Cleft Lip and Palate- A Psychology Insight
Nitin Khargekar1, Naveen Khargekar2, Vandana Khargekar3, Surabhi Rajan1
1Department of Orthodontics, AECS Maaruti College of Dental Sciences, Bangalore, India
2Department of Preventive Oncology, Tata Memorial Cancer Hospital, Mumbai, India
3Department of Preventive Medicine, Oxford Medical College, Bangalore, India
To cite this article:
Nitin Khargekar, Naveen Khargekar, Vandana Khargekar, Surabhi Rajan. Cleft Lip and Palate- A Psychology Insight. Science Journal of Clinical Medicine. Special Issue: Clinical Conspectus on Cleft Deformities. Vol. 5, No. 4-1, 2016, pp. 37-40. doi: 10.11648/j.sjcm.s.2016050401.17
Received: February 17, 2016; Accepted: April 4, 2016; Published: May 19, 2016
Abstract: Cleft lip and cleft palate are considered to be the most common birth defects involving craniofacial structure. Clefts affects not only aesthetically but also affects different functions. Complete clefts have an effect on feeding, hearing, nasal breathing, and phonation. All these aspects are addressed as part of an integral treatment. Though the physical rehabilitation of the patient is done, psychological issues are always neglected. For the positive outcome of the treatment along with proper treatment the patient should be psychologically strong with high self esteem to term the treatment as success. As a cleft child grows to adult through adolescence he comes across many people and situations which can make him psychologically weak or strong. Hence the current study was undertaken to evaluate the psychological factors associated with cleft lip and palate patients.
Keywords: Cleft Lip, Cleft Palate, Psychology, Treatment
Cleft lip and cleft palate are considered to be the most commonly seen birth defects involving craniofacial structure. Case incidence of cleft lip and palate varies worldwide. Clefts which have multifactorial etiology, in which both genetic and environmental factors play an important role in it. 
Despite advanced scanning techniques the birth of a baby with cleft is rarely predicted. Parents expect a normal birth. Once a baby is born with cleft the initial reactions of parents will be in the form of shock, confusion, grief, guilt and superstitions. 
The craniofacial abnormality which leaves the face physically distorted is primarily corrected by surgery within the first few months. The multi-specialty team focuses on the physical correction of defect with a neglected psychological views. 
Early concern in caring of children born with cleft lip and palate is reduce mortality, increased survival, proper feeding and correction of structural deformities. Comprehensive and coordinated care for the patient from infancy through adolescence is essential in order to achieve an ideal treatment results. Specific goals for care of children born with cleft lip and palate include the following -normalized esthetic appearance of the lip and nose, intact primary and secondary palate, normal speech, language, hearing, nasal airway patency, class I occlusion with normal masticatory function, good dental and periodontal health, and normal psychosocial development.However the, ultimate goal of treatment of cleft lip and palate care is the hope that the total additive effect of individual specialist intervention will together cumulatively allow for a "normally functioning adult" or allow for maximum possible potential development. Although there are many techniques for a diagnosis and mapping of clefts, facial disfigurement, speech defects and audibility there are no standard recognized techniques for measuring the psychological variables. With latest advances in field of orthodontics, surgery and various specialties associated with cleft treatment psychological development still takes a beating.
Hence a study was undertaken to assess the psychology of cleft patients.
2. Theoretical Background
Psychology is the study of behavior and mind, embracing all aspects of human experience. In recent decades,there have been many advances in the surgical technique and sequencing of the treatment procedures has allowed for improved repair of cleft lip and palate. Similarly advances have been seen in the awareness of the problem and attention to the psychological effects that cleft lip and palate may have on individuals born with cleft. With this there is seen a shift in paradigm from focusing purely on the surgical treatment of cleft lip and palate to a more holistic and idealistic approach including geneticists, pediatricians, psychologists and social workers.,Most research in the areas of psychological effects of cleft lip and palate leaves many questions unanswered. While the majority of studies report that cleft lip and palate has a negligible psychological impact on an individual, overall well being, specific psychological issues such as behavioral difficulties, dissatisfaction of facial appearance, withdrawal from social situations and symptoms of anxiety and depression have been identified.,
Several factors would have lead to the development of the psychological factor, due to these methodological weaknesses, the specific psychosocial effects of cleft lip and palate do remain undetermined and underestimated.
For the purpose of this review, the term psychosocial refers to an individuals psychological development and interaction with a social environment. Based on the previous studies, in this critical review, the following constructs are included: self-concept, body image, satisfaction with facial appearance, satisfaction with speech, behavioral problems, social functioning, anxiety, depression, attachment, development and learning.,
A research done to assess intellectual functioning of children affected with cleft lip and palate suggested that there may be a slight decrease in verbal intelligence related to cleft condition but non verbal intelligence is usually seen to be normally distributed. There is also lots evidence to indicate that cleft type, hearing level, sex, speech and language difficulties and the presence of other congenital anomalies may be related to intellectual abilities.,, Cleft children performances in schools were assessed where cleft children as a group tend to achieve below expectations based on intellectual ability, teachers always tend to underestimate the potential of the intellectual ability of average and above average cleft children with more facial disfigurement . Cleft children are perceived by teachers as inhibited or handicapped in the classroom frequently, which leads to underachievement by the child. Parents having lower confidence levels and lower expectations from their cleft child resulting in lower academic performances. ,,
3. Materials and Method
40 patients in age group of 15-40 years who had cleft lip or palate in Bangalore city.
3.1. Inclusion Criteria
Patient with either cleft lip or cleftpalate or both
Age group 15-40 years.
Willing to consent for the study
3.2. Exclusion Criteria
Other craniofacial defects or syndromes
Mentally unsound patients
Other physical disability
A study questionnaire was devised on the problems faced by the cleft lip and palate patients, the feelings of the patients and behavior towards them. Patients with clefts were searched on database available with the treatment done for hospitals treating cleft lip and palate. The patients were informed about the study and consent forms were taken in accordance with the institutional review board. After obtaining the consent the patients were given the questionnaire form. Patient was given sufficient time and personal space to fill the questionnaire. Patients were given the liberty to quit the study in any stage. The questionnaire consisted of behavior of people towards them. The perception of the problem by self, behavior of peers, family members, doctors and the general society towards them were recorded. The recorded data were then analyzed. The results were derived based on the analysis of the recorded data.
|Sl. No||Problems Felt By patients||Percentage|
|1||Aware of the problem||89|
|2||Over protected by their parents and were differently treated than other siblings||75.67|
|3||Teased by sibling||48.64|
|4||Teased by school friends||75.67|
|5||Not comfortable being introduced to new people||83.78|
|6||Cleft is hampering communication with others||78.37|
|7||Loss of confidence in job interviews||54.05|
|8||Problem in marriage because of cleft||72.97|
|9||Different behavior by the doctors and were not satisfied with the outcome of treatment||72.97|
Of the 40 patients studied 23 were female and 17 were male. 3subjects quit the study as they were uncomfortable answering the questions. Out of 37 subjects 33 were aware of the cleft problem and treatment being given to them. Majority started feeling the problem after the age of 6. 28 patients felt they were over protected by their parents and were differently treated than other siblings,18 subjects reported being teased by sibling, 28 subjects reported to be teased by school friends, 31 subjects were not comfortable being introduced to new people, 29 subjects felt their cleft is hampering communication with others. 20 subjects felt loss of confidence in job interviews they attended, 27 subjects felt problem in marriage because of cleft, 27 of them reported with different behavior by the doctors and were not satisfied with the outcome of treatment.
Various psychological and sociocultural factors contribute to development of psychosocial issues among individuals with any form of facial anomaly in general and most commonly cleft lip and palate. Attractive children are perceived as brighter, having more positive social behavior and these children receive more positive treatment than their less attractive counterparts. ,  A negative response from outsiders, actual or perceived, may adversely affect self-image.  Behavior of parents of children with cleft also shapes ones perception. The attitudes, expectations and degree of support shown by the parents of affected children can influence a child’s perception of cleft impairment. , A cleft child undergoes many traumas from the birth to his adulthood. The multiple treatment and reconstructive surgeries that are aimed at correction of the cleft lip and palate and normal restoring of other growth defects of the craniofacial region. Despite the successful treatment there stays a scar which disfigures the face. A multifactorial associated psychological disorder develops. According to our study 3 subjects quit the study as they were uncomfortable answering the questions, which could be due to the lowered self- esteem.
Majority of the patients were aware of the problem, treatment being given and started understanding the problem after 6 years of age. Cleft patients felt they are specially treated by their parents when compared to their siblings. They also complained of teasing by siblings till a certain age. Parents of children with clefts may be more tolerant of misbehavior in their child are overprotective.Being teased in school and having felt difficulty in communication due to the presence of cleft and the scar there were difficulty in social interactions which resulted in cleft patients not being comfortable to be introduced in front of new people, loss of confidence in job interviews, difficulty in marriage because of physical appearance and lower self-esteem.
The cleft patients felt that they were differently seen by the doctors treating them, and they were not satisfied by the treatment outcome. Surgery for disfigurement results in increased self- esteem, self-confidence and satisfaction with facial looks. Unrealistic expectations from surgery end in dis satisfied post surgical results. Hence the patient must be given the realistic picture of the treatment.
Existing multi-specialty care team is primarily aimed at physical rehabilitation with the psychological issues of care often being neglected. The current study has the shortcoming in the number of patients studied, a larger sample can be used for further studies.
From our study we can conclude that multiple factors are responsible for development of psychological problems like lowered self-esteem and difficulty in social interactions. A cleft patient is always psychologically distressed. Treatment should be aimed at both physical and psychological rehabilitation of the cleft patient. Along with the treatment for cleft, psychological counselling of the patient, parents and general public needs to be undertaken to achieve positive outcome and well being of the patient.