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

Benefit Finding in Craniofacial Conditions: A Qualitative Analysis of Patient and Parent Perspectives

OBJECTIVE

Craniofacial conditions (CFCs) can be associated with adverse effects on quality of life (QoL). However, few studies have examined perceived benefits related to CFCs. This study described perceived benefits in an international sample of children and adolescents with CFCs and their parents.

DESIGN

Semistructured qualitative interviews were completed in English or Spanish as part of a larger study. Deductive content analysis described and quantified perceived benefits associated with CFCs.

SETTING

Interviews were during standard visits at Rady Children's Hospital-San Diego in the USA and the Hospital Infantil de las Californias in Tijuana, Baja California, Mexico.

PARTICIPANTS

Patients were ages 7 to 20 years (n = 32) with CFCs (cleft lip and/or palate, craniosynostosis, microtia, hemifacial microsomia, dermatologic conditions/neurovascular malformations, and trauma-acquired CFC), and parents (n = 71) had children ages 5 months to 23 years with CFCs. Of the total sample, there were 14 patient-parent dyads.

RESULTS

A total of 230 benefits were identified. Of the patients (47%) and parents (73%) who identified at least 1 benefit, themes included personal growth (40%), understanding or helping others facing challenges (25%), social relationships (23%), spiritual or religious beliefs (4%), philanthropy (4%), material or external gains (3%), and personal health (1%).

CONCLUSIONS

Patients with CFCs and their parents report multiple positive effects of CFCs on their QoL. These findings indicate that benefit finding is a common experience in this population and may be leveraged by clinicians to help promote positive adjustment to living with a CFC.

Cross-condition risk and protective factors for psychosocial distress in parents and carers of children and young people with appearance-affecting conditions and injuries

Alongside typical parenting challenges, initial condition-specific research suggests thadifferent experiences and support needs.t parents of children with different visible differences may experience similar psychosocial difficulties. Despite this, large-scale cross-condition research to identify risk and protective factors for parental distress and psychosocial adjustment has been lacking. Two hundred and nine parents and carers of children with a range of visible differences completed an online survey comprised of standardised outcome measures, study-specific measures, and open-ended questions. Multiple regression modelling identified possible risk and protective factors, and data collected via open-ended questions were analysed using content analysis. Findings support themes previously identified in small-scale cross-condition qualitative research with parents of children with visible differences. Risk factors for parental negative affect and stress included parental reports of the noticeability of their child's visible difference and teasing. Protective factors included good parent-child communication, self-compassion, knowledge of their child's condition and satisfaction with treatment. The risk and protective factors identified provide important insight into the experiences of this parent population and indicate possible avenues for psychosocial intervention.

Early Follow-up of Parents by a Specialized Cleft Nurse After the Birth of an Infant with Cleft lip and/or Palate

OBJECTIVE

To document the impact of early follow-up by specialized cleft nurses (SCNs) to families of infants with cleft lip and/or cleft palate (CL/P).

DESIGN

Prospective inclusion of a control group, which received standard care alone, followed by an intervention group, which in addition received early SCN follow-up.

SETTING

The cleft lip and palate team at a University hospital.

PARTICIPANTS

70 families (69 mothers and 57 fathers); control group (n = 38); intervention group (n = 32).

INTERVENTION

SCNs offered a consultation at the maternity ward and follow-ups by phone or face-to-face at one, three, eight weeks and six months after birth.

OUTCOME MEASURES

Use of Internet-Questionnaire, Quality of discharge teaching scale (QDTS), Post discharge coping difficulty scale (PDCDS), Response on follow-up by health professionals.

RESULTS

Infants in the intervention group were admitted less frequently to a Neonatal Intensive Care unit (NICU); 21.9% vs 51.4%, P = .012. Parents in the intervention group used internet for cleft-related reasons less frequently (74.6% vs 85.9%), P = .112 and the mothers benefitted less from cleft-related activity on the internet (P = .013). The intervention group reported higher mean score for satisfaction with total cleft care (P = .001). There were no significant group differences regarding mean total score for discharge teaching (P = .315) and coping difficulties (P = .919).

CONCLUSION

Early follow-up by a SCN with expertise in cleft care is highly valued by parents. Closer cooperation between the cleft team and health professionals at birth hospitals and Child health centers is necessary for optimal follow-up.

"I can't provide what my child needs": Early feeding experiences of caregivers of children with craniofacial microsomia

PURPOSE

Craniofacial microsomia (CFM) is a congenital condition that can be associated with feeding challenges in infants. As part of the larger 'Craniofacial microsomia: Accelerating Research and Education (CARE)' program, this study described caregivers' early feeding experiences.

DESIGN AND MATERIALS

US-based caregivers of 34 children with CFM participated in remote narrative interviews. Two authors completed inductive thematic analysis in an iterative process until consensus was reached.

RESULTS

Caregivers' narratives outlined the inherent challenges of feeding an infant with special healthcare needs. The first theme 'Navigating Challenges and Managing Expectations' describes the distress participants experienced when they were unable to breastfeed and the negative emotional effect of switching to formula. The second theme 'Making Adaptations' outlines the methods participants tried, including breast pumps and feeding tubes. The third theme 'Accessing Support' describes participants' interactions with healthcare providers and challenges accessing feeding support. The final theme 'Growing from Adversity' recounts participants' relief once their child established a feeding pattern and the personal growth gained from their experiences.

CONCLUSIONS

Caregivers reported several feeding related challenges associated with CFM, many of which negatively affected their wellbeing. Negative consequences were particularly pronounced in cases where caregivers' feeding experiences differed from their expectations. Participants identified challenges in accessing reliable feeding information and support. Despite difficult experiences, caregivers cited some positive outcomes, including increased confidence and resilience.

PRACTICE IMPLICATIONS

Holistic feeding information and support for families affected by CFM should be inclusive of several feeding methods to improve care delivery, child health, and the caregiver experience.

Clinician- and Patient-Centred Outcomes of Digital Impressions in Infants with Cleft Lip and Palate: A Systematic Review

This systematic review examines the effectiveness of digital impressions in infants with cleft lip and palate (CLP), focusing on accuracy, operator preferences, and parents' perceptions. The PICO-formulated focused questions assessed the accuracy and operator preference of digital impressions compared to conventional impressions in infants with cleft lip and palate, while also exploring parents' perceptions as patient-centred outcomes. Electronic and manual searches were conducted in five databases including PubMed, Scopus, Web of Science, Embase, and Cochrane Library; to acquire grey literature, Google Scholar was also consulted. Both experimental and observational studies that used digital impressions in the clinical care of infants with CLP were included. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess the quality of the included studies. Out of 503 records, 12 studies met the inclusion criteria. The accuracy assessment included surface discrepancy and intra-arch measurements. Surface discrepancy studies showed variations in the premaxillary segments, while intra-arch measurements revealed no significant differences. Operators preferred digital impressions, citing reduced stress and streamlined workflows. Parents expressed a clear preference for digital over conventional impressions. The conclusions drawn were substantiated by weak evidence due to the limited number and the high risk of bias of the included studies. Challenges remain here, warranting continued research to enhance accuracy and assess parents' preferences, ensuring optimal outcomes for infants with CLP.

Evaluation of Anxiety in Turkish Parents of Newborns with Cleft Palate with or Without Cleft Lip

OBJECTIVE

(1) To compare anxiety between parents of newborns with cleft lip and palate (CLP), isolated cleft palate (CP), and healthy newborns and (2) to evaluate anxiety between parental dyads within these groups.

DESIGN

A cross-sectional study.

SETTING

University Hospital.

PARTICIPANTS

Surveys were completed by 20 mothers and 20 fathers of newborns with CLP, 21 mothers and 21 fathers of newborns with CP, and 23 mothers and 23 fathers of healthy newborns (controls).

MAIN OUTCOME MEASURE

The State-Trait Anxiety Inventory (STAI) assessed parental anxiety. Mothers of newborns with a cleft reported on concerns regarding cleft-related issues and facial appearance.

RESULTS

State and trait anxiety were generally in the moderate range for parents of newborns with a cleft, while control parents had low state anxiety and moderate trait anxiety. Mothers of newborns with CP and CLP had significantly higher state and trait anxiety levels than control mothers (p < .05). Fathers of newborns with CLP had a higher state anxiety level than control fathers. When maternal and paternal anxiety was compared within the groups, only trait anxiety scores were significantly higher in mothers of newborns with CLP than that of fathers (p < .05). More than half of mothers of newborns with a cleft were concerned about their newborn's feeding, speech, and palate.

CONCLUSIONS

Parents of children with a cleft may need psychological support in the early postnatal period. It is important for neonatal cleft team providers to help reduce parental anxiety and educate families about cleft care, with a focus on feeding.

Social Media and Website Use: The Experiences of Parents and Carers Accessing Care at the Oxford Craniofacial Unit

INTRODUCTION

Historically, medical professionals have been the providers of specialist information about rare medical conditions. Now, increasingly, patients and the public are using the internet to access and generate information about medical diagnoses. The global nature of the internet allows patients to connect across geographical borders, and to obtain and share information that would have been previously inaccessible to them. This research investigated the use of website and social media by parents of children with craniosynostosis.

METHODS

A cross-sectional survey-based design was employed. Participants were parents of children with craniosynostosis attending multidisciplinary craniofacial clinics within the Oxford Craniofacial Unit. A questionnaire was administered which assessed social media and website use adapted from the questionnaire created by Khouri and colleagues (2016) and Huggons and colleagues (2019). The surveys were administered over an 18-month period (November 2020 to May 2022).

RESULTS

The final sample comprised 82 parents [70 mothers; 10 fathers; 1 sister/carer and 1 parent (mother/father unspecified)]. The children were aged 11 months-16 years of age (average age 6 y and 3 mo). Children had a variety of diagnoses: 31 sagittal, 19 metopic, 14 syndromic craniosynostosis, 8 unicoronal, 6 multisuture, 3 bicoronal, and 1 unilambdoid.Results showed that 93% (n=76/82) of parents used the internet to find out more about craniosynostosis, with 72% (n=59/82) of parents specifically using social media to find out more about craniosynostosis. The social media platforms used included: Facebook 64% (n=53/82), Instagram 24% (n=20/82), Blogs 12% (n=10/82), Twitter 4% (n= 4/82), Tik Tok 2% (n=2/82), and Snapchat 0.01% (n=1/82).Parents reported that Facebook was the most helpful source of information about craniosynostosis (52%; n=43/82). Parents indicated the key timepoints they used social media included: when their child received a diagnosis (70%; n=58/82), before their child's surgery (34%; n=28/82), before their first craniofacial clinic appointment (83%; n=25/30), and when child was older (17%; n=14/84). Forty percent (n=33/82) of parents said that a diagnosis of craniosynostosis made no difference to their social media use, whereas 34% (n=28/82) of parents used social media more, and 20% (n=16/82) used it less.

CONCLUSION

Results highlight that parents use social media and other websites to access information relating to craniosynostosis. Future research should examine whether parental use of social media changes across their child's lifespan and evaluate the quality of this information.

Raising a Child with Craniosynostosis: Psychosocial Adjustment in Caregivers

OBJECTIVE

While knowledge of the psychosocial impact of craniofacial conditions is growing, literature regarding the impact on parents remains limited. Parents of children born with a health condition may be at risk of experiencing a range of psychosocial challenges. This study conducted an initial investigation of psychosocial adjustment of parents of individuals with craniosynostosis to inform support provision for families.

SETTING

An online UK-wide mixed-methods survey was distributed to members of Headlines Craniofacial Support.

DESIGN

Quantitative data including standardized measures were analysed using descriptive statistics and independent samples t-tests, and inductive content analysis was used for open-ended questions.

PARTICIPANTS

Mothers (n  =  109) and fathers (n  =  9) of individuals ages 3 months to 49 years with single suture (63%) or syndromic (33%) craniosynostosis participated.

RESULTS

Compared to the general population, parents of individuals with craniosynostosis reported higher levels of stress, anxiety, and depression; lower levels of resilience and optimism. Qualitative responses provided insight into parents' experiences of birth, diagnosis, healthcare provision, familial wellbeing, and relationships. Parents reported several unmet information and support needs, alongside a range of positive outcomes.

CONCLUSIONS

This study illustrates the potential long-term psychosocial implications for parents raising children with craniosynostosis. There is a need for routine psychological screening for family members and provision of appropriate psychological support for those at risk for distress. Non-specialist health professionals may benefit from additional training about craniofacial conditions so they are better equipped to support and refer families.

The Impact of the Covid-19 Pandemic on Cleft Lip and Palate Service Delivery for New Families in the United Kingdom: Medical and Community Service Provider Perspectives

OBJECTIVES

Professionals in the United Kingdom providing care to new families affected by cleft lip and/or palate (CL/P) had to adapt to ensure families' needs were met during a time of uncertainty due to Covid-19. The aims of this study were to explore the impacts of the pandemic on CL/P care provision for new families from the perspectives of professionals working in medical and community settings along with any personal impact on professionals and their reflections on the future of CL/P care.

DESIGN

Semistructured interviews (n  =  27) were completed about experiences from March 2020 to October 2020 with consultant cleft surgeons (n  =  15), lead clinical nurse specialists (n  =  8), and staff working at the Cleft Lip and Palate Association (n  =  4). Transcripts were analyzed using inductive thematic analysis.

RESULTS

Three themes were identified: (1) the impact of Covid-19 on the provision of cleft care in the United Kingdom, including working conditions, delays to treatment, and Covid-19 policies; (2) the impact of the pandemic on professionals' mental health, including personal distress and concerns about Covid-19 exposure; and (3) reflections on the future of CL/P care, whereby professionals expressed both hope and concern about the Covid-19 recovery effort.

CONCLUSIONS

The ongoing Covid-19 pandemic has impacted CL/P service delivery for new families significantly, warranting recommendations for cohesive psychological support for families in addition to a safe and resourced recovery effort. Support for professionals is also suggested, following existing evidence-based models for providers' needs that address the difficulties of working throughout challenging times.

"Have We Done Enough?" A Cross-condition Exploration of the Experiences of Parents Caring for A Child with an Appearance-affecting Condition or Injury

Children and young people (CYP) with appearance-affecting conditions/injuries report common pervasive psychosocial difficulties, regardless of cause, nature or extent of their visible differences. Parents or carers can also experience psychosocial difficulties and challenges specific to having CYP with a visible difference. Current literature is confined to exploring condition-specific concerns of parents, typically in more prevalent appearance-affecting conditions/injuries, whilst the experiences of parents of CYP with other visible differences are unknown. Thirty-one interviews (parents n = 20, health and support professionals n = 11) and 4 parent focus groups (n = 25) were conducted. Three overarching themes were constructed: "Appearance does(n't) matter" describes the impact of having a child with a socially undesirable appearance; "Being 'battle' ready" reflects parents' desire to arm their child with resources to manage challenges, whilst "Walking the tightrope" reflects parents' lack of clarity about how best to approach this. Findings highlight shared and common cross-condition psychosocial difficulties among parents and carers.

Persistence, strength, isolation, and trauma: An ethnographic exploration of raising children with cleft palate

BACKGROUND

The lives of families of young children with cleft palate (±lip) are complex. Multiple interventions are required as part of the long-term multidisciplinary treatment for children with CP±L, with an impairment-focused approach prevailing. Research with young children with CP±L has focused on treatment and intervention, and previous qualitative research has been collected predominantly via interviews, so little is understood about the day-to-day lives of families of young children with CP±L.

AIMS

(1) To increase understanding of the lives of children with CP±L and their families by applying an ethnographic lens to improve clinical practice (2) to identify key interactions and encounters that shape the experiences of children with CP±L and their families (3) to examine how family-centered practice can enhance practitioner-family relationships in providing effective and evidence-based care for children with CP±L.

METHOD

Ethnographic observations of seven families of children with CP±L and their families and educators including parents, siblings, aunts, grandparents, and teachers involved multiple site visits. Rich data were collected to gather information about different aspects of their lives (such as their strengths, routines, preferences, challenges and experiences). There were 84 artefacts collected: 18 interviews, 29 videos, one extended audio recording of a mealtime, seven photos contributed by families, seven case history questionnaires, and 22 field notes. These data were analyzed inductively using thematic analysis.

RESULTS

Three overarching themes and 11 subthemes were identified: (1) the whole child (persistence, communication, activities, mealtimes), (2) family strength and support (strong families, external support, attitudes, advocacy, positive medical experiences) and (3) family isolation and trauma (negative medical experiences, traumatic and challenging experiences).

CONCLUSION

This is the first study to use ethnographic methodology to facilitate the collection of unique insights into the lives of young children with CP±L and their families to improve clinical practice for SLPs. The unique application of family-centered practice with these families promoted trust and highlighted their challenges and strengths which could be considered by SLPs to provide holistic intervention.

The effectiveness of interventions to improve psychosocial outcomes in parents of children with appearance-affecting health conditions: A systematic review

BACKGROUND

Although many cope well, the impact of supporting a child with an Appearance-Affecting Health Condition (AAHC) can place a significant demand on parents. As such, it is vital that families have access to appropriate psychosocial support to reduce any potential difficulties. Although previous reviews have explored the effectiveness of psychosocial interventions for parents of Children and Young People (CYP) with general health conditions, the evidence of effectiveness remains limited. Further, little is known about the effectiveness of such interventions specifically among parents of CYP with AAHCs. This review aimed to identify and assess the evidence of effectiveness of psychosocial interventions among parents of CYP with AAHCs.

METHODS

Database searches were conducted using MEDLINE, PsychARTICLES, PsychINFO, CINAHL Plus, the British Nursing Database and the Cochrane Library. Results were reviewed against the inclusion criteria and data were extracted. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool, and a narrative synthesis was conducted.

RESULTS

Fifteen studies, evaluating 10 interventions, were included and overall seven interventions were found to be effective (effect sizes and methodological quality varied).

CONCLUSIONS

This review finds moderate to strong evidence of effectiveness of the Triple P Positive Parenting Program, the Early Family Intervention Program and general parent education/training interventions. These findings offer useful insights relating to the delivery of current support, as well as for the development of future parent and family interventions. Finally, recommendations for future intervention evaluation studies in this area are made.

Satisfaction With Health Care in Families Following a Diagnosis of Cleft Lip and/or Palate in the United Kingdom

OBJECTIVE

Having a child born with a cleft lip and/or palate (CL/P) poses several challenges for new parents and can have a significant psychological impact on the family as a whole. Previous research has indicated that dissatisfaction with health care is a risk factor for poor parental adjustment and family functioning. Yet, knowledge is lacking in regard to which aspects of care parents may be dissatisfied with. The current study aimed to comprehensively evaluate health-care satisfaction in families following a diagnosis of CL/P by utilizing data collected from a UK-wide birth cohort.

METHODS

Self-reported questionnaire data were obtained from 517 parent dyads enrolled in The Cleft Collective Birth Cohort Study. The "Pediatric Quality of Life Inventory-Healthcare Satisfaction Generic Module" was used as the primary outcome measure.

RESULTS

Overall, parents were satisfied with the care they had received. However, less favorable scores were identified in relation to the information parents had been given. A good degree of agreement between mothers and fathers was observed. However, marginal evidence suggested that fathers were significantly more dissatisfied than mothers regarding the "Communication" and "Inclusion of Family" subscales.

CONCLUSIONS

Although the findings of this large-scale study reflect overall health-care satisfaction, issues are raised in relation to the quality of information families received, particularly for fathers. In addition, fathers may feel less included in their child's treatment pathway. These findings offer practical suggestions as to which areas of care could be targeted by all health professionals to improve parents' health-care experiences and promote overall familial adjustment.

Maternal and Paternal Well-Being During Nasoalveolar Molding and Primary Surgery Periods

AIM

The aim was to evaluate the anxiety and depression of both the father and mother of an infant with cleft lip and palate (CLP) before, during and after nasoalveolar molding (NAM) therapy and before and after the lip surgery.

SUBJECTS AND METHOD

Forty mothers (age range: 18-36; mean ± SD: 23.6 ± 4.51) and 40 fathers (age range: 19-40; mean ± SD: 26.9 ± 4.69) of infants with CLP were asked to answer the 21-item Beck Depression as well as Anxiety Inventory (BDI and BAI) at 1 week after birth and before any intervention (T1), after impression taking (T2), after 2 months of NAM (T3), immediate before primary surgery (T4) and approximately 1 month of recovery after surgery (T5).

RESULTS

Maternal and paternal depression levels between T1, T2, T3, T4, and T5 showed significant differences (P < 0.05). The BDI scores decrease from T2 to T3 and T4 to T5. The increases of scores from T3 to T4 were significant (P < 0.05). The maternal depression and anxiety levels were higher than the paternal ones in all time periods. The BDI and BAI levels were lesser in mothers and fathers of babies with unilateral than bilateral CLP (P < 0.05).

CONCLUSION

Hence realizing of recovery, being in contact with the cleft team and other families, and having an active role in the therapy, the maternal and parental well-being increase with NAM therapy. However, depression and anxiety levels significantly increase before the lip surgery. It may be recommended that the cleft team deliver information and psychological support especially at birth and before the surgical approaches.

Provision of Care for Families Affected by Craniofacial Conditions: The Views of Nonspecialist Health Professionals

OBJECTIVE

A diagnosis of a congenital craniofacial condition can have a significant impact on the psychological well-being of the affected family. As the first health professionals likely to come into contact with families, nonspecialists, such as diagnostic sonographers, midwives, and health visitors play a crucial role in facilitating familial adjustment. Yet, previous research has demonstrated parental dissatisfaction with the care delivered by nonspecialists. The aim of this study was to investigate the provision of care for families affected by craniofacial conditions from the perspective of nonspecialist health professionals, with a view to informing the development of educational materials.

DESIGN

Individual semistructured telephone interviews (n = 14) were conducted with 3 diagnostic sonographers, 2 fetal medicine consultants, 3 midwives, 4 health visitors, and 2 children's nurses.

RESULTS

Participants identified a range of barriers to the delivery of optimal care, including dealing with parental reactions, time pressure, hospital protocols and resources, a lack of contact with specialist craniofacial teams, and the emotional impact of delivering a diagnosis. Most participants had received no prior training in the area of congenital craniofacial conditions, while those who had felt current training materials were insufficient. All participants expressed a desire for further training and provided guidance regarding preferred content and format.

CONCLUSIONS

This study provides insight into the challenges faced by nonspecialists, as well as a range of information and training needs that could improve their knowledge and confidence. Suggestions for the development of educational materials for nonspecialist health professionals are made.

Risk and Protective Factors for Psychological Distress in Families Following a Diagnosis of Cleft Lip and/or Palate

OBJECTIVES

Despite the potential psychological impact of a diagnosis of cleft lip and/or palate (CL/P) on parents, few large-scale studies currently exist. Utilizing data extracted from The Cleft Collective Birth Cohort Study, the current study aimed to examine the psychological impact of the diagnosis on parent and family functioning and to identify risk and/or protective factors contributing to parental adjustment in order to inform future psychological intervention.

METHODS

Parent-reported questionnaire data were extracted for 1163 parents (644 mothers and 519 fathers). Outcome measures included the PedsQL-Family Impact Module, the Perceived Stress Scale, the Hospital Anxiety and Depression Scale, and a condition-specific tool designed by the Psychology Clinical Excellence Network.

RESULTS

Overall, findings suggest that parents adjust well to the diagnosis. Factors found to be protective against psychological distress for both mothers and fathers included a positive life orientation, satisfaction with health care, and relationship satisfaction. Close friendships were also protective against depression in mothers. Risk factors for mothers included the presence of a prior mental health condition, and stressful life events during pregnancy. Risk factors for fathers included being older at the time of conception, and recently being absent from work.

CONCLUSIONS

Findings suggest a need for appropriate psychological screening of both parents following a diagnosis of CL/P and emphasize the importance of coordinated multidisciplinary care for psychological health. Preventative models of intervention to strengthen familial relationships and build resilience require further investigation.

Types of Parenting of Fathers during Early Childhood: A Q Methodological Approach

Purpose

The purpose of this study was to examine types of parenting among fathers. The characteristics of parenting each type in early childhood were identified by systematically analyzing and classifying father’s perceptions of parenting using the Q-methodology, which places importance on the perspective of the performer.

Methods

The Q-method, which is effective for measuring individual subjectivity was used. The subjects in this study were 50 fathers with young children (2~36 months).

Results

Four parenting types were identified analyzing the subjective perceptions of fathers with young children about parenting. One type was centered on character development. Another was centered on social development. A third was centered on physical health and development. The fourth was centered on building values.

Conclusion

Parenting education programs should be developed based on type-specific characteristics and further research should investigate the effects of father’s parenting type.

Delivering effective genetic services for patients and families affected by cleft lip and/or palate

Genetic services for individuals affected by cleft lip and/or palate (CL/P) and their families are an important aspect of clinical care; yet debate exists as to how this service should be offered. This study explored the utility, acceptability, and delivery of genetic services from the perspectives of cleft-specialist clinicians, genetic counsellors, and affected families. Analysis of data collected from three focus groups and eleven individual interviews identified two overarching themes "Referring patients and families to genetic services" and "The role of a genetic specialist in the context of CL/P". The first examines the common reasons for referral to the genetics service, how best to judge the timing of a referral, and the optimal approach to the delivery of sensitive genetic information. The second theme discusses the role of the genetic specialist in the context of cleft care, including the optimal management of affected individuals and their families, and the delivery of basic genetics training and support for health professionals working in other disciplines. A model for the effective delivery of genetic services in CL/P is subsequently proposed. Coordination and financial implications of the proposed model ultimately require further consideration and evaluation to determine its effectiveness.

Parental views of antenatal testing and termination following a diagnosis of cleft lip

Fetal anomaly screening at 18-21 weeks now routinely includes cleft lip. If detected, the manner in which the diagnosis is communicated can considerably influence prospective parents' decision-making in regard to further testing and termination of pregnancy (TOP). Given the known psychological impact of an antenatal diagnosis of cleft lip on prospective parents, this study aimed to explore the decision-making process from the parents' perspective, in order to evaluate how well current practice is meeting guidelines. Data from 217 parents of children born with cleft lip (with or without cleft palate) were collected using a mixed-methods online survey. Respondents reported feeling upset, offended and/or anxious following the diagnosis, due to unsatisfactory information and a perceived lack of empathy from health professionals. Some respondents had felt under pressure to make a decision quickly, with a minority having regretted undergoing amniocentesis, and/or experiencing significant distress at having come close to TOP unnecessarily. A number of suggestions are made as to how the discussion between parents and health professionals could be improved, to ensure that the information and support needs of families affected by cleft lip are fully addressed.

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.

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

Background

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

Design

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

Result

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

Conclusions

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

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

Objective

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

Methods

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

Measures

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

Result

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

Conclusions

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

Strengths and Difficulties Questionnaire (SDQ)

Objective:

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

Design:

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

Setting:

Centralized and multidisciplinary treatment setting.

Participants:

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

Outcome measures:

Strengths and Difficulties Questionnaire (SDQ).

Results:

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

Conclusions:

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

A Standard Set of Outcome Measures for the Comprehensive Appraisal of Cleft Care

Care of the patient with cleft lip and/or palate remains complex. Prior attempts at aggregating data to study the effectiveness of specific interventions or overall treatment protocols have been hindered by a lack of data standards. There exists a critical need to better define the outcomes- particularly those that matter most to patients and their families-and to standardize the methods by which these outcomes will be measured. This report summarizes the recommendations of an international, multidisciplinary working group with regard to which outcomes a typical cleft team could track, how those outcomes could be measured and recorded, and what strategies may be employed to sustainably implement a system for prospective data collection. It is only by agreeing on a common, standard set of outcome measures for the comprehensive appraisal of cleft care that intercenter comparisons can become possible. This is important for quality-improvement endeavors, comparative effectiveness research, and value-based health-care reform.

Experiences of Couples Caring for a Child Born with Cleft Lip and/or Palate: Impact of the Timing of Diagnosis

Raising a child born with cleft lip and/or palate (CL/P) can be challenging for parents. Few researchers have examined how having a child born with CL/P impacts couples. The purpose of this descriptive qualitative study was to examine how a child's CL/P diagnosis affects couples' relational adjustment and coping. We conducted interviews with 17 couples (10 prenatal and seven postnatal) caring for children born with CL/P. After conducting thematic content analysis, six overarching themes emerged: (a) relationship growth, (b) challenges, (c) roles and responsibilities, (d) sources of support, (e) talking about cleft, and (f) lessons learned. Findings suggest that couples should be routinely assessed for psychosocial issues and prevention programs should be tailored to preexisting stressors and timing of the diagnosis.

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.

The Psychosocial Impact of Cleft Lip and/or Palate on Unaffected Siblings

Background

Sibling relationships are among the most unique social connections, significantly affecting psychosocial adjustment. Previous reviews in the fields of chronic illness and disability have concluded that unaffected siblings of children with long-term conditions are at risk of poorer psychological functioning as a consequence. Much research has investigated the psychosocial impact of CL/P on affected individuals and their parents, yet comparatively little is known about the impact on other close family members.

Objective

To gain a better understanding of the experience of unaffected siblings of children born with CL/P, with a view to informing service provision and support.

Design

Individual qualitative interviews conducted over the telephone/Internet with five siblings and eight parents, including five sibling-parent pairs from the same family.

Results

Thematic analysis identified three key themes applicable across both parent and sibling interviews: perceptions of positive and negative impacts, factors affecting the degree of impact, and support for families.

Conclusions

This study provides insight into a population that is often overlooked in the context of cleft care. The analysis identified a number of sibling support and information needs, along with suggestions of how to incorporate support for siblings in practice. The findings suggest that an inclusive approach to health care encompassing all members of the family is essential for optimal familial adjustment.

Does the visibility of a congenital anomaly affect maternal-infant attachment levels?

PURPOSE

To determine whether congenital anomaly visibility affects maternal-infant attachment levels.

DESIGN AND METHODS

The study population consisted of mothers who had infants with cleft lip/palate or congenital heart anomalies who were receiving treatment in a university hospital. The data were collected using the Structured Questionnaire Form and the Maternal Attachment Inventory.

RESULTS

Statistically significant differences in maternal-infant attachment levels were observed between infants with cleft lips/palates and healthy infants and between infants with congenital heart anomalies and healthy infants.

PRACTICE IMPLICATIONS

It is important to apply appropriate nursing interventions for these mothers during the postpartum period.

Achieving Consensus in the Measurement of Psychological Adjustment to Cleft Lip and/or Palate

Background

Psychological adjustment to cleft lip/palate is multifaceted and can fluctuate over time and across different situations. Consequently, a comprehensive understanding of adjustment is difficult to capture, and the challenge of achieving consensus among researchers and clinicians regarding key constructs and processes is considerable. Numerous measures have been used in research and clinical audit, resulting in conflicting findings and difficulties in evidencing the value of psychological intervention. The launch of the world's largest cleft lip/palate cohort study has provided an opportunity to standardize data collection across the United Kingdom.

Objective

To describe the collaborative process used to achieve consensus in the academic and clinical measurement of psychological adjustment to cleft lip/palate.

Results

Extensive work based on existing literature and clinical experience has resulted in a conceptual framework comprising six domains of adjustment and corresponding risk/protective factors that are measureable across key developmental time points. Driven by this framework, a core pack of standardized measures has been selected according to psychometric properties, clinical utility, and pragmatic considerations.

Conclusions

To date, these measures have been implemented within a UK-wide longitudinal cohort study (at diagnosis, 18 months, 3 years, 5 years, and 8 years) and adopted into the national routine clinical audit protocol for cleft lip/palate at age 5. Further data collection points will follow as the cohorts age. Over time, consistency in data collection will allow researchers to address some of the key unanswered questions in relation to psychological adjustment to cleft lip/palate.

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

Background

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

Objective

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

Results

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

Conclusions

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

Psychosocial well-being of parents of children with oral clefts

BACKGROUND

Parents of children with oral clefts may be impacted psychosocially in several ways, but empirical evidence remains relatively sparse. The aim of this study was to identify predictors of psychosocial well-being of parents of affected children.

METHODS

The study included a total sample of 287 parents (171 mothers and 116 fathers) of children with oral clefts. Parents completed validated psychosocial instruments to measure social avoidance and distress, fear of negative evaluation scale, self-esteem and interpersonal support. Regression analysis was used to evaluate how selected child, parent and household characteristics relate to psychosocial outcomes focusing on child's cleft type, sex and age, differences between mothers and fathers, marital status and household income.

RESULTS

Fathers had higher self-esteem than mothers (P = 0.01) and lower concern of being negatively judged by others (P < 0.0001) but also had lower perception of having someone to talk to about their problems (P = 0.01). High household income was associated with greater self-esteem and perception of social support (<0.05). Parents of male affected children had greater perception of social support than parents of female affected children (P = 0.04). No significant differences in parental psychosocial status measures were found by cleft type. Similarly, there is little evidence of changes with child age, except for an increase in parental distress and decline in self-esteem during mid-adolescence (age 15-17 years).

CONCLUSIONS

The results indicate that mothers and fathers of children with oral clefts may differ in their psychosocial adjustment and that mothers may overall experience more psychosocial problems than fathers. Also, parents from less wealthy households may be at greater risk. Parental psychosocial status should be considered in holistic family-based treatment approaches to reduce burden on affected families and improve their well-being.

Coping With Cleft: A Conceptual Framework of Caregiver Responses to Nasoalveolar Molding

OBJECTIVE

To present a conceptual framework of caregiver coping and adaptation to early cleft care using nasoalveolar molding.

DESIGN

In-depth interviews were conducted at three time points with caregivers of infants with cleft lip or cleft lip and palate whose children had nasoalveolar molding to treat their cleft. Qualitative data were analyzed using modified grounded theory.

RESULTS

Most caregivers expressed initial apprehension and anxiety about the responsibilities of care associated with nasoalveolar molding (e.g., changing and positioning tapes, cleaning the appliance). In subsequent interviews, caregivers often reported positive feelings related to their active participation in their child's treatment for cleft. These positive feelings were associated with increased self-esteem and feelings of empowerment for the caregivers. Although caregivers also identified burdens associated with nasoalveolar molding (e.g., stress related to lip taping, concerns about the appliance causing sores in their child's mouth, travel to weekly appointments), they tended to minimize the impact of these issues in comparison with the perceived benefits of nasoalveolar molding.

CONCLUSIONS

Despite the increased burden of care, many caregivers of infants with cleft used nasoalveolar molding as a problem-focused coping strategy to deal with their child's cleft. Completing nasoalveolar molding was often associated with positive factors such as increased empowerment, self-esteem, and bonding with their infant.

A Qualitative Study of Children's Perspectives on Their Peer Relationships in the Context of Living With a Craniofacial Anomaly

OBJECTIVE

To gain understanding of perspectives on peer relationships from children with congenital craniofacial anomalies (CFA).

DESIGN

This was qualitative research based in a phenomenological approach, using narratives that captured children's responses to open-ended and objective questions about peer relations and life with a CFA. Interviews were audio recorded and transcribed. Transcripts were coded according to thematic categories.

SETTING

Children were patients at a reconstructive plastic surgery center in an urban hospital and medical school and were recruited from a regional support organization for families of children with CFA that was associated with the hospital.

PATIENTS, PARTICIPANTS

Nine children with congenital CFA aged 9 to 14 years.

MAIN OUTCOME MEASURES

Thematic coding categories were developed from the narratives using an open coding strategy; these categories focused on aspects of children's interactions with peers and their appraisals of the role of their CFA in their lives.

RESULTS

Children reported satisfaction with most aspects of their peer relationships and expressed confidence in their ability to manage challenges. They acknowledged some difficulties with living with a CFA but tended to hold a balanced perspective on the impact of a CFA on their lives, and they expressed optimism about their future lives.

CONCLUSIONS

This sample of children with CFA exhibited much resilience. Although they may not be representative of all children with CFA, they provide examples that can be used to generate hypotheses for future research.

Risk and Protective Factors at Age 16: Psychological Adjustment in Children with a Cleft Lip and/or Palate

Objective

Explore psychological functioning in adolescents with a cleft at age 16 from a broad perspective, including cognitive, emotional, behavioral, appearance-related, and psychosocial adjustment. High-risk groups were identified within each area of adjustment to investigate whether vulnerable adolescents were found across domains or whether risk was limited to specific areas of adjustment.

Methods

Cross-sectional data based on psychological assessments at age 16 (N = 857). The effect of gender, cleft visibility, and the presence of an additional condition were investigated on all outcome variables. Results were compared with large national samples.

Measures

Hopkins Symptom Checklist, Harter Self-Perception Scale for Adolescents, Child Experience Questionnaire, and Satisfaction With Appearance scale.

Results

The main factor influencing psychological adjustment across domains was gender, with girls in general reporting more psychological problems, as seen in reference groups. The presence of an additional condition also negatively affected some of the measures. No support was found for cleft visibility as a risk factor except for dissatisfaction with appearance. Correlation analyses of risk groups seem to point to an association between social and emotional risk and between social risk and dissatisfaction with appearance. Associations between other domains were found to be weak.

Conclusions

The results point to areas of both risk and strength in adolescents born with a cleft lip and/or palate. Future research should investigate how protective factors could counteract potential risk in adolescents with a cleft.

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

Background

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

Objective

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

Design

Fifty-two individual telephone interviews eliciting qualitative data.

Results

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

Conclusions

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