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

Facilitators, barriers, and strategies of communication in Malaysian school-age children with non-syndromic cleft lip and palate: Results of in-depth online qualitative interviews

This study explores the perceptions of facilitators, barriers to communication and strategies in Malaysian school-aged children with non-syndromic cleft lip and palate (CL/P), parents, and teachers. Fourteen children with non-syndromic CL/P aged 7 to 12 years, their parents (n = 16), and their teachers (n = 10) were recruited via purposive sampling. Participants were selected based on resilience scores (RS-10; (Wagnild, 2015) distinguishing low (<34) from high resilience (35-40) (Wagnild, 2015). Individual in-depth interviews were conducted online and evaluated qualitatively. The analyses were conducted utilising the guidelines by Braun and Clarke (2006). Inductive thematic analysis was performed. Facilitators for communication identified by children, parents and teachers were the child's personal attributes, common interests, and helping others. Barriers that were identified were unfamiliar conversation partners, and insensitive comments or questions. Children used passive (e.g. ignored) and active (e.g. retorted, explained the condition) strategies to address social communication issues. Children with high resilience responded more actively than children with low resilience. Strategies that were described by the parents included accepting the child, empowering themselves, following the cleft management plan, and empowering the child. Teachers adopted general approaches such as giving encouragement, increasing confidence, and teaching empathy. The presence of face masks was perceived as both a facilitator and a barrier to communication. The study provides information on challenges encountered and coping mechanisms used by children with non-syndromic CL/P, their parents and their teachers. This knowledge may help the development of targeted interventions to support the communication of children with non-syndromic CL/P in school.

Congenital melanocytic naevus (CMN) through the lens: Using photo-elicitation interviews to explore adjustment in adolescents with a rare birthmark condition

Adolescents with the rare birthmarks congenital melanocytic naevi (CMN) experience physical and psychosocial challenges, many of which stem from looking different from the 'norm'. However, some adjust and have positive experiences. Understanding the lived experiences of adolescents who have adjusted to CMN can provide a holistic picture of adjustment and inform the development of support and interventions for others with the condition. Open, participant-driven photo-elicitation interviews were conducted with four White females (15-17 years) who self-identified as having adjusted to CMN. Participants chose five photographs which were used to guide the interviews (47-80 min). Interpretative phenomenological analysis (IPA) was used to analyse the transcribed interview data. Three superordinate themes were identified: 'Accepting My 'True' Self' (1), 'I am Not Alone in This' (2), and 'Developing as a Person' (3). The themes related to accepting CMN as part of their identity, developing a positive body image (e.g., body appreciation, broad conceptualisations of beauty, body image flexibility), feeling supported and accepted by family, friends, and others with CMN, and developing adaptive coping skills. Findings suggest positive body image may be important for adjustment and can be determined by an individual. The benefits of using photo-elicitation within appearance research are discussed.

Parental and Child Diagnosis Storytelling and Self-Image in French Children With Cleft lip With or Without Cleft Palate

OBJECTIVE

Psychosocial adjustment can be challenging for children with cleft lip with or without a cleft palate (CL ± P). Previous studies have linked social integration with self-acceptance and highlighted the impact of the parents' stress on self-acceptance. Teasing can be linked to children having difficulties explaining their diagnosis to others. This prospective research aimed to gain a better understanding of family communication about cleft, children's oral storytelling about their cleft, and explore their self-image and perceived familial acceptance.

PARTICIPANTS

Parents and their children with CL ± P (N = 54; average age: 5.6 years).

DESIGN

Semistructured interviews with parents and structured interviews with children were conducted regarding their oral storytelling focusing on scars from cleft lip surgery. Children completed a projective test to explore their self-image and perceptions of familial acceptance. Language screening was completed with the French Wechsler Preschool Primary Scale of Intelligence-Fourth Edition.

RESULTS

Only 30% of children explained their cleft in a way appropriate for peers, including presence at birth, having had surgery, and scar location. Children's ability to explain their cleft was not related to language performance, which was in the average range of 84%. Children's cleft explanations were dependent on parents' narratives and education methods, including the use of verbal explanations and preoperative photographs. Children's storytelling was related to their self-image and perceived parental acceptance.

CONCLUSION

Cleft teams should assist families in building their cleft story based on a complete explanation with photographs and a positive and accepting approach.

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

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

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

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

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

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

Relationship Between Stigma Experience and Self-Perception Related to Facial Appearance in Young Japanese Patients with Cleft lip and/or Palate

OBJECTIVE

To examine the relationship between stigma experience related to facial appearance in Japanese youths with cleft lip and/or palate (CL/P) and their self-perception.

DESIGN

A cross-sectional study.

PARTICIPANTS

Sixty-nine Japanese youths with CL/P (11-18 years old).

OUTCOME MEASURES

The participants' stigma experience in relation to facial appearance (measured with 7 single contextual scale items) and their self-perception (measured with 5 domain scores based on 30 perceptual items) were assessed using the Japanese version of the Youth Quality of Life Instrument-Facial Differences Module. Participants were categorized into high and low self-perception subgroups with a threshold of 1 standard deviation for each domain. The frequency of stigma experiences was compared between the following 2 subgroups: age, sex, cleft palate only versus other cleft, and high versus low self-perception. Correlations between the responses regarding stigma and all domain scores were examined.

RESULTS

Sixteen percent of the participants reported experiencing stigma. Hearing others say something about their face occurred significantly more frequently in youths 15 to 18 years of age than in youths 11 to 14 years of age. Stigma frequency was not found to differ by sex or cleft type. Stigma experiences were significantly more frequent for youth with higher scores across negative self-perception domains as well as higher coping skills. Significant correlations were identified between responses regarding stigma items and all domain scores (r  =  0.27-0.63, p < .05).

CONCLUSIONS

It was found that stigma experiences related to facial appearance may influence negative self-perceptions of facial differences as well as higher coping skills among Japanese youths with CL/P.

Treatment Outcomes of Interdisciplinary Care on Speech and Health-Related Quality of Life Outcomes in Adults With Cleft Palate

PURPOSE

Individuals born with a cleft palate with or without a cleft lip (CP ± L) often experience functional, aesthetic, and psychosocial consequences well into adulthood. This study aimed to investigate outcomes of speech and health-related quality of life (HRQoL) in adults with a CP ± L who received interdisciplinary cleft care at the Ghent University Hospital using valid, reliable, and condition-specific instruments.

METHOD

Thirteen Belgian Dutch-speaking participants with a CP ± L with a mean age of 25.4 years (SD = 5.1, range: 20-33 years) and an age- and gender-matched control group of 13 participants without a CP ± L with a mean age of 25.2 years (SD = 4.8, range: 20-32 years) were included in this study. Speech characteristics were evaluated perceptually and instrumentally. HRQoL was assessed through standardized patient-reported outcome measures. Outcomes were compared with those of the control group and to normative data where available.

RESULTS

Participants with a CP ± L in this sample demonstrated significantly lower speech acceptability (p < .001) and higher rates of hypernasality (p = .015) and nasal turbulence (p = .005) than the control group. They showed significantly higher satisfaction with appearance of the cleft scar compared with norms of adults with a CP ± L (p = .047). No other differences in speech characteristics, sociodemographics, or HRQoL were found between participants with and without a CP ± L.

CONCLUSIONS

The reduced speech acceptability and the presence of resonance and nasal airflow disorders may indicate the need for standardized long-term outcome measurement and interdisciplinary follow-up for speech characteristics and velopharyngeal insufficiency in young and middle adulthood in future clinical practice. Additional research is necessary to further substantiate these findings and to determine predictors for these continuing complications in adults with a CP ± L.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24243901.

Follow-Up Care Barriers for Patients with Orofacial Clefts

OBJECTIVE

The aim of this study was to evaluate whether a patient with a cleft's age, associated syndrome, cleft phenotype or travel distance affects their follow-up rate.

DESIGN

This study is a retrospective review of patients with CL/P treated by a craniofacial clinic.

SETTING

The setting was a craniofacial clinic at a tertiary care university hospital.

PATIENTS, PARTICIPANTS

Candidates were patients seen by the craniofacial clinic between January 2007 and December 2019. An initial pool of 589 patients was then reduced to 440 due to exclusion criteria.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

The outcome measure was actual patient attendance to the craniofacial team compared to the team goal expectation of annual return visits.

RESULTS

The mean age of participants at the end of the study was 9.0 ±  5.4 years with a mean follow-up period (total possible follow-up period length based on patient age at presentation and study window) of 5.5 ±  3.6 years. There was no association between cleft phenotype, type of syndrome, or distance to the clinic with attendance. Children with syndromes had an 11% decrease in the odds of attending follow-up visits with each 1-year increase in age compared to a 4% decrease in children without syndromes.

CONCLUSIONS

The only significant factors determining patient attendance were the presence of a syndrome and increasing age.

Association of Patient Factors and Follow-Up in an International Volunteer Cleft Lip and Palate Repair Clinic in El Salvador

BACKGROUND

In countries which lack robust health care systems, congenital conditions such as cleft lip and/or palate deformities are often untreated in certain individuals. Many volunteer organizations have stepped in to fill this gap but certain factors, such as continuity of care, are yet to be studied for these clinics.

METHODS

This is a retrospective cohort study of 167 pediatric patients with cleft lip and/or palate residing in El Salvador treated by a nongovernmental organizations between 2011 and 2020. This data was used in univariate and multivariable models to associate particular patient factors to their likelihood of following up to their annual clinic visits.

RESULTS

Each 1-year increase in duration of follow-up was associated with a 27% decrease in the odds of attending a visit. In addition, 33.7% of cleft lip and 49.7% of cleft palate/cleft lip and palate patients returned at least once. Males had 36% higher odds of attending a return visit compared with females but this difference was not statistically significant. Time spent travelling to the clinic had no effect on follow-up rates.

CONCLUSION

Nongovernmental organizations utilizing a diagonal care model should consider using more strategies to maximize continuity of care by increasing communication with patients and emphasizing the need of following up during clinic visits. Continued and increased collaboration with the local team is also of great importance.

Factors Associated With Psychological Adjustment in Adults With Cleft Lip and/or Palate: Findings From a National Survey in the United Kingdom

OBJECTIVES

Research has identified adults born with cleft lip and/or palate (CL/P) to be at risk of poorer psychological outcomes compared to the general population. This study investigated factors that may contribute to positive and negative adjustment in adults born with CL/P.

DESIGN

A survey was designed and distributed by the Cleft Lip and Palate Association in collaboration with the Centre for Appearance Research CAR at the University of the West of England (UWE). There were 207 eligible responses (95% completed online) received between July and October 2018. Dependent variables included the Body Esteem Scale for Adolescents and Adults, Harter's Self Perception Profile for Adults (Global Self-Worth, Social Competence, and Intimacy subscales), the Fear of Negative Appearance Evaluation Scale, and the Revised Adult Attachment Scale. Independent variables were the Revised Life Orientation Test, biodemographic data, and self-reported single-item questions.

RESULTS

Factors associated with positive adjustment included reports of a happy childhood, talking about CL/P with family, close friendships, comfort in public spaces, satisfaction with appearance, and a positive life orientation. Psychological distress was associated with a desire for further surgery to improve appearance and/or function.

CONCLUSIONS

Several factors were identified that may influence psychological adjustment in adults with CL/P. Throughout childhood, family-centered practice to support family cohesion and an open dialogue about CL/P is indicated, as is support for young people to develop social confidence. For adults returning to the cleft service, treatment options for appearance and/or functional concerns should be explored, with access to psychological support when indicated. Interventions to increase optimism, resilience, and self-acceptance may also be warranted throughout the life span.

Influence of Gender, Dispositional Optimism, and Coping Strategies on Appearance-Related Distress Among Swedish Adults With Cleft Lip and Palate

Objective:

To investigate the influence of gender, dispositional optimism, and coping strategies on appearance-related distress among individuals with unilateral cleft lip and palate (UCLP).

Design:

Cross-sectional design with self-report questionnaires analyzed primarily with Spearman correlations (r_s) and multivariate regression analyses.

Setting:

A tertiary cleft center in Sweden.

Participants:

Eighty individuals with UCLP born 1966 to 1986. The mean age for men (n = 50) and women (n = 30) was 38.8 and 37.4 years, respectively.

Main Outcome Measures:

The Derriford Appearance Scale 24 measured appearance-related distress, the Life Orientation Test–Revised, short version measured dispositional optimism and pessimism, and the Coping Orientation to Problems Experienced, short version included 14 coping strategies.

Results:

Women had higher appearance-related distress than men, which was significantly (P < .05) related to self-blame (r_s = 0.59), pessimism (r_s = 0.59), and low optimism (r_s = −0.56). Men’s appearance-related distress was significantly associated with low active coping (r_s = 0.35), low use of emotional support (r_s = 0.29), denial (r_s = 0.39), behavioral disengagement (r_s = 0.41), and pessimism (r_s = 0.28). The only significant gender interaction reflected greater impact of optimism in reducing appearance-related distress for women (β = −0.06).

Conclusions:

This study showed that high levels of dispositional optimism decrease appearance-related distress, particularly for women. The coping strategies used differed between men and women, and the results suggest that both gender and psychosocial facto r_s need to be considered in regard to appearance-related distress among individuals with UCLP in both clinical and research settings. A possible way to decrease distress is to strengthen positive coping strategies and dispositional optimism.

Scores of the Cleft Hearing, Appearance and Speech Questionnaire (CHASQ) in Swedish Participants With Cleft lip and/or Cleft Palate and a Control Population

OBJECTIVE

The primary aim of this study was to investigate whether there was any difference in scores of the Cleft Hearing, Appearance and Speech Questionnaire (CHASQ) between patients with cleft lip and/or cleft palate (CL/P) and a control population. The second aim was to compare CL/P and control population scores in this study with a British norm CL/P population.

DESIGN

Single-site, cross-sectional study with an age-matched control population.

SETTING

Participants were recruited from a hospital, a school, and a sports club. They answered the CHASQ in the hospital or at home.

PARTICIPANTS

Sixty-four participants with CL/P (7-19 years of age) and a control population of 56 participants without CL/P (9-20 years of age).

MAIN OUTCOME MEASURE

CHASQ.

RESULTS

There was no statistically significant difference in satisfaction with cleft-related features between the CL/P and the control population. Participants with CL/P were significantly more satisfied with non-cleft-related features than the control population. Cleft Hearing, Appearance and Speech Questionnaire scores were also similar to earlier established British normative data of a CL/P population.

CONCLUSION

The results indicated that children and young people with CL/P were as satisfied with their appearance, hearing, and speech as children and young people without CL/P. Swedish CHASQ scores were also similar to British scores.

Exploring 10-15-year-old patients' perspectives of fixed orthodontic treatment

OBJECTIVE

To explore and understand young people's perspectives of fixed orthodontic treatment. In particular, understanding how young people perceived and experienced having a fixed appliance and how their experiences can change during their treatment.

DESIGN

Qualitative study carried out longitudinally.

SETTING

In-depth qualitative interviews carried out in participants' homes, video diaries recorded by participants when and where they wish.

PARTICIPANTS

Fifteen patients aged 10-15 years undergoing NHS fixed appliance treatment.

METHODS

Data were collected by in-depth interviews and video diaries throughout the participants' course of orthodontic treatment. Data were analysed using thematic analysis.

RESULTS

Young people's friends, family and social media influenced how young people felt about the appearance of their teeth. Young people can perceive negative social judgements are made about them based on the appearance of their teeth; however, the appearance of the brace was not a concern. For some of the young people, the presence of the brace formed a rite of passage throughout adolescence. Pain and discomfort caused by fixed appliances was expected and tolerated and felt normal with time.

CONCLUSION

Young people's perceptions about appearance are influenced by people around them and social media. The physical feeling of the brace was normalised, although it did affect young people's lives.

Social Experiences of Turkish Parents Raising a Child With Apert Syndrome: A Qualitative Study

OBJECTIVE

Apert syndrome is a rare and understudied craniofacial condition with regard to its psychosocial impact on children and their parents. Due to the lack of studies focusing solely on the social experiences of children and families with Apert syndrome, it is difficult to develop interventions and strategies to support well-being and positive adjustment for this particular population. This study addressed this gap by assessing the unique social experiences of parents who are raising their children with Apert syndrome including difficulties they face and strategies they use to cope with challenges.

DESIGN

Descriptive qualitative study using thematic analysis.

PARTICIPANTS

Participants included 21 parents of 12 children (aged 1-12 years) with Apert syndrome (9 couples, 2 fathers, and 1 mother) who were recruited from a pediatric neurosurgery unit in Turkey.

RESULTS

The qualitative analysis yielded four main themes describing the experiences of parents including (1) social challenges; (2) coping with negative reactions; (3) promoting socialization and independence; and (4) sources of strength.

CONCLUSIONS

Parents reported several challenges, including social stigmatization, and utilized a range of strategies to support both their own and their child's positive adaptation and resiliency, including the use of religion and reliance on their spouses for support. Results offer clinically relevant insights about the strengths and challenges of families coping with Apert syndrome.

Decision-making process to undergo surgery among adolescent patients with cleft lip and/or palate

AIM

As patients with cleft lip and/or palate grow older, the main decision-making process for treatment is likely to shift from a parent-centered to a patient-centered process. However, many adolescent patients have difficulty in treatment decision-making. This study aimed to clarify the decision-making process regarding undergoing surgery among adolescent patients with cleft lip and/or palate.

METHODS

Participants were adolescent patients with cleft lip and/or palate aged 14-18 years who were admitted to a hospital in Japan for surgery. Fourteen patients (six boys, eight girls) and their parents agreed to participate in this study. Data were collected in face-to-face semi-structured interviews. Data were analyzed qualitatively with inductive content analysis.

RESULTS

Fifteen categories were classified into three themes for adolescent patients' decision-making processes regarding undergoing surgery. The three themes were: (a) a doctor's recommendation for surgery, (b) psychological conflict about surgery, and (c) a final decision about surgery.

CONCLUSION

This study's findings suggest that adolescent patients with cleft lip and/or palate were not adequately involved in the decision-making process before undergoing surgery. Medical staff need to explain other treatment options, the risks and benefits of surgery with materials and methods that adolescent patients can understand as part of "a doctor's recommendation for surgery." Medical staff and parents need to encourage adolescent patients to communicate their preferences and values to reduce patients' "psychological conflict about surgery" and adolescent patients' intentions should be considered in "a final decision about surgery."

Saving Face: Patient Strategies to Reduce Stigma and Barriers to Effective Decision-Making Among Children With Cleft Lip

Facial differences associated with cleft lips are often stigmatizing and can negatively impact psychosocial development and quality of life. However, little is known regarding patients' responses to societal expectations of appearance, or how these responses may impact utilization of revision surgery. Thus, patients with cleft lips at least 8 years of age (n = 31) were purposively sampled for semi-structured interviews. After verbatim transcription, first cycle coding proceeded with a semantic approach, which revealed patterns that warranted second cycle coding. The authors utilized an eclectic coding design to capture deeper meanings in thematic analysis. Additionally, survey data from a separate study were examined to evaluate participants' interest in improving appearance. Three major themes emerged, all of which reflected a desire to "save face" when interacting with society: (1) Cultural Mantras, which included societal mottos that minimized the importance of appearance; (2) Toughening Up, wherein the participants downplayed the difficulty of having a cleft; and (3) Deflection, wherein the participants took pride in facial features unrelated to their clefts. Despite these efforts to "save face," 78% of participants expressed interest in improving their appearance in the separate survey data.In conclusion, children with cleft lips try to "save face" when interacting with society by depreciating appearance, making light of clefts, and focusing on non-cleft related features. Paradoxically, many desired improvements of their appearance in an earlier survey. Awareness of these coping strategies is critical, as they may negatively impact surgeon-patient communication and inhibit patients from expressing interest in revision surgery.

"I smile, but Without Showing My Teeth": The Lived Experience of Cleft, Lip, and Palate in Adults

Objective:

To explore and describe the experience of growing up with unilateral cleft lip and palate (CLP) in adults.

Design:

Face-to-face interviews. Giorgi’s phenomenological method was used for analysis.

Participants:

Twenty-one (mean age: 40.8 years) adults treated for unilateral CLP during childhood and adolescence participated in the study.

Results:

Growing up with CLP meant to become aware of bodily otherness. The possible reactions from peers early in life complicated the striving for inclusion outside the close family. Being self-confident, clever in school, physically fit, and having trusted friends represented barriers against teasing and bullying. Nevertheless, the reflected image, in mirrors, windows, and photos, reminded the participants of the objectifying looks from others and often led to bodily adjustments that persisted into adulthood. The trajectory of treatment was not questioned during childhood, and the participants accepted the decisions on care made by experts and parents. Although problems related to the cleft could persist or return after the termination of ordinary treatment, a more hesitant view on the possible benefits of additional surgery was typical in adulthood.

Conclusions:

In retrospect, growing up with a unilateral CLP was found to have been an unquestioned part of the adult participants’ childhood, a burden that they feared would, to some extent, also be passed to their own children. However, the CLP had not prevented them from achieving goals and satisfaction in life. The occurrence of persisting psychological, functional, and esthetic challenges in adults suggests the need for an individualized, lifelong, and multidisciplinary perspective on CLP follow-up.

Achieving Consensus in the Measurement of Psychological Adjustment to Cleft Lip and/or Palate at Age 8+ Years

BACKGROUND

Consensus regarding optimal outcome measurement has been identified as one of the most important, yet most challenging developments for the future of cleft lip and/or palate (CL/P) services. In 2011, a process began to adopt a shared conceptual framework and to identify a set of core outcome measures for the comprehensive assessment of psychological adjustment.

OBJECTIVES

The aim of the current article is to outline the collaborative process used to achieve consensus in the academic and clinical measurement of psychological adjustment to CL/P from the age of 8 years onward.

RESULTS

A conceptual framework and corresponding parent- and self-reported outcome measures for use at ages 8, 10, 12, 15, 18, 20, and 25 years have been agreed upon by clinicians, researchers, and patient and parent representatives. All measures have been evaluated according to their psychometric properties, clinical utility, ability to produce meaningful longitudinal data, and a range of pragmatic considerations.

CONCLUSIONS

Although the collaborative process has been challenging and has required ongoing dedication from multiple stakeholders, consistency in data collection over time will allow for key research questions in CL/P to be addressed, both in the United Kingdom (UK) and internationally. The process has also demonstrated the clinical utility of the measures and the potential for the gradual integration of the measures into clinical practice. UK progress has sparked global interest, and the adaptation of the framework and its corresponding measures for worldwide use is now a prominent focus.

Emotional Well-Being in Adults Born With Cleft Lip and/or Palate: A Whole of Life Survey in the United Kingdom

Objectives:

Previous research with adults born with cleft lip and/or palate (CL/P) has identified a range of concerns regarding mental health and quality of life, concluding that overall emotional functioning is poorer compared to the general population. The aim of the current study was to build on this previous work by investigating the self-reported emotional well-being of adults born with CL/P in the United Kingdom.

Design:

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 and independent t tests.

Results:

Almost half of the sample reported a diagnosis of a mental health condition. Scores on standardized measures indicated significantly lower global self-worth, higher levels of fear of negative appearance evaluation, and lower self-perceived job competence compared to normative data. Scores of overall body esteem were in line with the general population. Most participants had not received psychological support from their regional CL/P team and 41% were unaware of their entitlement to treatment from the National Health Service.

Conclusions:

Individuals with CL/P may be at risk of emotional distress persisting into adulthood. The integration of routine psychological support from an early age is highly recommended, as is information for young adults about to complete routine treatment. Comprehensive psychological screening for adults returning to the service later in life is also strongly advised.

Systematic review of body image measures

This systematic review synthesizes and critically appraises measurement properties of influential body image measures. Eight measures that met the definition of an assessment of body image (i.e., an individual's cognitive or affective evaluation of their body or appearance with a positive or negative valence), and scored high on systematic expert priority ranking, were included. These measures were: the Body Appreciation Scale (original BAS and BAS-2), the Body Esteem Scale for Adolescents and Adults, the Body Shape Questionnaire, the Centre for Appearance Research Valence Scale, the Drive for Muscularity Scale, two subscales of the Eating Disorders Examination Questionnaire, one subscale of the Eating Disorder Inventory 3, and two subscales of the Multidimensional Body Relations Questionnaire. Articles assessing these scales' psychometric properties (N = 136) were evaluated for their methodological quality using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist, and a best evidence synthesis was performed. The results supported the majority of measures in terms of reliability and validity; however, suitability varied across populations, and some measurement properties were insufficiently evaluated. The measures are discussed in detail, including recommendations for their future use in research and clinical practice.

Decision-Making in Cleft-Related Surgery: A Qualitative Analysis of Patients and Caregivers

OBJECTIVE

Preference-sensitive surgical decisions merit shared decision-making, as decision engagement can reduce decisional conflict and regret. Elective cleft-related procedures are often preference sensitive, and therefore, we sought to better understand decision-making in this population.

DESIGN

Semistructured interviews were conducted to elicit qualitative data. A hierarchical codebook was developed through an iterative process in preparation for thematic analysis. Thematic analysis was performed to examine differences between patients and caregivers.

SETTING

Multidisciplinary cleft clinic at a tertiary care center.

PARTICIPANTS

Patients with cleft lip aged 8 and older (n = 31) and their caregivers (n = 31) were purposively sampled. Inability to converse in English, intellectual disability, or syndromic diagnoses resulted in exclusion.

MAIN OUTCOME MEASURES

Preferences surrounding surgical decision-making identified during thematic analysis.

RESULTS

Mean patient age was 12.7 (standard deviation: 3.1). Most had unilateral cleft lip and palate (43.8%). Three themes emerged: Insufficient Understanding of Facial Difference and Treatment, Diversity of Surgical Indications, and Barriers to Patient Autonomy. Almost half of caregivers believed their children understood their clefts, but most of these children failed to provide information about their cleft. Although many patients and caregivers acknowledged that surgery addressed function and/or appearance, patients and caregivers exhibited differences regarding the necessity of surgery. Furthermore, a large proportion of patients believed their opinions mattered in decisions, but less than half of caregivers agreed.

CONCLUSIONS

Patients with clefts desire to participate in surgical decisions but have limited understanding of their facial difference and surgical indications. Cleft surgeons must educate patients and facilitate shared decision-making.

Quality of Life and Patient Satisfaction in Adults Treated for a Cleft Lip and Palate: A Qualitative Analysis

Objective:

Long-term outcomes of patients born with a cleft lip and palate (CLP) are scarcely investigated. Yet, this patient group is of particular interest, as they can provide a valuable retrospective view upon their treatment experiences and psychological adjustment. Qualitative accounts may be especially useful in understanding the patient journey.

Design:

The present study set out to evaluate quality of life and satisfaction with treatment in adult patients previously treated for CLP at the Wilhelmina Children’s Hospital. Semistructured interviews were performed.

Patients:

A total of 22 patients aged 17 to 35 years (mean: 25 years) were interviewed about their experiences of growing up with CLP and of the treatment they received. Interviews were audio-recorded and factors thought to influence psychological adjustment were identified.

Results:

Four main themes were identified: background factors, support systems, treatment factors, and coping/internal factors. Each theme was described with illustrative quotes.

Conclusion:

This study underlines that psychological adjustment can fluctuate over time and greatly differs between individuals, even during adulthood. Psychological support should therefore be available beyond the finalization of the treatment course. Furthermore, the majority of participants stated they had wanted more psychological support as a child to facilitate resilience and to help them cope with challenges.

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.

The Psychosocial Impact of Cleft in a Western Australian Cohort Across 3 Age Groups

BACKGROUND

Management of a cleft of the lip and/or palate (CL/P) involves a multidisciplinary team approach lasting from birth to potentially postskeletal maturity. This condition is complex, with both medical and psychosocial implications that may place individuals with a cleft at higher risk of developing psychosocial problems.

METHODOLOGY

A self-administered questionnaire was completed by a sample from the Western Australian cleft population comprising 3 age groups: child (n = 100), adolescent (n = 101), and adult (n = 158).

RESULTS

Public speaking, being photographed, special relationships, and participation in school were identified as the areas most impacted by having a cleft. Hearing and speech were reported to have a higher importance than facial and dental appearance. Participants rated support given to them by their parents as the most important, with high ratings for treatment providers. For teasing, the impact of cleft was significantly higher among participants with cleft lip and palate for both the adolescent and adult age groups. There was little significant difference by gender across the variables, which suggests that males are just as likely to require support as females.

CONCLUSION

The impact of a cleft across multiple psychosocial domains needs to be recognized and addressed as part of craniofacial team care across age groups.

Adult-Specific Life Outcomes of Cleft Lip and Palate in a Western Australian Cohort

BACKGROUND

People with a cleft of the lip and/or palate (CL/P) differ from their peers due to their facial appearance, hearing and speech difficulties, and the significant time spent attending appointments and recovering from surgical interventions. These differences may impact life outcomes including occupation, income, education, relationships, psychosocial health issues, and lifestyle choices.

METHODOLOGY

A self-administered questionnaire was posted to 338 former and current patients of the Cleft Lip and Palate Unit of Princess Margaret Hospital (PMH), Perth, Western Australia.

RESULTS

Completed questionnaires were returned by 158 former and current patients. In comparison to the Australian Bureau of Statistics, study participants attained equivalent highest education levels, full-time annual income levels, occupational categories, employment rates, and home ownership levels. They did not marry later and demonstrated positive health-related lifestyle behaviors. However independent living was significantly delayed, and the number of romantic relationships, marriages, and children was lower, with separation/divorce rates also being lower. A key finding was that 78% of participants self-reported that they experienced at least 1 psychosocial health issue and more than half experienced anxiety and/or depression.

CONCLUSION

When comparing the sociological outcomes for the study participants, the psychosocial outcomes were the areas of most concern. Further investigation is required to determine the causes for the high self-reported rates of anxiety and/or depression found in this study.

#CleftProud

Background:

More than 2 billion people worldwide now use social networking sites, with an increasing number of users accessing these sites to obtain health information and engage in emotional support. Yet, investigation of social networking sites in the context of cleft lip and/or palate (CL/P) has been scarce.

Methods:

Real-time data posted during 2 weeks in April 2017 were collected from 2 existing private Facebook groups (hosted by the Cleft Lip and Palate Association United Kingdom) using video screen capture software. The number of posts, comments, unique contributors, and post “likes” was recorded, as well as the type and theme of each post. Data relating to the benefits and challenges of participation in the 2 groups were also collected via an online survey.

Results:

A content analysis of real-time data identified perioperative care, associated syndromes, and dental health to be particular areas of concern for parents/caregivers. Expectations, experiences, and outcomes of further treatment were key topics of discussion for adults with CL/P. Common benefits of the groups included the ability to connect with others, learn about local events, give and receive emotional support, and obtain quick responses to queries in a semi-anonymous environment. Disadvantages of the groups included a reliance upon opinion rather than medical fact and the frequent use of inappropriate terminology.

Conclusions:

Social networking sites appear to be a helpful source of health-related information and peer support for the CL/P population, yet closer monitoring of these groups may be required.

Assessment and Management of Psychosocial Needs: Social Work Utilization in Comprehensive Cleft Team Care

OBJECTIVE

To determine family-reported psychosocial stressors and social worker assessments and interventions within a comprehensive cleft team.

DESIGN

Single-institution prospective provider-completed survey.

PATIENTS

Four hundred one families seen by cleft team social worker over a 7-month period.

RESULTS

Most families (n = 331; 83%) participated in the team social work assessment. At least 1 active psychosocial stressor was reported by 238 (72%) families, with 63 (19%) families reported 3 or more stressors. There were 34 types of stressors reported. Most common were financial strain, young age of patient, new cleft diagnosis, and distance from clinic (57% of families live over an hour away). Family structure and home environment were assessed in detail for 288 (87%) families. Detailed assessments for access to care and behavioral/developmental issues also figured prominently. Social work interventions were provided in 264 (80%) of the visits, of which 91 were for families of new patients with over half who had infants less than 3 months old. Of the 643 interventions provided, the most frequent were parent mental health screens and counseling, early intervention referrals, transportation assistance, securing local hotel discounts, orthodontic referrals, and orthodontic cost coverage. Approximately 10% of encounters required follow-up contact related to the psychosocial concerns identified in clinic.

CONCLUSIONS

The inclusion of a cleft team social worker is a critical component of comprehensive cleft team care as evidenced by the large proportion of families who required assistance. Ongoing social work assessments are recommended for each patient to help address the variety of psychosocial stressors families face.

Factors affecting subjective appearance evaluations among patients with congenital craniofacial conditions: An application of Cash's cognitive-behavioural model of body image development

Satisfaction with appearance is of central importance for psychological well-being and health. For individuals with an unusual appearance, such as congenital craniofacial anomalies (CFA), appearance evaluations could be especially important. However, few, if any papers have presented a comprehensive synthesis of the factors found to affect subjective satisfaction with appearance among children, adolescents, and adults born with a CFA. Further, only a handful of craniofacial studies have applied psychological theories or models to their findings, resulting in an overall lack of guidance for researchers in the field. This paper summarises the literature pertaining to satisfaction with appearance among those affected by CFAs, and examines the extent to which Cash's cognitive-behavioural model of body image development (2012) fits with this literature. Given the overlap between factors of interest in the field of CFAs, and in the area of body image more broadly, a closer collaboration between the two research fields is suggested.

What Matters to Patients With Cleft Lip and/or Palate

Objective:

The goal of treatment for individuals with cleft lip and/or palate (CL/P) is to improve physical, psychological, and social health. Outcomes of treatment are rarely measured from the patient’s perspective. The aim of the study was to develop a conceptual framework for a patient-reported outcome (PRO) instrument for individuals with clefts (CLEFT-Q) by developing an in-depth understanding of issues that individuals consider to be important.

Design:

The qualitative methodology of interpretive description was used. Setting, Participants, and Intervention: We performed 136 individual in-depth interviews with participants with clefts of any age, presenting for cleft care, across 6 countries. Parents were involved if the child was more comfortable. Interviews were audio-recorded, transcribed verbatim, and coded using constant comparison. The data were used to develop a refined conceptual framework.

Results:

Participants described concepts of interest in 3 top-level domains, each of which included subdomains: appearance (face, nose, nostrils, teeth, lips, jaw, cleft lip scar), health-related quality of life (psychological, social, school, speech-related distress), and facial function (speech, eating/drinking). Participants were able to describe changes over time with regard to the 3 domains.

Conclusions:

A conceptual framework of concepts of interest to individuals with CL/P formed the basis of the scales in the CLEFT-Q. Each subdomain represents an independently functioning scale. Understanding what matters to patients is essential in guiding PRO measurement.

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.