repair (mean age, 13.7 months) ( P = .78). Of 87 patients, 30 (34.5%) developed normal speech after cleft palate repair. Of 93 nonsyndromic Pierre Robin sequence patients, 31 (33.3%) had or are having surgery for velopharyngeal insufficiency, a rate that is significantly higher when compared with a control group of cleft palate–only patients (19.4%; P = .004). Of 31 patients, 25 (80.6%) developed normal resonance after surgery for velopharyngeal insufficiency. There was no significant difference in the rate of syndromes between the Pierre Robin sequence patients and a control group of cleft palate patients without Pierre Robin sequence ( P = .25). Seven of 39 boys (17.9%) with Pierre Robin sequence had a diagnosis of autism spectrum disorder.

Conclusion

Even though the mean weight percentile for newborns with Pierre Robin sequence was low, the patients did not show a growth spurt during the first year of life. The high rate of velopharyngeal insufficiency after cleft palate repair in patients with Pierre Robin sequence needs further investigation. Also, the high rate of autism spectrum disorder among boys with Pierre Robin sequence prompts further investigation.

Young Person and Parent Perspectives on the Impact of Cleft Lip and/or Palate Within an Educational Setting

Background:

During the school years, a cleft of the lip and/or palate (CL/P) may pose a risk to educational achievement. To further understand this multifaceted association, and to offer suggestions as to how young people’s educational experiences might be improved, qualitative investigation is warranted.

Design:

Semi-structured telephone interviews were conducted with young people born with CL/P (n = 10; aged 10-16 years) and their parents (n = 10). The resulting data were subjected to inductive thematic analysis.

Results:

Negative social interactions, cleft-related treatment, the presence of an additional condition, and a lack of appropriate support from teachers was found to influence young people’s educational experience. Methods for promoting diversity, support from clinical teams, facilitation of positive school transitions, implementation of training for teachers, and a holistic approach to the measurement of “success” were suggested by participants as potential ways of improving this experience.

Conclusions:

The findings of this study point to a need for a range of school-focused interventions, as well as the inclusion of a number of potentially impactful variables within future quantitative research.

Strengths and Difficulties Questionnaire (SDQ)

Objective:

Informant discrepancies on psychological measures may affect the assessment, classification, and treatment of children’s mental health. Concordance between different informants has been shown to be low to moderately correlated. The present study examined the agreement between children with cleft lip and/or palate (CL/P) and their parents.

Design:

Cross-sectional data from 7 consecutive birth cohorts based on routine psychological assessments at age 10 with comparisons to national reference groups.

Setting:

Centralized and multidisciplinary treatment setting.

Participants:

323 children age 10, born with CL/P and their parents (participation rate: 89%).

Outcome measures:

Strengths and Difficulties Questionnaire (SDQ).

Results:

Children born with CL/P and their parents tend to follow similar patterns of disagreement on the SDQ as reported in the general population, with children reporting more symptoms than their parents, and boys having more problems than girls on most subscales. Child and parent reports were low to moderately correlated, and not affected by the child’s gender or the presence of conditions additional to the cleft.

Conclusions:

Differences between informants on the SDQ reflect different perspectives of the child’s adjustment, and both informants are important in the assessment of mental health. Children with CL/P and their parents do not significantly differ from children and parents in the general population on their agreement of the child’s psychological adjustment. As with the general population, clinical assessments should be based on a mixture of both informants’ reports.

Toward a Conceptual and Methodological Shift in Craniofacial Research

Objective:

To date, research investigating the psychological impact of craniofacial conditions has produced variability across outcomes. The aims of this article were to summarize the challenges that may contribute to this variability, and to offer alternative perspectives and approaches to guide future research and practice.

Design:

A comprehensive evaluation of papers exploring adjustment to congenital craniofacial conditions was conducted. Methodological approaches and underlying conceptual issues were identified and summarized.

Results:

The conceptual limitations identified include inherent challenges pertaining to the multifactorial and fluctuating nature of adjustment, a lack of consensus regarding the primary constituents of a positive outcome, scant use of appropriate models and theories, and a predominant focus on “deficits” over “strengths.” The methodological shortcomings identified include a lack of representative samples, biomedical inclusion/exclusion criteria, inconsistency in measurement, a relative absence of the patient perspective, variability in approaches to data analysis and interpretation, and the failure to draw on knowledge from other disciplines and related fields of health research. Findings are believed to be relevant to all disciplines involved in craniofacial research and practice.

Conclusions:

Existing literature remains markedly affected by a range of conceptual and methodological challenges, despite these challenges being identified 25 years ago. The present article proposes that a shift in the way we conceptualize and study craniofacial conditions is needed, in order to construct a comprehensive understanding of adjustment to craniofacial conditions, and to address the key unanswered questions important to all stakeholders.

Health-Related Quality of Life and the Desire for Revision Surgery Among Children With Cleft Lip and Palate

PURPOSE

Children with cleft lip with or without palate (CLCP) require multiple reconstructive procedures, however, little is known about their desire for surgical revision. The purpose of this study was to examine the relationship between health-related quality of life (HRQOL) and the desire for revision.

METHODS

The authors surveyed children with CLCP (n = 71) and their caregivers regarding general and cleft-specific HRQOL and the desire for revision surgery. The authors used logistic regression models to evaluate the relationship between HRQOL and the desire for revision stratified by age, and determined the level of agreement between caregivers and children.

RESULTS

In this cohort, 54.9% of children desired revision, primarily of the nose (n = 23), lip (n = 20), and dentoalveolar structures (n = 19). Children 11 years or older were more likely to desire revision than younger children (OR 3.39, 95% CI [1.19, 9.67], P <0.05). Children who reported poorer HRQOL with respect to appearance (OR 2.31, 95% CI [1.25-4.29], P = 0.008), social development (OR 0.91, 95% CI [0.84-0.99], P = 0.02), and communication (OR 0.94, 95% CI [0.89-0.99], P = 0.02) were significantly more likely to desire revision than children who reported more positive HRQOL. Caregivers' and children's desires for revision were only modestly correlated (r = 0.41).

CONCLUSIONS

Children with CLCP who report poorer HRQOL are more likely to desire revision than children with higher HRQOL; these differences are further magnified among older children. Given the modest correlation between patient and caregiver goals for revision, it is important to evaluate both perspectives when considering revision surgery.

Speech, Language, and Reading in 10-Year-Olds with Cleft: Associations with Teasing, Satisfaction with Speech, and Psychological Adjustment

Background

Despite the use of multidisciplinary services, little research has addressed issues involved in the care of those with cleft lip and/or palate across disciplines. The aim was to investigate associations between speech, language, reading, and reports of teasing, subjective satisfaction with speech, and psychological adjustment.

Design

Cross-sectional data collected during routine, multidisciplinary assessments in a centralized treatment setting, including speech and language therapists and clinical psychologists.

Participants

Children with cleft with palatal involvement aged 10 years from three birth cohorts (N = 170) and their parents.

Outcome Measures

Speech: SVANTE-N. Language: Language 6-16 (sentence recall, serial recall, vocabulary, and phonological awareness). Reading: Word Chain Test and Reading Comprehension Test. Psychological measures: Strengths and Difficulties Questionnaire and extracts from the Satisfaction With Appearance Scale and Child Experience Questionnaire.

Results

Reading skills were associated with self- and parent-reported psychological adjustment in the child. Subjective satisfaction with speech was associated with psychological adjustment, while not being consistently associated with speech therapists’ assessments. Parent-reported teasing was found to be associated with lower levels of reading skills. Having a medical and/or psychological condition in addition to the cleft was found to affect speech, language, and reading significantly.

Conclusions

Cleft teams need to be aware of speech, language, and/or reading problems as potential indicators of psychological risk in children with cleft. This study highlights the importance of multiple reports (self, parent, and specialist) and a multidisciplinary approach to cleft care and research.

Speech, language, and reading skills in 10-year-old children with palatal clefts: The impact of additional conditions

BACKGROUND

This study examined speech (hypernasality and intelligibility), language, and reading skills in children with a cleft palate, specifically investigating additional conditions to the cleft, in order to differentiate challenges related to a cleft only, and challenges associated with an additional condition.

DESIGN

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

PARTICIPANTS

Children born with cleft with palatal involvement from four birth cohorts (n=184), aged 10.

OUTCOME MEASURES

Speech: SVANTE-N; Language: Language 6-16; Reading: Word Chain Test and Reading Comprehension Test.

RESULTS

Descriptive analyses revealed that 123 of the children had a cleft only (66.8%), while 61 children (33.2%) had a cleft that was associated with an additional condition (syndrome, developmental difficulty, attentional difficulties). Due to close associations with the outcome variables, children with specific language impairments and dyslexia were excluded from the sample (n=14). In the total cleft sample, 33.1% had mild to severe hypernasality, and 27.9% had mild to severe intelligibility deviances. Most children with intelligibility and hypernasality scores within the normal range had a cleft without any other condition. A high number of children with developmental difficulties (63.2%) or AD/HD (45.5%) had problems with intelligibility. Hypernasality scores were also associated with developmental difficulties (58.8%), whereas most children with AD/HD had normal hypernasality scores (83.3%). As could be expected, results demonstrated that children with a cleft and an additional condition had language and reading scores below average. Children with a cleft only had language and reading scores within the normal range. Among the children with scores below average, 33.3-44.7% had no other conditions explaining difficulties with language and reading.

CONCLUSIONS

The findings highlight the need for routine assessments of language and reading skills, in addition to assessments of speech, in children with a cleft, in order to identify potential problems as early as possible. Study designs need to take additional difficulties into account, so that potential problems with language and reading are not ascribed the cleft diagnosis, and can be followed by appropriate treatment and interventions.

Self-perceptions of romantic appeal in adolescents with a cleft lip and/or palate

During adolescence, romantic relationships are a key developmental milestone. Coupled with the increasing salience of appearance and social acceptance, adolescents with an appearance-altering condition may feel particularly vulnerable when it comes to romantic relationships. This study aimed to explore the prevalence of romantic experiences among adolescents with a cleft lip and/or palate (CL/P), and to investigate how these experiences could be related to depressive symptoms and global self-worth. The study included 661 Norwegian adolescents with CL/P, who were compared to a large national sample. The prevalence of romantic relationships was lower among adolescents with CL/P compared to the reference group, although the overall impact on depressive symptoms and global self-worth appeared to be low. This study is one of few to explore the impact of a congenital visible condition on experiences of romantic relationships and provides preliminary insight into a significant, yet complex topic.

Opportunities and Challenges in Establishing a Cohort Study: An Example from Cleft Lip/Palate Research in the United Kingdom

Background

Cleft lip and/or palate (CL/P) is one of the most common birth conditions in the world, but little is known about its causes. Professional opinion remains divided as to which treatments may be the most beneficial for patients with CL/P, and the factors that contribute to psychological adjustment are poorly understood. The use of different methodological approaches and tools plays a key role in hampering efforts to address discrepancies within the evidence base. A new UK-wide program of research, The Cleft Collective, was established to combat many of these methodological challenges and to address some of the key research questions important to all CL/P stakeholders.

Objective

To describe the establishment of CL/P cohort studies in the United Kingdom and to consider the many opportunities this resource will generate.

Results

To date, protocols have been developed and implemented within most UK cleft teams. Biological samples, environmental information, and data pertaining to parental psychological well-being and child development are being collected successfully. Recruitment is currently on track to meet the ambitious target of approximately 9800 individuals from just more than 3000 families.

Conclusions

The Cleft Collective cohort studies represent a significant step forward for research in the field of CL/P. The data collected will form a comprehensive resource of information about individuals with CL/P and their families. This resource will provide the basis for many future projects and collaborations, both in the United Kingdom and around the world.

A longitudinal study of 340 young people with or without a visible difference: The impact of teasing on self-perceptions of appearance and depressive symptoms

Previous research in both the general population and in those with a visible facial difference has identified potential associations between teasing, dissatisfaction with appearance and emotional distress. However, most studies are based on cross-sectional and retrospective methodology, restricting the interpretation of findings. The present study explored the longitudinal impact of perceived teasing on satisfaction with appearance and depressive symptoms in young people with and without a visible congenital condition. Routine psychological assessments were conducted at ages 10 and 16 years (N=340). Experiences of teasing after the age of 10 significantly impacted on appearance evaluations and depressive symptoms in adolescent females. The impact of teasing on adolescent males was possibly counteracted by reports of more positive social experiences. Early identification of perceived teasing in all children to prevent the development of emotional problems and dissatisfaction with appearance is of vital importance.

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.

“It Doesn't All Just Stop at 18”: Psychological Adjustment and Support Needs of Adults Born with Cleft Lip and/or Palate

Background

Cleft in the lip and/or the palate (CL/P) is considered to be a lifelong condition, yet relatively little is known about the long-term outcomes for patients. Existing literature is largely outdated and conflicted, with an almost exclusive focus on medical aspects and deficits.

Objective

To explore the psychological adjustment and possible support needs of a large number of adults born with CL/P from their own perspective.

Design

Fifty-two individual telephone interviews eliciting qualitative data.

Results

Qualitative analysis identified five themes. Participants reported a range of challenges in relation to discharge from the service, additional surgery as an adult, social and romantic relationships, higher education, vocational achievement, and access to psychological support. The findings imply that most adults with a cleft adjust well to these challenges and report many positive outcomes. For a minority of patients, issues attributed to the cleft may continue to cause distress in adulthood.

Conclusions

Adults with CL/P may require psychological support, information about the heritability of cleft, signposting and referrals from nonspecialists, support regarding further treatment, and opportunities to take part in research and activities. New issues arising in adulthood, such as entering the workplace, forming long-term relationships, and starting a family, may warrant both further investigation and additional support. Further work is needed to identify the factors that contribute to psychological distress and resilience, as well as the timing of particular points of risk and opportunity for personal growth.

Starting a Family: The Experience of Parents with Cleft Lip and/or Palate

Background

One of the key challenges facing young adults with cleft lip and/or palate is making decisions about starting a family, because there is an increased likelihood of their own child being diagnosed with cleft lip and/or palate. Should this occur, a second key challenge is how to deal with their child's diagnosis and subsequent treatment.

Objective

To explore the views, experiences and possible support needs of this unique group of parents in order to inform the services provided by nonspecialist Health Professionals, cleft teams, and genetic counselors.

Design

Individual telephone interviews eliciting qualitative data.

Results

Qualitative thematic analysis identified five themes. Accessing accurate information and appropriate support around heritability presented a significant challenge. Parents described feelings of responsibility and distress at their child's diagnosis, as well as a number of factors that had helped or hindered their adjustment. Parents also described ways in which their own experiences had impacted their parenting style and how becoming a parent had changed the way they felt about their own cleft.

Conclusions

Young adults' understanding of what it means to grow up with cleft lip and/or palate may impact their decision to start a family and their experiences of having children. Possible methods of supporting prospective parents through this potentially difficult stage will be discussed.

Parenting a Child with a Cleft: The Father's Perspective

Objective

To explore the impact of having a child born with a cleft lip and/or palate from the father's perspective.

Design

Individual qualitative telephone interviews.

Participants

A total of 15 fathers of children born with cleft lip and/or palate were recruited throughout the U.K. via advertisements.

Results

Supported by a number of subthemes, four overarching themes were identified: variations in care and support; appraisals of the cleft; perceptions of treatment; and looking back and moving forward.

Conclusions

Fathers reported experiences comparable to those previously reported by mothers, in addition to a number of further support and information needs. Participants played a key role in supporting their families through the treatment process, yet fathers are underrepresented in the research literature. Recommendations are made for the adequate inclusion of fathers in future research and in relation to methods of support for fathers through their children's diagnosis and treatment.