Measuring the quality of life of youth with facial differences

Impact of Multidisciplinary Cleft Team Care on Oral Health Quality of Life in Children With Unilateral Cleft Lip and Palate: A Focus on Early Intervention vs. Sporadic Treatment

Objective: This is a study evaluating oral health-related quality of life (OHRQoL) using the Farsi version of Early Childhood Oral Health Impact Scale (F-ECOHIS) in children with unilateral cleft lip and palate (UCLP) who were treated at a multi-disciplinary cleft center, adopted from another surgeon, and the ones did not have clefts and were treated at that dental clinic. Design: Cross-sectional study. Setting: The study was conducted at the Lip and Palate Cleft Clinic (Orthodontic Research Center, Shiraz University of Medical Sciences). Patients: The participants were enrolled from the Lip and Palate Cleft Clinic and the Department of Pediatric Dentistry. Main Outcome Measures: The OHRQoL of preschool children and their caregivers. Results: The total score of (ECOHIS) in all subscales of both domains of child impact and family impact was statistically lower for the study group than the other groups. Two by two comparisons showed significant differences between the team-managed and non-team groups (p < 0.001). In any domain subscale, there were no gender differences among the three groups (p > 0.05). Conclusions: The team-managed group obtained better scores in all subscales in comparison to the control and the non-team patient groups; however, since randomization and a controlled surgical method were not possible, the improvements in quality-of-life scores cannot be directly related to the surgical method.

Awareness, Knowledge, and Attitude Assessment of Cleft Lip With or Without Palate Management Among Vietnamese Dental and Medical Students: A Cross-Sectional Study

Background Cleft lip and/or palate (CL/P) are congenital malformations that require multidisciplinary treatment and in-depth knowledge for effective management, especially in countries like Vietnam, where the incidence rate is 1.4 per 1,000 live births. This study aimed to develop and validate a questionnaire to assess the awareness, knowledge, and attitudes of undergraduate medical and dental students at Hanoi Medical University, Vietnam, regarding CL/P management. Materials and methods The questionnaire was administered using Google Forms (Google LLC, USA). The study participants were 284 (55.6%) dental students and 227 (44.4%) medical students at Hanoi Medical University, Vietnam. The questionnaire comprised four sections: general information, awareness, knowledge, and attitude assessments. Results In the awareness assessment, 97.5% of students were aware of CL/P. However, 84.1% and 66.5% of medical and dental students, respectively, lacked confidence in their current knowledge. Confidence levels increased gradually from third-year to final-year students. Regarding etiology, most students believed genetic factors were the primary cause of CL/P, followed by environmental factors. The most commonly chosen treatment methods were oral, maxillofacial, and plastic surgeries. Dental students showed more interest in CL/P and felt a greater need for additional training in CL/P treatment and management than medical students. Both dental and medical students favored early intervention. However, 19.4% of students were unsure about the optimal time to begin treatment, with this uncertainty being more prevalent among medical students (26%) than among dental students (14.1%) (p<0.001). Conclusion This study emphasizes the need for improved education among undergraduate students, especially medical students, to improve CL/P management.

Long-Term Functional Outcomes in Pediatric Head and Neck Cancer Patients: A Systematic Review

OBJECTIVE

The multimodal treatments for pediatric head and neck (H&N) malignancies can have significant long-term functional consequences for growing patients. This systematic review aims to analyze the current knowledge of functional outcomes for pediatric H&N cancer survivors.

DATA SOURCES

PubMed, Embase, Web of Science.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed, and 1356 papers were reviewed by 3 team members with conflict resolution by a senior member.

RESULTS

Fourteen studies were included. Nine of 14 (64%) papers reported issues with swallowing, characterized as either dysphagia, odynophagia, oropharyngeal fibrosis, esophageal stenosis, xerostomia, trismus, or general issues with the throat and mouth. Six of 14 papers noted nutritional and feeding deficiencies, and 5 of 14 additionally noted issues with speech and voice changes. Four of 14 (29%) reported hearing impairments and/or loss. A majority of papers (9/14) reported long-term functional characteristics as a secondary outcome. Three of 14 (21%) reported a quality of life (QoL) measure. Heterogeneity in methodology and reporting precluded analysis of any relationship between treatment type and functional outcomes. Recommendations include integration of objective measures of feeding support and swallowing, as well as regular measurements of function and QoL parameters during treatment to better understand the evolution of QoL and function throughout care.

CONCLUSION

Relatively few studies focus on functional outcomes following the treatment of pediatric H&N cancer. Swallowing difficulty is the most frequently reported deficit, but objective data is rarely reported. Standardization of functional outcome assessment could improve the quality of evidence for pediatric patients treated for H&N cancer.

Patient-reported outcomes measure for patients with cleft palate

Cleft palate presents multifaceted challenges impacting speech, hearing, appearance, and cognition, significantly affecting patients' quality of life (QoL). While surgical advancements aim to restore function and improve appearance, traditional clinical measures often fail to comprehensively capture patients' experiences. Patient-reported outcomes measure (PROMs) have emerged as crucial tools in evaluating QoL, offering insights into various aspects such as esthetic results, speech function, and social integration. This review explores PROMs relevant to cleft palate complications, including velopharyngeal insufficiency, oronasal fistulas, maxillary hypoplasia, sleep-disordered breathing, and caregiver QoL. Additionally, the review highlights the need for cleft palate-specific scales to better address the unique challenges faced by patients. By incorporating PROMs, healthcare providers can achieve more personalized, patient-centered care, improve communication, and enhance treatment outcomes. Future research should focus on developing and validating specialized PROMs to further refine patient assessments and care strategies.

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.

Psychosocial Burden of Pediatric and Adult Patients With Congenital Versus Traumatic Facial Differences: Assessment of Psychiatric Distress and Healthcare Utilization in the United States From 2004 to 2012

BACKGROUND

Psychiatric distress and its effects on healthcare utilization in pediatric patients with congenital and traumatic facial differences remain poorly understood. This study analyzes the psychosocial burden along with mental health and reconstructive surgery services utilization of this patient population in comparison with adult patients with such facial differences.

METHODS

The 2004-2012 Medical Expenditures Panel Survey was queried for all patients with facial differences. Socioeconomic variables, Patient Health Questionnaire 2 and Kessler 6 scores, responses from validated screening surveys, and utilization of mental health and reconstructive surgery (ie, plastic surgery and otolaryngology) services were compared between pediatric and adult patients with congenital and traumatic facial differences.

RESULTS

Children ages 5 to 12 years were more likely to be affected by facial trauma, whereas adolescents aged 13 to 17 years were more affected by congenital facial conditions. Pediatric patients with congenital facial conditions had higher rates of medical care, education, and special therapy utilization ( P < 0.0001), although their facial trauma counterparts used mental health services more often ( P < 0.0001). In adults, more facial trauma patients reported poorer perceived mental health status ( P = 0.01). Among patients with any facial difference, distressed adult patients were less likely to see a reconstructive surgeon even when controlling for socioeconomic variables (0.55 [0.31-0.97], P = 0.04).

CONCLUSIONS

In the pediatric population, psychosocial considerations should include both age and etiology of facial differences to best optimize care. Among adults with facial trauma, poor mental health may contribute to lower rates of surgical follow-up, highlighting a potential benefit for provision of mental health services earlier for these patient populations.

Skin Disease in Children: Effects on Quality of Life, Stigmatization, Bullying, and Suicide Risk in Pediatric Acne, Atopic Dermatitis, and Psoriasis Patients

Acne, atopic dermatitis (AD), and psoriasis are all chronic dermatologic conditions that greatly impact the lives of pediatric patients and their caregivers. The visible nature of these diseases negatively affects the self-image of children early in life as well as their relationships with their families and peers. Physicians recognize the importance of addressing both the physical and mental symptoms of their patients but are currently not equipped with clear guidelines to manage long-term psychosocial comorbidities in pediatric dermatologic patients. A PubMed and Google Scholar search of key words was conducted to explore self-image in pediatric patients with acne, AD, and psoriasis. Chronic skin diseases put pediatric patients at risk for strained family relationships, poor self-image, psychiatric comorbidities, stigmatization, and eventual suicidal behavior. A limitation of this study is a lack of a validated measure of quality of life in the pediatric population that fulfills enough criteria to evaluate long term quality of life in children and adults. Possible management options, including connecting patients with the same diagnosis and allocating resources to parents and teachers to better understand these chronic skin conditions, may provide pediatric patients with the support they need to develop resilience in the face of these challenges.

Primary Cleft Lip Repair in Adults Under Local Anesthesia

OBJECTIVE

There are many adults with cleft lip deformities in developing countries. This is due to the lack of public awareness, social stigma, distance from the health center, and parents' financial condition. Lip repair under local anesthesia is safe, cost-effective and would be beneficial for the underprivileged population.

DESIGN

A retrospective cohort study with follow-up of 1 to 8 years.

SETTING

Academic Hospital.

PATIENTS/PARTICIPANTS

Cleft lip repair was performed in 252 patients of age more than 12 years from 2012 to 2019. Patients with cleft palate, cardiopulmonary disease, who did not consent for the procedure while awake were excluded.

INTERVENTIONS

Cleft lip surgery done under local anesthesia.

MAIN OUTCOME MEASURES

Outcome measures were patients' self-satisfaction and comments of peer.

RESULTS

Two hundred fifty-two primary cleft lip operations were done in 168 male and 84 female patients. The mean age was 23.62 years, and the mean weight was 49.66 kg. Unilateral was 227, Bilateral cleft lip 25. The postoperative period was uneventful. No case of wound dehiscence or wound infection was observed. Patients were discharged on the same day, except the ones who traveled a long distance.

CONCLUSION

Cleft lip repair in adults under local anesthesia is safe and cost-effective.

Satisfaction and health-related quality of life of patients with microtia following reconstructive surgery using the Nagata technique

Objective

This study aimed to investigate the functional outcomes, satisfaction, and quality of life of patients with microtia following reconstructive surgery.

Methods

This cross-sectional study was conducted using retrospective data of patients with microtia following reconstructive surgery using the Nagata technique. Data were obtained from the medical records of patients who underwent reconstructive surgery at the Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck Surgery, Dr. Cipto Mangunkusumo Hospital between 2014 and 2018. All eligible patients were referred to participate in this study between November 2018 and March 2019. The hearing function was assessed by a professional audiologist after surgery. Patient satisfaction was evaluated by interview using a previously developed questionnaire, while quality of life was assessed using the EuroQol-5D-Young questionnaire.

Results

Thirty-one eligible subjects were included in the study. Pain and discomfort were the most commonly reported factors related to the quality of life following surgery. Approximately 67.7% of the patients were satisfied; 19.4% were very satisfied, and 12.9% reported acceptance of their surgical outcomes. The most common complication was infection (n = 8). Most patients did not experience any problems in their lives after microtia surgery.

Conclusions

The highest rate of satisfactory outcomes was observed for the lobule subunit, which was assumed to be associated with the use of the Z-plasty technique. The most common complication was infection, as environmental hygiene was the most important factor. Thus, further concern for maintaining good hygiene is necessary to improve the quality of reconstructive surgery. The level of satisfaction with microtia reconstructive surgery was adequate. Most patients had a good health-related quality of life without experiencing any problems.

Evaluation of Facial Appearance-Related Quality of Life in Young Japanese Patients With Cleft Lip and/or Palate

OBJECTIVE

(1) To confirm the reliability of a Japanese version of the Youth Quality of Life Instrument-Facial Differences Module (YQOL-FD); (2) to assess the quality of life (QoL) related to facial difference in Japanese youths with cleft lip and/or palate (CL/P) using this instrument; and (3) to examine the QoL differences according to age, sex, and cleft type.

DESIGN

A cross-sectional study.

SETTING

Japanese youths with CL/P were recruited through our hospital and asked to complete the YQOL-FD.

PARTICIPANTS

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

OUTCOME MEASURES

The domain scores of stigma, negative consequences, negative self-image, positive consequences, and coping in the YQOL-FD, and the reliability of such scores were evaluated.

RESULTS

The instrument showed an acceptable internal consistency (Cronbach α = 0.74-0.92) and test-retest reliability (intraclass correlation coefficient = 0.94-0.98), except for the coping domain. The individual's domain scores were spread out from the lowest score to the high scores among all domains, thus indicating the negative and positive impacts of living with facial differences regarding their QoL may vary among individuals with CL/P. All domain scores in the 15- to 18-year-old group were significantly higher than those in 11- to 14-year-old group; there were no significant differences according to sex or cleft type.

CONCLUSIONS

The instrument showed acceptable reliability, except for the coping domain. There were individual variations in QoL concerning the facial difference among Japanese youths with CL/P as measured by the YQOL-FD, suggesting the importance of individual evaluations. Perceptions were influenced by age, but not sex or cleft type.

Stigma and psychological distress among pediatric participants in the FD/MAS Alliance Patient Registry

Background

Stigma, both enacted and internalized, is part of the illness experience of many chronic conditions / diseases and has been found to increase psychological distress, lower self-esteem, and impact social engagement lowering quality of life (QOL). Stigma among pediatric patients is of particular concern due to its potential impact on identity formation. Using patient data from the online FD/MAS Alliance Patient Registry (FDMASAPR), this study seeks to 1) determine levels of enacted and self-stigma in a pediatric population of fibrous dysplasia (FD) / McCune Albright syndrome (MAS) patients and 2) to explore the relationship between stigma and anxiety and depression.

Methods

This is a cross sectional analysis of deidentified self-report data from 18 pediatric patients. Key analytic variables include the Neuro-QOL stigma short form, the Hospital Anxiety and Depression Scale (HADS), diagnostic category and craniofacial involvement, and select demographics. Sample means and score distributions are examined. Bivariate relationships between stigma, anxiety and depression and patient’s personal and medical characteristics are established through analysis of variance and correlation.

Results

Composite stigma levels for FD/MAS pediatric patients were comparable to those of children with multiple sclerosis, epilepsy, and muscular dystrophy. Self-stigma was more frequently reported than enacted/felt stigma, but few patients indicated complete freedom from either type of stigma. Diagnosis was significantly related to self-stigma. Significant bivariate relationships were found between depression and enacted/felt and self-stigma and between anxiety and self-stigma.

Conclusions

This study establishes the illness experience of pediatric patients with FD / MAS is impacted by stigma and suggests they should be regularly screened for stigma and psychological distress. It supports the integration of clinical psychologists/ therapists in regular patient care, referral of families to advocacy organizations, and indicates that rare disease patient registries can be a useful tool in efforts to improve the QOL of patients.

Topical rapamycin in the treatment of facial angiofibromas in tuberous sclerosis: a systematic review based on evidence

INTRODUCTION

facial angiofibromas of tuberous sclerosis are the most prevalent cutaneous manifestation, affecting 80% of patients, which cause facial lesions with negative psychosocial consequences. Newly, topical rapamycin has been established as an effective and safe therapy for this skin condition.

PURPOSE

to analyze the available scientific evidence about the effectiveness and safety of topical sirolimus in the treatment of facial angiofibromas in tuberous sclerosis.

METHODS

a literature search was conducted in PubMed and Cochrane. Effectiveness and safety were analyzed along with the main characteristics of each formulation in all included studies.

RESULTS

thirty studies were included involving a total of 508 patients, developed in the last 20 years. Four randomized clinical trial, 17 case series and 9 single case reports were founded. Multiple topical rapamycin concentrations (0.003-1%) and formulations (gel, ointment, solution) were found in literature. Rapamycin demonstrated its effectiveness in all studies included, except for 5 patients in a 1 b study. Rapamycin was shown to be safe for the treatment of FA.

CONCLUSIONS

Topical sirolimus can be considered an effective and safety option for the treatment of facial angiofibromas in tuberous sclerosis. However, further long-term studies need to establish an evidence-based therapeutic protocol.KEY MESSAGEUpdated review to date in topical rapamycin for facial angiofibromas, allowing support in therapeutic decisions.

The Psychosocial Patient-Reported Outcomes of End of Pathway Cleft Surgery: A Systematic Review

OBJECTIVE

To identify and review the literature on the psychosocial patient-reported outcomes (PROs) of surgery at the end of the cleft treatment pathway.

DESIGN

A systematic literature search was performed using electronic databases (Medline, PubMed, EMBASE, PsycInfo, Web of Science, and Science Direct) from database inception to September 2017, to identify studies measuring and reporting the psychosocial PROs of end of pathway cleft surgery.

RESULTS

Of 263 identified papers, 22 studies were eligible for inclusion. Apart from one randomized controlled study, studies were largely observational and adopted a cross-sectional or retrospective design. The majority (n = 16) were small-scale studies. The methodological quality was variable in terms of what, how, and when psychosocial outcomes were measured and reported. None of the studies utilized a psychosocial PRO measure validated in the cleft population, and few studies measured outcomes prospectively. A high proportion of studies utilized bespoke measures of patient satisfaction. Taken together, findings from the included studies are tentative but seem to suggest patients derive some benefit from undergoing end of pathway cleft surgery, in terms of increased satisfaction, quality of life, social interactions, and decreased appearance-related distress.

CONCLUSIONS

Due to methodological challenges and the heterogeneity of what, how, and when outcomes are measured and currently reported, it is difficult to determine the psychosocial PROs of end of pathway cleft surgeries. Consequently, this review advocates the conduct of well-designed, longitudinal studies using cleft-sensitive tool/s to capture the psychosocial PROs of end of pathway cleft surgery at various time points.

Sex differences in perceived stigmatization, body image disturbance, and satisfaction with facial appearance and speech among adolescents with craniofacial conditions

Youth with craniofacial conditions often have appearance and speech differences and are vulnerable to social stigmatization and body image disturbances. Given sociocultural pressures for female attractiveness, adolescent girls with craniofacial conditions may be especially vulnerable to body dissatisfaction and appearance-related social stigmatization, though such sex differences have been infrequently studied in this population. This study aimed to: (1) examine sex differences in body image disturbance, satisfaction with speech and facial appearance, and perceived stigmatization among adolescents with craniofacial conditions; and (2) evaluate whether stigmatization perceptions are predictive of body image disturbance and satisfaction with facial appearance and speech. Using a cross-sectional design, 110 adolescents from two craniofacial centers completed measures of body image disturbance, satisfaction with speech and facial appearance, and perceived stigmatization. Females reported significantly greater levels of body image disturbance and lower satisfaction with facial appearance compared to males. There were no significant sex differences for satisfaction with speech or perceived stigmatization. Perceived stigmatization was a significant predictor of body image disturbance, and satisfaction with facial appearance and speech while controlling for sex, body mass index, and age. Interventions to prevent and/or address body image and stigmatization concerns are clinically indicated for both sexes.

Quality of life outcomes following velopharyngeal insufficiency surgery

OBJECTIVES

Velopharyngeal insufficiency (VPI) may be due to functional or anatomic causes, and can lead to speech deficits, communication difficulty, and emotional strain on patients and their caregivers. The VPI Effects on Life Outcomes (VELO) instrument quantifies quality of life outcomes in VPI patients both before and after VPI surgery. This study aims to identify pre-operative patient characteristics associated with better post-operative quality of life.

METHODS

This study is a retrospective chart review of 51 patients who underwent VPI surgery between 2009 and 2018 at a tertiary free-standing children's hospital. A 26-item parent-proxy VELO questionnaire was administered by telephone to parents to assess their child's quality of life post-VPI surgery.

RESULTS

Twenty-seven parents responded to the VELO questionnaire. Average post-operative VELO score was significantly higher in non-syndromic patients as compared with syndromic patients. Average post-operative VELO score was not significantly different between patients with and without submucous cleft (SMC) or those with mild to moderate versus severe pre-operative hypernasality. On multivariate analysis, absence of genetic syndrome, lack of submucous cleft, and presence of severe-pre-operative hypernasality were significantly and positively associated with increased post-operative VELO scores.

CONCLUSION

Children who undergo VPI surgery are more likely to have better post-operative quality of life outcomes if their VPI was not associated with a genetic syndrome or submucous cleft. Non-syndromic and non-SMC patients with severe pre-operative hypernasality may benefit significantly from VPI surgery and have improved post-operative quality of life.

Examining the Psychosocial Needs of Adolescents With Craniofacial Conditions: A Mixed-Methods Approach

Objective:

To determine, for intervention development, the psychosocial needs of adolescents diagnosed with a craniofacial condition who attended focus group sessions.

Design:

A mixed-methods design combining qualitative focus groups with quantitative measures.

Setting:

An outpatient clinic at a major medical center in Manhattan, New York.

Participants:

Fourteen adolescents, aged 14 to 18, with craniofacial conditions.

Main Measures:

Participants completed measures assessing a range of psychological constructs. Average scores were compared to clinical cutoff scores and normative data for adolescents. The 2 focus groups were coded using an inductive approach to assess pertinent themes. Additionally, the acceptability and feasibility of a proposed intervention was measured.

Results:

Adolescents with craniofacial conditions were within normal ranges for quality of life, self-esteem, and body image and they reported higher resiliency. They were above cutoff scores for perceived stress and post-traumatic stress disorder symptoms and below cutoff scores for mindfulness. When compared to normative samples, they displayed higher perceived social support, but lower coping. Based on qualitative analyses, 6 themes emerged: stress, bullying, coping, resiliency, mindfulness, and social support. Both qualitative and quantitative analyses revealed most participants were supportive of a future intervention for this population.

Conclusions:

The present study identified several factors associated with psychological well-being of adolescents with craniofacial diagnoses and demonstrates the importance of creating interventions to target specific psychosocial needs. Findings from this study may guide researchers in developing and refining a specific program for this population and provide information to help those with craniofacial conditions who are experiencing psychosocial challenges.

Development and Application of a Novel Patient-Reported Outcome Measure on QoL and Facial Aesthetics-A Study on South Indian Population

BACKGROUND

The goal of cleft therapy has progressed from simply correcting the deformity to uplifting the patient's quality of life (QoL). At the end of comprehensive treatment, a patient with cleft lip and palate (CLP) should report with satisfactory QoL scores in all domains such as aesthetics, speech, function, and psychology.

OBJECTIVE

To develop and validate a novel, disease-specific questionnaire designed in 2 regional languages to assess the QoL in young adult patients with CLP of South India following comprehensive treatment.

METHODS

A preliminary questionnaire was created from the literature review and patient interviews, considering regional sociodemographic conditions. The questionnaire was then validated by subject experts and pilot tested. The resultant tool was implemented on patients at treatment completion. Data collected were assimilated for statistical evaluation.

RESULTS

The questionnaire was deemed reliable (Cronbach α = .854 and test-retest reliability, κ = 0.8) and was administered to 100 young adult patients with CLP (mean age: 22 years). A large majority (83%) of the population felt more confident about themselves, with positive responses to familial relations, social interaction, and self-image. About 25% of the patients faced problems with speech regularly, while a majority of patients did not face problems with chewing and swallowing. Nearly 60% of patients were fully satisfied with their facial appearance, while others had concerns about their lip and nose aesthetics. The results were descriptive of the local population.

CONCLUSIONS

Most patients achieved satisfactory QoL in all domains following comprehensive multispeciality therapy. The novel tool is simple, reliable, and can be adapted to homogenous population groups.

Caregiver-Reported Outcomes and Barriers to Care among Patients with Cleft Lip and Palate

BACKGROUND

For children with cleft lip and/or palate, access to care is vital for optimizing speech, appearance, and psychosocial outcomes. The authors posited that inadequate access to care negatively impacts outcomes in this population.

METHODS

Sixty caregivers of children with cleft lip and palate were surveyed to assess perceived barriers using the validated Barriers to Care questionnaire. The questionnaire includes 39 items divided into five subscales, with higher scores indicating fewer barriers. Caregiver-reported outcomes were assessed using the Cleft Evaluation Profile, which captures cleft-specific appearance- and speech-related outcomes. Higher scores correspond to less satisfactory outcomes. Desire for revision surgery was assessed as a binary outcome among caregivers. Multivariable regression was used to evaluate the relationship of barriers to care, caregiver-reported outcomes, and desire for revision, adjusting for clinical and demographic covariates.

RESULTS

Sixty percent of caregivers perceived barriers to care, and caregivers who reported poorer access to care described poorer cleft-related outcomes (r = 0.19, p = 0.024). Caregivers with poorer skills (r = 0.17, p = 0.037), expectations (r = 0.17, p = 0.045), and pragmatics (r = 0.18, p = 0.026) subscale scores were associated with worse Cleft Evaluation Profile scores. Barriers were also negatively associated with aesthetic item scores (r = 0.11, p = 0.025). Finally, caregivers reporting fewer barriers were 21.2 percent less likely to express interest in revision surgery.

CONCLUSIONS

Barriers to care were associated with poorer appearance-related outcomes and increased interest in revision among caregivers of cleft patients. Enhancing access to care is critical in order to effectively meet goals of care for these families.

Psychosocial well-being of long-term survivors of pediatric head-neck rhabdomyosarcoma

BACKGROUND

Head and neck rhabdomyosarcoma (HNRMS) survivors are at risk to develop adverse events (AEs). The impact of these AEs on psychosocial well-being is unclear. We aimed to assess psychosocial well-being of HNRMS survivors and examine whether psychosocial outcomes were associated with burden of therapy.

PROCEDURE

Sixty-five HNRMS survivors (median follow-up: 11.5 years), treated in the Netherlands and the United Kingdom between 1990 and 2010 and alive ≥2 years after treatment visited the outpatient multidisciplinary follow-up clinic once, in which AEs were scored based on a predefined list according to the Common Terminology Criteria for Adverse Events. Survivors were asked to complete questionnaires on health-related quality of life (HRQoL; PedsQL and YQOL-FD), self-perception (KIDSCREEN), and satisfaction with appearances (SWA). HRQoL and self-perception scores were compared with reference values, and the correlation between physician-assessed AEs and psychosocial well-being was assessed.

RESULTS

HNRMS survivors showed significantly lower scores on PedsQL school/work domain (P ≤ 0.01, P = 0.02, respectively), YQOL-FD domains negative self-image and positive consequences (P ≤ 0.01, P = 0.04, respectively) compared with norm data; scores on negative consequences domain were significantly higher (P = 0.03). Over 50% of survivors negatively rated their appearances on three or more items. Burden of AEs was not associated with generic HRQoL and self-perception scores, but was associated with disease-specific QoL (YQOL-FD).

CONCLUSION

In general, HRQoL in HNRMS survivors was comparable to reference groups; however, survivors did report disease-specific consequences. We therefore recommend including specific questionnaires related to difficulties with facial appearance in a systematic monitoring program to determine the necessity for tailored care.

Content Validity of Patient-Reported Outcome Instruments used with Pediatric Patients with Facial Differences

Objective:

The aim of this systematic review was to identify patient-reported outcome (PRO) instruments used in research with children/youth with conditions associated with facial differences to identify the health concepts measured.

Design:

MEDLINE, EMBASE, CINAHL, and PsycINFO were searched from 2004 to 2016 to identify PRO instruments used in acne vulgaris, birthmarks, burns, ear anomalies, facial asymmetries, and facial paralysis patients. We performed a content analysis whereby the items were coded to identify concepts and categorized as positive or negative content or phrasing.

Results:

A total of 7,835 articles were screened; 6 generic and 11 condition-specific PRO instruments were used in 96 publications. Condition-specific instruments were for acne (four), oral health (two), dermatology (one), facial asymmetries (two), microtia (one), and burns (one). The PRO instruments provided 554 items (295 generic; 259 condition specific) that were sorted into 4 domains, 11 subdomains, and 91 health concepts. The most common domain was psychological (n = 224 items). Of the identified items, 76% had negative content or phrasing (e.g., “Because of the way my face looks I wish I had never been born”). Given the small number of items measuring facial appearance (n = 19) and function (n = 22), the PRO instruments reviewed lacked content validity for patients whose condition impacted facial function and/or appearance.

Conclusions:

Treatments can change facial appearance and function. This review draws attention to a problem with content validity in existing PRO instruments. Our team is now developing a new PRO instrument called FACE-Q Kids to address this problem.

Using Photovoice to Explore Quality of Life Factors of Adults With Crouzon Syndrome

In the United States, one in 60,000 adults live with Crouzon Syndrome (CS) and facial malformations. Phenomenological studies about their lived experiences and quality of life are lacking. The purpose of this participatory action research study was to gain a richer understanding of the perceived biopsychosocial and socioecological factors that impact quality of life for adults living with CS using Photovoice. Another aim was to develop a conceptual framework of quality of life for those experiencing CS to enhance tailored health education and services. A purposeful sample of nine adults with CS were recruited from U.S. national surgery centers and support groups. Participants used photography to represent their experiences and participated in individual interviews and focus groups. Data were analyzed with the participants using thematic analysis, and 44 themes emerged which informed the development of a quality of life conceptual framework and action plan described in this article.

The impact of pediatric skin disease on self-esteem

Background

Pediatric skin disorders can affect children's self-esteem, relationships with caregivers and peers, and performance in school and activities.

Objective

This review describes common pediatric congenital and acquired dermatologic disorders and the impact that these disorders can have on children's self-esteem.

Methods

A review of current, English-language literature was conducted with use of the PubMed database. Search terms included atopic dermatitis, acne, infantile hemangiomas, port wine stains, congenital melanocytic nevi, hidradenitis suppurativa, and self-esteem.

Results

During infancy and toddlerhood, skin disorders such as infantile hemangiomas primarily affect the attachment between child and caregiver. School-aged children with port wine stains and atopic dermatitis report increased bullying, teasing, and social isolation. Acne and hidradenitis typically affect older children and teens and these conditions are associated with increased risks of depression and suicidal ideation. Effective management of these conditions has been shown to increase patients' self-esteem.

Conclusion

Pediatric dermatologic disorders impact self-esteem throughout childhood. In addition to the surgical and medical management of these disorders, clinicians can also take an active role in the assessment and improvement of the psychosocial impact of these skin disorders.

People living with facial disfigurement after having had noma disease: A systematic review of the literature

Noma disease often results in impairment, morbidity and severe facial disfigurement. This article reports a systematic review of literatures published between 2006 and 2015 to establish existing knowledge about social stigma associated with facial disfigurements. Five databases were searched and 114 citations were screened, of which only 15 met the relevant criteria. Titles and abstracts of the retrieved articles were independently reviewed. The research was heterogeneous; therefore, overall synthesis using meta-analysis was inappropriate. It can be seen that the review demonstrates that facial disfigurements are far more complex than was previously thought.

A Population-Based Exploration of the Social Implications Associated with Cleft Lip and/or Palate

Background:

Clefts of the lip and/or palate (CL/P) carry a social stigma that often causes psychosocial stress. The purpose of this study was to consider the association of cleft phenotype and age with self-reported aspects of psychosocial stress.

Methods:

Children with nonsyndromic CL/P and unaffected children born between 1997 and 2003 were identified through the North Carolina Birth Defects Monitoring Program and North Carolina birth records, respectively. The psychosocial concerns of children with CL/P were assessed via a 29-question subset of a larger survey. Responses were analyzed according to school age and cleft phenotype (cleft lip with/without cleft alveolus, CL ± A; cleft palate only, CP; or cleft lip with cleft palate, CL + P).

Results:

Surveys were returned for 176 children with CL/P and 333 unaffected children. When compared with unaffected children, responses differed for CL ± A in 4/29 questions, for CP in 7/29 questions, and for CL + P in 8/29 questions (P < 0.05). When stratified by school age, children with CL/P in elementary, middle, and high school differed from unaffected children by 1/29, 7/29, and 2/29 questions, respectively. Middle school–aged children with CL/P were more affected by aesthetic concerns, bullying, and difficulties with friendship, and social interaction. Children with CL + P reported more severe aesthetic-related concerns than children with CL ± A or CP but experienced similar speech-related distress as children with CP only.

Conclusion:

Social implications associated with CL/P are most pronounced during middle school, and less so during elementary and high school. This information identifies areas of social improvement aimed at reducing the stigma of CL/P.

Health-Related Quality-of-Life Instruments for Pediatric Patients with Diverse Facial Deformities: A Systematic Literature Review

BACKGROUND

Treatment for patients with diverse craniofacial conditions is complex and long-term. Craniofacial conditions profoundly influence health-related quality of life, and patient- and parent-reported outcomes provide a critical and complementary perspective on the multidisciplinary treatment of patients. However, little is known regarding the health-related quality of life among children with diverse craniofacial conditions. The purpose of this study was to systematically review the literature regarding patient- and parent-reported outcomes measures for patients with diverse craniofacial conditions.

METHODS

Articles from the PubMed, PsychINFO, CINAHL, Embase/MEDLINE, Scopus, and Web of Science databases that used patient- and/or parent-reported outcome instruments in patients with diverse craniofacial conditions were reviewed. Diagnoses included were cleft lip and/or palate, craniosynostosis, microtia, craniofacial microsomia, facial vascular malformations, and congenital nevi across pediatric populations (0 to 22 years of age).

RESULTS

Six hundred ninety articles were identified, and 155 were selected for inclusion. One hundred twenty different health-related quality-of-life tools were used to analyze factors such as physical, psychological, or social function. Of these, the 10 most common psychometrically tested tools were identified in 59 studies. Five tools had both parent and patient versions. Two tools were developed and validated for patients with diverse craniofacial conditions, but neither was developed for nonadolescent children.

CONCLUSIONS

Many parent- and patient-reported instruments are used to measure varying health-related quality of life factors in this population, but no tool exists that was developed and psychometrically tested in different facial deformities that measures comprehensive health-related quality of life issues across all pediatric ages. This study will guide the development of new tools to measure the parent and patient health-related quality-of-life perspective in patients with diverse craniofacial conditions.

Establishing Content Validity of the CLEFT-Q: A New Patient-reported Outcome Instrument for Cleft Lip/Palate

BACKGROUND

The CLEFT-Q is a new patient-reported outcome instrument designed to measure outcomes that matter to patients. The aim of this qualitative study was to establish content validity of the CLEFT-Q in patients who differ by age and culture.

METHODS

Patients aged between 6 and 29 years were recruited from plastic surgery clinics in Canada, India, Ireland, the Philippines, the Netherlands and the United States. Healthcare providers and other experts participated in a focus group or provided individual feedback. Input was sought on all aspects of the CLEFT-Q (item wording, instructions, and response options), and to identify missing content. Patient interviews and expert feedback took place between September 2013 and September 2014.

RESULTS

Sixty-nine patients and 44 experts participated. The first draft of the CLEFT-Q consisted of 163 items measuring 12 constructs. The first round of feedback identified 92 items that required revision. In total, 3 rounds of interviews, and the involvement of an artist to create pictures for 17 items, were needed to establish content validity. At the conclusion of cognitive interviews, the CLEFT-Q consisted of 13 scales (total 171 items) that measure appearance, health-related quality of life, and facial function. The mean Flesch-Kincaid readability statistic for items was 1.4 (0 to 5.2).

CONCLUSION

Cognitive interviews and expert review allowed us to identify items that required re-wording, re-conceptualizing, or to be removed, as well as any missing items. This process was useful for refining the CLEFT-Q scales for further testing.

Oral health-related quality of life in youth receiving cleft-related surgery: self-report and proxy ratings

PURPOSE

This paper evaluated the impact of cleft-related surgery on the oral health-related quality of life (OHRQoL) of youth with cleft over time.

METHODS

Data were derived from a 5-year, multi-center, prospective, longitudinal study of 1196 youth with cleft lip and/or palate and their caregivers. Eligible youth were between 7.5 and 18.5 years old, spoke English or Spanish, and were non-syndromic. During each observational period, which included baseline, and 1- and 2-year post-baseline follow-up visits, youths and their caregivers completed the Child Oral Health Impact Profile, a validated measure of OHRQoL. Multilevel mixed-effects models were used to analyze the effects of receipt of craniofacial surgery on OHRQoL over time.

RESULTS

During the course of this study a total of 516 patients (43 %) received at least one surgery. Youth in the surgery recommendation group had lower self- (β = -2.18, p < 0.05) and proxy-rated (β = -2.92, p < 0.02) OHRQoL when compared to non-surgical self- and proxy-rated OHRQoL at baseline. Both surgical and non-surgical youth (β = 3.73, p < 0.001) and caregiver (β = 1.91, p < 0.05) ratings of OHRQoL improved over time. There was significant incremental improvement (time × surgery interaction) in self-reported OHRQoL for youth postsurgery (β = 1.04, p < 0.05), but this postsurgery increment was not seen in the caregiver proxy ratings.

CONCLUSIONS

Surgical intervention impacts OHRQoL among youth with cleft. Youth who were surgical candidates had lower baseline self- and caregiver-rated OHRQoL when compared to non-surgical youth. Youth who underwent cleft-related surgery had significant incremental improvements in self-rated but not caregiver (proxy)-rated OHRQoL after surgery.

Body Image and Quality of Life in Adolescents With Craniofacial Conditions

OBJECTIVE

To evaluate body image in adolescents with and without craniofacial conditions and to examine relationships between body image and quality of life.

DESIGN

Case-control design.

SETTING

A pediatric hospital's craniofacial center and primary care practices.

PARTICIPANTS

Seventy adolescents with visible craniofacial conditions and a demographically matched sample of 42 adolescents without craniofacial conditions.

MAIN OUTCOME MEASURE

Adolescents completed measures of quality of life and body image including satisfaction with weight, facial and overall appearance, investment in appearance (importance of appearance to self-worth), and body image disturbance (appearance-related distress and impairment in functioning).

RESULTS

Adolescents with craniofacial conditions reported lower appearance investment (P < .001) and were more likely to report concerns about facial features (P < .02) compared with nonaffected youth. Females in both groups reported greater investment in appearance, greater body image disturbance, and lower weight satisfaction compared with males (P < .01). Within both groups, greater body image disturbance was associated with lower quality of life (P < .01). The two groups did not differ significantly on measures of quality of life, body image disturbance, or satisfaction with appearance.

CONCLUSIONS

Body image and quality of life in adolescents with craniofacial conditions are similar to nonaffected youth. Relationships between body image and quality of life emphasize that appearance perceptions are important to adolescents' well-being regardless of whether they have a facial disfigurement. Investment in one's appearance may explain variations in body image satisfaction and serve as an intervention target, particularly for females.

Psychological adjustment to craniofacial conditions (excluding oral clefts): A review of the literature

OBJECTIVE

A congenital craniofacial anomaly (CFA) is expected to impact upon several domains of psychological, emotional and social functioning, yet no recent reviews have comprehensively summarised the available literature. Further, existing reviews tend to draw upon literature in the field of cleft lip and palate, and do not give substantive attention to other types of CFAs.

DESIGN

A review of 41 papers published between January 2000 and March 2016 pertaining to psychological adjustment to CFAs.

MAIN OUTCOME MEASURES

Findings are presented according to key psychological domains: General Psychological Well-being, Quality of Life, Behaviour, Emotional Well-being, Social Experiences, Appearance, and Treatment-Related Experiences.

RESULTS

Current literature offers a contradictory picture of adjustment to CFAs. Psychological adjustment appeared to be comparable to norms and reference groups in approximately half of the papers related to non-syndromic CFAs, while more variation was found across domains among samples with syndromic CFAs. Associations were found between adjustment, physical health and cognitive function in several papers. The review identified a number of gaps in the literature, such as the inclusion of a wide range of diagnoses within research samples.

CONCLUSIONS

This review demonstrates the complexity of findings, both within and across domains, and highlights a number of methodological challenges.

Effect of Angiofibromas on Quality of Life and Access to Care in Tuberous Sclerosis Patients and Their Caregivers

BACKGROUND/OBJECTIVES

Facial angiofibromas (AF) have the potential to cause disfigurement in children with tuberous sclerosis complex (TSC). Facial disfigurement can impact the quality of life (QoL) of individuals and their families, leading to negative psychosocial outcomes. QoL has not been studied in TSC patients with AF.

METHODS

We conducted a cross-sectional survey study to investigate QoL of TSC patients with AF and their caregivers and to explore the current state of access to treatment for AF. TSC patients and caregivers in TSC clinic at Boston Children's Hospital and through the Tuberous Sclerosis Alliance were recruited to complete QoL surveys including the CADIS, CDLQI, and Skindex-teen questionnaires, and a survey on access to treatment of AF.

RESULTS

Fifty-eight patients with TSC and 161 caregivers participated in the study. Caregivers of patients with AF had significantly poorer QoL scores compared to caregivers of those without AF, as measured by a modified CADIS questionnaire (mean 31.7 vs. 11.7, p = 0.004). Among patients with AF, those who received treatment had significantly better QoL scores compared with those without treatment, as measured by the CDLQI (mean 3.8 vs. 9.5, p = 0.001). Forty-one and two-tenths percent of subjects reported never receiving treatment for AF. Forty-seven and three-tenths percent of subjects were prescribed topical rapamycin, 47.7% of whom experienced difficulty with insurance coverage.

CONCLUSIONS

Presence and lack of treatment of AF significantly impacts QoL in TSC patients and their caregivers. Access to care for AF is limited by multiple factors and should be addressed by clinicians working with this patient population.

Shared Surgical Decision Making and Youth Resilience Correlates of Satisfaction With Clinical Outcomes

The aim of this study was to identify factors associated with youth satisfaction with surgical procedures performed to address oral cleft or craniofacial conditions (CFCs). It was hypothesized that youth mental health, participation in decision making, perceived consequences of living with a CFC, and coping strategies would be associated with satisfaction with past surgeries. A total of 203 youth between the ages of 11 and 18 years (mean age = 14.5, standard deviation = 2.0, 61% male participants, 78% oral cleft) completed a series of questionnaires measuring depression, self-esteem, participation in decision making, condition severity, negative and positive consequences of having a CFC, coping, and satisfaction with past surgeries. Multiple regression analysis using boot-strapping techniques found that youth participation in decision making, youth perception of positive consequences of having a CFC, and coping accounted for 32% of the variance in satisfaction with past surgeries (P < 0.001). Youth age, sex, and assessment of condition severity were not significantly associated with satisfaction with surgical outcome. Depression, self-esteem, and negative consequences of having a CFC were not associated with satisfaction with past surgeries. Youth should be actively involved in the decision for craniofacial surgery. Youth who were more satisfied with their surgical outcomes also viewed themselves as having gained from the experience of living with a CFC. They felt that having a CFC made them stronger people and they believed that they were more accepting of others and more in touch with others' feelings because of what they had been through.

Measurement of Health-Related and Oral Health–Related Quality of Life among Individuals with Nonsyndromic Orofacial Clefts: A Systematic Review and Meta-Analysis

Objective

To compare health-related quality of life and oral health–related quality of life between nonsyndromic individuals with and without cleft lip and/or cleft palate and to identify the most affected quality of life dimensions in individuals with cleft lip and/or palate.

Design

Systematic review and meta-analysis were conducted. Of the 314 identified citations, 23 articles were submitted to quality assessment. Data from nine studies on health-related quality of life and six on oral health–related quality of life were extracted for meta-analysis.

Main Outcome Measures

Pooled mean differences of health-related quality of life between adults with and without cleft lip and/or palate, pooled means of health-related quality of life dimensions of children and adults with cleft lip and/or palate and oral health–related quality of life dimensions of children and adolescents with cleft lip and/or palate with a 95% confidence interval were calculated.

Results

Quality assessment revealed methodological differences between studies. Lack of subgroup stratification and absence of control for confounders were the main limitations. Heterogeneity was detected on the comparison of oral health–related quality of life and health-related quality of life between children with and without cleft lip and/or palate, and oral health–related quality of life between adolescents with and without cleft lip and/or palate. A random-effect model showed a significant difference on health-related quality of life between adults with and without cleft lip and/or palate (mean difference = 0.10; 95% confidence interval, 0.16 to 0.05). Psychological health (mean, 78.9; 95% confidence interval, 70.1 to 87.7) and vitality (mean, 68.1; 95% confidence interval, 48.0 to 88.1) were the most affected health-related quality of life dimensions in children and adults with cleft lip and/or palate, respectively. Means of health-related quality of life dimensions in children and adults with cleft lip and/or palate and oral health–related quality of life in children and adolescents with cleft lip and/or palate varied yet did not differ in indirect comparisons.

Conclusion

The presence of cleft lip and/or palate negatively affected the health-related quality of life of adults, mainly on psychosocial dimensions.

Examining factors associated with oral health-related quality of life for youth with cleft

BACKGROUND

Patient-reported quality-of-life outcomes in cleft lip-cleft palate treatment are critical for evidence-based care. Scant data exist analyzing treatment from the patient's perspective. The authors examined the interrelationship among variables associated with oral health-related quality of life among youth with cleft.

METHODS

As part of an ongoing longitudinal study, clinical evaluations and research questionnaire packets were completed before surgical recommendations were made (baseline). Participants completed the Child Oral Health Impact Profile, a validated oral health-related quality-of-life measure for children with cleft. During the baseline clinical evaluations, plastic surgeons determined whether surgical interventions were recommended within the year (expert determination represents a greater degree of current clinical need). General linear models incorporating surgical recommendation, gender, and age were fit for each subscale of and for the total Child Oral Health Impact Profile. Significant interaction terms were evaluated for their effect on the subscale.

RESULTS

Baseline assessments were obtained from 1200 participants (mean, 11.8 years; 57 percent male). Participants with a surgical recommendation had lower quality of life on all but the self-esteem subscale compared with those without a surgical recommendation (p < 0.002). Two subscales had statistically significant age-sex interactions (p < 0.003), whereas another subscale had a statistically significant surgery by sex interaction term (p = 0.027).

CONCLUSIONS

Overall, youth for whom surgery is currently recommended had lower oral health-related quality-of-life scores on the Child Oral Health Impact Profile Total scale than those with no surgical recommendation; older female subjects had lower quality-of-life scores than male subjects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Examination of a theoretical model for oral health-related quality of life among youths with cleft

OBJECTIVES

We evaluated relationships among physical and psychological indicators and oral health-related quality of life (OHRQOL) in youths with cleft.

METHODS

We recruited youths aged 7 to 18 years with cleft palate (n = 282) or cleft lip and palate (n = 918) and their caregivers into a 5-year observational investigation at 6 US treatment centers from 2009 to 2011. At baseline, youths completed surveys to assess psychological status. After clinical evaluation, 433 youths received a recommendation for surgery. We developed structural models from the baseline data incorporating age, gender, race, and cleft diagnosis to examine direct relationships between depressive symptoms and, in separate models, self-concept and sense of mastery and OHRQOL. Subsequent models examined the possible mediating effect of surgical recommendation.

RESULTS

Depressive symptoms were negatively and self-concept and self-efficacy were positively associated with OHRQOL. Surgical recommendation appeared to mediate the effect of psychological well-being, but not depression, on OHRQOL, even after adjustment for cleft diagnosis. In some models, individual-level characteristics were significant.

CONCLUSIONS

Path analyses support the theoretical model and underscore the importance of examining positive psychosocial characteristics such as resiliency and self-concept in this patient population.

Cleft lip - a comprehensive review

Orofacial clefts comprise a range of congenital deformities and are the most common head and neck congenital malformation. Clefting has significant psychological and socio- economic effects on patient quality of life and require a multidisciplinary team approach for management. The complex interplay between genetic and environmental factors play a significant role in the incidence and cause of clefting. In this review, the embryology, classification, epidemiology, and etiology of cleft lip are discussed. The primary goals of surgical repair are to restore normal function, speech development, and facial esthetics. Different techniques are employed based on surgeon expertise and the unique patient presentations. Pre-surgical orthopedics are frequently employed prior to definitive repair to improve outcomes. Long term follow up and quality of life studies are discussed.

Clinical care in craniofacial microsomia: a review of current management recommendations and opportunities to advance research

Craniofacial microsomia (CFM) is a complex condition associated with microtia, mandibular hypoplasia, and preauricular tags. It is the second most common congenital facial condition treated in many craniofacial centers and requires longitudinal multidisciplinary patient care. The purpose of this article is to summarize current recommendations for clinical management and discuss opportunities to advance clinical research in CFM.

Predictors of Mental Health in Adults with Congenital Craniofacial Conditions Attending the Australian Craniofacial Unit

Objective

Adults with craniofacial conditions experience more psychosocial problems than adults in the general population, but little is known about the factors that render a person more or less susceptible to these problems. Guided by research on adults with other conditions that affect appearance, this study examined predictors of psychosocial outcome in adults with craniofacial conditions.

Design

Single-sample cross-sectional design.

Setting

The Australian Craniofacial Unit, Women's and Children's Hospital, Adelaide, one of the main craniofacial treatment centers in Australia.

Participants

Adults (N = 93; 36.9% of the potential sample) with congenital craniofacial conditions (excluding cleft lip and/or cleft palate) who were treated in the Australian Craniofacial Unit.

Main Outcome Measures

All participants completed measures assessing anxiety, depression, and quality of life (Hospital Anxiety and Depression Scale, Short-Form Health Survey) and variables predicted to affect these outcomes (SF-36 Health Survey - Multidimensional Scale of Perceived Social Support, Rosenberg Self-Esteem Scale, Cleft Satisfaction Profile, Brief Fear of Negative Evaluation Scale, Derriford Appearance Scale).

Results

Multiple regression analyses revealed that anxiety was predicted by social support, self-esteem, and fear of negative evaluation, while depression was predicted by self-esteem and social support. Physical quality of life was not predicted by any of the measures. Satisfaction with appearance, gender, age, and education were not related to outcome.

Conclusions

Interventions designed to increase perceived social support and self-esteem and reduce fear of negative evaluation appear to be indicated and may assist in establishing a causal relationship between these variables.

Evaluation of the similarities and differences in response patterns to the Pediatric Quality of Life Inventory and the Child Oral Health Impact Scores among youth with cleft

PURPOSE

To examine (a) the pattern of responses to a generic health-related quality of life (HRQL) measure (Pediatric Quality of Life Inventory--PedsQL) and an oral health-related quality of life (OHRQoL) measure (Child Oral Health Impact Profile--COHIP), and (b) the associations of these scores with surgical recommendation status among youth with cleft.

METHODS

Cross-sectional data (baseline) regarding clinicians' surgical recommendations and quality of life (QoL) measures were examined from an ongoing observational study on treatment outcomes. Approximately one-third of the racially and geographically diverse sample (N = 1,200; mean = 11.6 years) received surgical recommendations to correct either visible (aesthetic) or invisible (functional) defects. Effect sizes were used to quantify differences in QoL based on surgical recommendation and to compare the sensitivity of the PedsQL and COHIP subscales. Using Pearson coefficients, the scores of those recommended for surgery were compared with those without a surgical recommendation.

RESULTS

A moderate correlation (0.52) was found between the total scores on the PedsQL and COHIP (p < 0.0001). Subscale correlations between the QoL measures ranged from 0.19 to 0.48 with the strongest correlation between the PedsQL Emotional (r = 0.47) and COHIP Socioemotional Well-being subscale. The effect size for the COHIP Socioemotional Well-being (0.39) was larger than the PedsQL Social/Emotional (0.07/0.11) subscale (Z = 5.30/Z = 4.64, p < 0.0001, respectively), and the total COHIP (0.31) was significantly greater than the total PedsQL scale (0.15, z = 2.65, p = 0.008).

CONCLUSIONS

A significant relationship was found between generic HRQL, OHRQoL, and surgical needs among youth with cleft with the COHIP having larger effect sizes than the PedsQL among surgical groups.

Living with Difference: Experiences of Adolescent Girls with Cleft Lip and Palate

Objective

This study explored the experiences of adolescent girls with cleft lip and palate who were preparing for orthognathic surgery.

Design

A qualitative study, based on a phenomenological approach, explored adolescents’ experiences. Two 1-hour semistructured interviews were conducted before surgery, and member checking was employed to verify findings with each participant.

Setting

A tertiary care pediatric hospital in central Canada.

Participants

A criterion sampling technique was used to recruit a sample of seven participants with cleft lip and palate ranging in age from 15 to 20 years who were scheduled for cleft orthognathic surgery.

Results

Participants described experiencing teasing, bullying, and stares. In many cases, participants sought to resist and dismiss negative social attitudes about their visible difference while working to combat this with a positive view of who they really are. To varying degrees, participants felt constricted in engaging in the community as they were worried what others thought of their visible difference. They worked at finding ways to reduce the impact of social stigma through coping strategies, social supports, and reconstructive surgery.

Conclusions

Adolescent girls can experience strain associated with living with a facial difference; however, they find strategies to cope with the perception of difference. Reconstructive surgery is viewed as a means to increase confidence. Further intervention is needed in understanding and addressing stigma and fostering resiliency related to female adolescents living with a facial difference.

Application of the International Classification of Functioning, Disability, and Health–Children and Youth Version (ICF-CY) to Cleft Lip and Palate

Objective

In recent health policy discussions, the World Health Organization has urged member states to implement the International Classification of Functioning, Disability, and Health: Children and Youth Version in their clinical practice and research. The purpose of this study was to identify codes from the International Classification of Functioning, Disability, and Health: Children and Youth Version relevant for use among children with cleft lip and/or palate, thereby highlighting the potential value of these codes for interprofessional cleft palate-craniofacial teams.

Design

The scope of recent published research in the area of cleft lip and/or palate was reviewed and compared with meaningful terms identified from the International Classification of Functioning, Disability, and Health: Children and Youth Version. In a five-step procedure, a consensus-based list of terms was developed that was linked separately to International Classification of Functioning, Disability, and Health: Children and Youth Version categories and codes. This provided a first draft of a core set for use in the cleft lip and/or palate field.

Conclusions

Adopting International Classification of Functioning, Disability, and Health: Children and Youth Version domains in cleft lip and/or palate may aid experts in identifying appropriate starting points for assessment, counseling, and therapy. When used as a clinical tool, it encourages health care professionals to go beyond treatment and outcome perspectives that are focused solely on the child and to include the children's environment and their familial/societal context. In order to establish improved, evidence-based interdisciplinary treatments for children with cleft lip and/or palate, more studies are needed that seek to identify all the influencing conditions of activities, children's participation, and barriers/facilitators in their environments.

Nasoalveolar molding: prevalence of cleft centers offering NAM and who seeks it

INTRODUCTION

Nasoalveolar molding (NAM) is a treatment option available for early cleft care. Despite the growing debate about the efficacy of nasoalveolar molding, questions remain regarding its prevalence and the demographic characteristics of families undergoing this technique prior to traditional cleft surgery.

OBJECTIVES

To determine the number of teams currently offering nasoalveolar molding and to identify salient clinical and sociodemographic variables in infants and families who choose nasoalveolar molding compared with those who choose traditional cleft care across three well-established cleft centers.

RESULTS

Via phone surveys, 89% of the U.S. cleft teams contacted revealed that nasoalveolar molding is available at 37% of these centers. Chart reviews and phone correspondence with caregivers indicate that the average distance to the cleft center was 65.5 miles and caregiver age averaged 30.9 ± 5.7 years. Of families who chose nasoalveolar molding, 85% received total or partial insurance coverage. No difference in caregiver education, income, or distance to the clinic between treatment groups was found. On average, infants receiving nasoalveolar molding and cleft surgery had larger clefts and had more clinic visits than infants receiving traditional cleft surgery. Infants who were firstborn and those who did not have other siblings were more likely to receive nasoalveolar molding than were infants who were residing with other siblings.

CONCLUSIONS

Currently more than one-third of U.S. cleft centers offer nasoalveolar molding. Although the cleft size was larger in the nasoalveolar molding group, no treatment group differences in education, income, and distance to the clinic were found.

Oral health-related quality of life: what, why, how, and future implications

Despite its relatively recent emergence over the past few decades, oral health-related quality of life (OHRQoL) has important implications for the clinical practice of dentistry and dental research. OHRQoL is a multidimensional construct that includes a subjective evaluation of the individual's oral health, functional well-being, emotional well-being, expectations and satisfaction with care, and sense of self. It has wide-reaching applications in survey and clinical research. OHRQoL is an integral part of general health and well-being. In fact, it is recognized by the World Health Organization (WHO) as an important segment of the Global Oral Health Program (2003). This paper identifies the what, why, and how of OHRQoL and presents an oral health theoretical model. The relevance of OHRQoL for dental practitioners and patients in community-based dental practices is presented. Implications for health policy and related oral health disparities are also discussed. A supplemental Appendix contains a Medline and ProQuest literature search regarding OHRQoL research from 1990-2010 by discipline and research design (e.g., descriptive, longitudinal, clinical trial, etc.). The search identified 300 articles with a notable surge in OHRQoL research in pediatrics and orthodontics in recent years.

Psychiatric assessment of children with nonsyndromic cleft lip and palate

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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