**6.1 Results of the Coopersmith self-esteem inventory and the depression scale for children assessments**

In the Coopersmith Self-Esteem Inventory, self-esteem level below a score of 50 is considered low, and self-esteem level above a score of 50 is considered high [28]. According to this data, in this study, it was found that self-esteem level was low in children and adolescent groups with CL/P. When the individuals with CL/P were compared, it was seen that the self-esteem level of the adolescent group was significantly lower than the children group (p < 0.05) (**Table 3**).

In the Depression Scale for Children, those with a scale score of 19 or higher were considered pathological [32]. According to this data, the scale scores of children and adolescent groups with CL/P did not show any pathology in terms of depression. There was no significant difference between children and adolescent groups in terms of depression scores (p > 0.05) (**Table 4**).


#### **Table 3.**

*Comparison of mean values of Coopersmith self-esteem and children's depression scale findings between child and adolescent groups.*


#### **Table 4.**

*Distrubution of Beck depression scale findings and comparison of the mean values of Beck depression findings between mothers of child and adolescent groups.*

*Assessment of Psychosocial Functioning among Patients with Cleft Lip/Palate and Their Mothers DOI: http://dx.doi.org/10.5772/intechopen.111667*

### **6.2 Results regarding the assessment of Beck depression inventory applied to mothers**

The mothers of children were found to have mostly moderate depression. Mild and severe depression rates were equal in this group. Mild depression rates were higher in the mothers of adolescents compared to the mothers of children (**Table 4**). According to Beck Depression Inventory scores, Beck Depression Inventory scores were significantly higher in the mothers of children than the mothers of adolescents. (p < 0.05) This finding indicates that the mothers of children are more prone to depression (**Table 4**).

### **6.3 Results regarding the assessment of SF-36 quality of life scale applied to mothers**

There was no significant difference between the groups in terms of the scores in the SF-36 Quality of Life scale. (p > 0.05) (**Table 5**). In the study of Aydemir et al. [37], when the SF 36 community standard values were compared with the findings in this study, it was seen that the "Emotional Role Difficulty" and "Social Functioning" scores were below the average of the social standards in both groups.



#### **Table 5.**

*Comparison of the mean values of SF 36 quality of life scale findings between mothers of child and adolescent groups.*

### **6.4 Results regarding the assessment of Rosenberg self-esteem scale applied to mothers**

According to the results of the Rosenberg Self-Esteem Scale in **Table 6** and the comparison between the groups, no significant difference was observed between the groups of the mothers of children and adolescents (p > 0.05). Except for the subscales of D3 – Trust in people, D4 – Sensitivity to criticism, D6 – Fancifulness, it was seen that the mothers of children obtained higher scores than the mothers of adolescents, but this difference was not statistically significant.

In this scale consisting of 12 sections, there was no significant difference between the groups, while the sections of D1 – Self-esteem, D2 – Self-concept continuity and D3 – Trust in people were found to be at a high level in both groups. Sensitivity to criticism (D4), depressive affect (D5) and fancifulness (D6) were found to be at a low level in both groups. Both groups had moderate psychosomatic symptoms (D7). Both groups were found to feel a low level of threat in their interpersonal relationships (D8) and their degree of participation in discussions (D9) was low. Parental interest (D10) levels were found to be high in both groups, while relationship with the father (D11) was found to be at a low level (**Table 6**). When the mean values of the Rosenberg Self-Esteem Scale and the values of this study were compared for the women given in **Table 6**, similar scores were found in all other subscales except the Relationship with the Father subscale (D11). According to the mean values of the women, the relationship with the father, which is the D11 subscale, was moderate, yet it was found that there was a low level of relationship in this study. Psychical isolation (D12) was found to be low in both groups.

According to the Pearson's correlation analysis between the D1 subscales and other subscales, Self-esteem (D1) and Depressive affect (D5) and Psychical isolation (D12) have a similar and low-level relationship. (p < 0.05) D1 and D12 scores increased as D1 scores increased. According to these findings, it was concluded that as self-esteem decreased, depressive affect and psychical isolation increased.


*Assessment of Psychosocial Functioning among Patients with Cleft Lip/Palate and Their Mothers DOI: http://dx.doi.org/10.5772/intechopen.111667*


*\*significant at the 0.05 level; SD standard deviation; Min minimum; Max Maximum; Adoles. Adolescent.*

#### **Table 6.**

*Comparison of mean values of Rosenberg self-esteem scale findings between mothers of child and adolescent groups.*

### **7. Discussion**

Cleft lip and palate (CL/P) is a common congenital anomaly that affects the structure of the lip and/or the roof of the mouth. The psychosocial implications of CL/P can be significant, and research has explored various aspects of the psychosocial development of individuals with CL/P and their families. However, the role of age in the psychosocial development of CL/P patients and their mothers is not fully understood.

The psychological and social effects of deformity in individuals with CL/P have been studied since the 1960s. Less self-esteem, difficulty in learning and tendency to be more depressed and anxious were found in individuals with CL/P [38]. In this study, three questionnaires were applied to individuals with CL/P and their mothers, and their quality of life, self-esteem and depression levels were examined psychosocially in three different aspects. To the best of our knowledge, there are no studies in the literature addressing the psychosocial status of individuals in a large scale and in several dimensions as in this study. In addition, a limited number of studies conducted in Turkish society examined the psychosocial status of either individual with CL/P or only their families [39, 40]. However, there are no previous studies examining both individuals with CL/P and their mothers. Therefore, this study aimed to include both individuals with CL/P and their mothers.

Several studies have suggested that psychosocial functioning may be influenced by age in CL/P patients and their mothers. For example, a study by Sischo et al. [4] found that older children with CL/P had poorer self-esteem than younger children. Similarly, a study by Marques et al. [5] found that mothers of younger children with CL/P had higher levels of anxiety and depression than mothers of older children. These findings suggest that age may play an important role in the psychosocial development of CL/P patients and their mothers. However, some studies have reported

*Assessment of Psychosocial Functioning among Patients with Cleft Lip/Palate and Their Mothers DOI: http://dx.doi.org/10.5772/intechopen.111667*

contradictory or inconclusive results regarding the relationship between age and psychosocial functioning in CL/P patients and their families. For instance, a study by Richman and Eliason [41] found no significant difference in self-esteem between younger and older adolescents with CL/P. Similarly, a study by O'Brien et al. [42] found no significant relationship between age and maternal anxiety or depression.

Overall, the literature suggests that the relationship between age and psychosocial functioning in CL/P patients and their mothers is complex and may be influenced by various factors, such as the severity of the cleft, the timing of surgical interventions, and the presence of comorbidities. Further research is needed to clarify the role of age in the psychosocial development of individuals with CL/P and their families.

### **8. Case selection**

In this study, no significant socioeconomic differences were found between the two age groups. In the study of Clark et al. [43], the relationship between the prevalence of CL/P and socioeconomic status could not be revealed. There is limited data about this relationship; therefore, furthermore research would provide better knowledge.

In this study, individuals with CL/P were divided into two groups at different age ranges, but no gender differentiation was made between the individuals. In a survey conducted by Bos and Prahl [44] to evaluate the quality of life of individuals with CL/P, no significant difference was found between males and females in quality of life levels. However, in the sample group where the age range was determined to be 8–15 years, the quality of life and emotional well-being of individuals aged 12 years and over were found to be lower than those of younger age groups. This indicates that quality of life levels change with age [44].

According to the survey conducted by Al-Ghamdi et al. [45], almost half of the parents who care for individuals with CL/P have difficulty managing their homes. In addition, it was reported that 50% of the parents were depressed before the treatment of their children, yet after the treatment, most parents had improved depression levels and only 11.9% had the same depression level. Based on these data, individuals in our study were examined in two age groups, including the groups of children (6–12 years) and adolescents (13–18 years). Mothers were also included in the study because usually mothers take care of the children and spend more time with their children.

#### **8.1 Generic health-related quality of life for children**

In this study, no statistically significant difference was found between the groups in any dimension (physical well-being, emotional well-being, self-esteem, family, friends and school) of the KINDL questionnaire used to evaluate the quality of life of individuals with CL/P. Similarly, there was no significant difference between groups in total quality of life. Also, quality of life scores of individuals with CL/P were found to be close to the normal values determined for Turkish society. These positive results can be explained by the quality of the team caring for them and the ability of these individuals to accept and cope with their situation.

Similar to our study, Naros et al. [46] applied the age-specific KINDL scale to 134 participants (47.8% of whom were females) aged 4–18 to evaluate the quality of life of individuals with CL/P in their study. In this study, compared with the normative data of surprisingly healthy individuals, higher quality of life was found in individuals with CL/P. However, the low rate of return of the questionnaires submitted caused

bias in the results. Considering this situation, it was concluded that the quality of life in individuals with CL/P was not significantly lower than in healthy children.

In a survey conducted by Rivaldo et al. [47] to evaluate the quality of life of 94 individuals with cleft lip and palate aged 12 years and over, lower quality of life scores were reported by women or older individuals [47].

In a survey conducted by Ward et al. [48], which was applied to 75 individuals with CL/P (with a mean age of 13 years) and their caregivers and control group consisting of 75 healthy individuals (with a mean age of 13.9 years), generic oral health-related quality of life scores of children with CL/P were significantly lower than those of the control group. In addition, the negative effects of the orofacial cleft on quality of life scores were reported to be higher in individuals between the ages of 15–18 compared to the younger individuals.

#### **8.2 Coopersmith self-esteem inventory**

The Coopersmith Self-Esteem Inventory (CSI) has become the most popular instrument for measuring self-esteem both in our country and in the world. The Turkish version of the inventory was found to be consistent with the original scale [49]. When the findings of the Coopersmith Self-Esteem Inventory were evaluated, low self-esteem levels were found in both groups according to norm values. At the same time, self-esteem scores in the adolescent group were found to be significantly lower than the children group. Individuals with CL/P may have difficulty in expressing themselves in school life and speaking in public compared to normal individuals. This may affect their self-esteem negatively. In adolescence, individuals' awareness about themselves increases and social and emotional relationships with the environment increase. Therefore, low self-esteem levels are an expected result in the adolescent group.

In a survey conducted by Noor and Musa [14] on 60 individuals (12–17 years of age) with CL/P and their parents, it was reported that individuals with CL/P were mocked for their speech, teeth and lip appearance. It was shown that this situation has a negative effect on self-esteem, with a similar result in our study. In addition, cleft patients aged 16–17 thought that their self-confidence was more affected by their condition than younger individuals as they mature toward adulthood at these ages and interactions with the opposite sex are compulsory for them. Parents of these individuals also reported that cleft lip and palate caused mockery and negatively affected their children's self-esteem. It was stated that the most important features for individuals and their parents were teeth, nose, lip and speech, respectively, in descending order of priority.

In their study, Andrade and Angerami [50] measured self-esteem levels of 608 adolescents (17–20 years of age), 235 of whom were individuals with CL/P and 373 of them were normal individuals. Similar to our study, it was demonstrated that adolescents with CL/P behave differently from normal individuals and have lower self-esteem scores.

In a study by Gussy and Kilpatrick [10] comparing 23 adolescents with CL/P and control groups, no significant difference was found between the self-concept of individuals with CL/P and control groups.

#### **8.3 Depression scale for children**

The Depression Scale for Children, which was prepared by Kovacs [29], is based on Beck Depression Inventory and includes questions related to childhood depression, specific school status and friendship. This scale is the most commonly used scale in childhood depression, of which psychometric properties have been investigated

*Assessment of Psychosocial Functioning among Patients with Cleft Lip/Palate and Their Mothers DOI: http://dx.doi.org/10.5772/intechopen.111667*

most [32]. According to the findings of this scale, no significant difference was found between the children and adolescents in terms of depression scores. The fact that depression scores in both groups are within normal values can be explained by the individuals' good adaptation to their condition.

In the study of Fadeyibi et al. [51], in order to investigate the psychosocial status of 116 individuals with CL/P under the age of 6 and between the ages of 6–12, the responses of CL/P patients were evaluated by their parents. It was shown that individuals with CL/P have a high level of anxiety, depression and deterioration in general well-being. In the 6–12 age group, the effects were reported to be higher.

In a survey conducted by Berk et al. [16] on 85 Chinese adult individuals with CL/P and 85 healthy individuals, it was demonstrated that adult individuals with CL/P had significantly higher social anxiety and lower self-esteem scores than the control group.

As a result of their meta-analytical study on adolescents and adults with CL/P (2276) in non-Anglo populations, Hutchinson et al. [52] indicated that males with CL/P are more prone to psychosocial problems than females, and adults are more prone to psychosocial problems compared to adolescents. In general, it was determined that individuals with CL/P show lower psychosocial development than normal individuals, regardless of age, gender or culture.

#### **8.4 SF-36 quality of life scale applied to mothers**

SF-36 [53], which was developed in order to evaluate the quality of life, is a short yet comprehensive, strong, general health questionnaire in terms of psychometric properties [54]. It is used to compare the effects of the disease and the benefits of different treatments in all age, disease and treatment groups. To date, it has been widely used in the general population [54]. Its reliability and validity study was conducted in Turkey [55]. When the subscales were evaluated, no statistically significant difference was found between the groups of the mothers of children and adolescents. In general, when the norm values of the SF-36 Scale for Turkish society were examined, all the remaining subscales were within the norm values except for the social functionality subscale in the mothers of children and adolescents with CL/P. Since the individuals with CL/P require almost lifelong multidisciplinary teamwork, families have to spend more time with their children, which leads to lower social activity and lower energy. Therefore it was an expected result that mothers' energy/vitality and related social functionality scores would be low.

In the study conducted by Aslan et al. [39], family functions and quality of life of the parents having children with CL/P were evaluated and compared with a normal group. In the study, parents were grouped according to the children's age ranges as 0–6, 7–12 and 13–18, and no significant differences were detected in the quality of life of parents between the CL/P and control groups in 0–6 and 7–12 age groups. However, it was reported that quality of life scores in physical, social and psychological fields was lower in the parents of adolescents with CL/P between the ages of 13–18 compared to the control group.

Antunes et al. [56] found that the quality of life of the families having children with CL/P (4–17 years) was negatively affected compared to the control group because they had to spend more time with their children. When the quality of life of the families of children with CL/P was compared according to the visibility of the deformity, the differences were found to be insignificant.

Crerand et al. [57] reported that stress factors such as the experience of having a child with CL/P could offer opportunities for the formation of protective factors that can improve families' resilience (for example, low levels of family conflict, healthy adjustment and expression).

In a study by Tobiasen and Hiebert [58], it was found that parents of the children with CL/P were significantly more tolerant toward behavioral problems in their children compared to parents of normal children. This result revealed that families having children with CL/P develop strategies to solve problems since they face many problems and stresses from the birth of their children.

In the pilot study by Eiserman [59], it was reported that parents of children with CL/P had positive outcomes such as empathy and increased sensitivity to others, ability to help, closer relationships and acceptance of life challenges, improved communication skills and greater adaptation.

In a study conducted by Baker et al. [60] in order to examine the coping strategies and psychological discomfort levels of 103 families having children with CL/P, the parents were divided into three groups according to the age range of their children (0–6 years, 7–12 years and 13–18 years). It was demonstrated that families with young children were affected more depending on age. This situation was explained by the necessity of more comprehensive treatment, more frequent surgical intervention and clinical visits at younger ages.

#### **8.5 Rosenberg self-esteem scale applied to mothers**

In this study, self-esteem levels were high and depressive effect levels were low in both groups and no significant difference was found between the groups of the mothers of children and adolescents.

According to the results of the survey conducted by Weatherley-White et al. [61] on 52 families in India, 64% of the parents stated that their children's social interaction was not restricted and they were not ashamed of this situation, while 26% stated that they imposed some restrictions and 10% stated that they completely isolated their children from the society and did not allow them to go out of the house or go to school. The responses of the majority of the parents in this study are similar to the subscales of the high level of self-esteem (D1), low level of depressive effect (D5), high level of trust in people (D3) and low level of sensitivity to criticism (D4) in our study.

#### **8.6 Beck depression inventory applied to mothers**

The Beck Depression Inventory was found to be a reliable scale that can be applied in a short time, of which reliability and validity study was conducted in Turkey [62]. In this study, it was found that mothers of children were significantly more prone to depression than mothers of adolescents. It is an expected result as mothers of children with CL/P are more concerned with the care of their children and more frequent surgical intervention and physician control are required in individuals of this age.

We have not met any studies evaluating depression levels in children and adolescents with CL/P and/or their parents. In other studies regarding depression, stress levels of families of individuals with CL/P in prenatal or infancy period before or after surgery were evaluated.

In the study of Nelson et al. [63], anxiety, depression and perceived stress levels of parents having 12–24 months old babies with CL/P were evaluated. Authors reported that anxiety and perceived stress scale were significantly higher in parents who blamed themselves for this condition in their babies; however, depression scores were not significantly higher [63].

*Assessment of Psychosocial Functioning among Patients with Cleft Lip/Palate and Their Mothers DOI: http://dx.doi.org/10.5772/intechopen.111667*

O'Hanlon et al. [64] investigated the effects of prenatal diagnosis of CL/P in their parents. According to the results, these parents were found to feel significantly more guilty compared to the parents in the control group.

In the study of Tabaquim and Marquesini [19], the stress levels of the mothers and fathers before surgery of CL/P patients were evaluated, and it was revealed that stress level was high in 21.4% of the parents, moderate in 28.6% and low in 50% before surgery. On the other hand, stress level was high in 7.1%, moderate in 21.4% and low in 71.4% of parents after surgery.

It is reported that parents are concerned about operations, physical appearance and social functionality [17]. Therefore parents should be informed about how to communicate with their children with CL/P and what types of surgeries and medical procedures they will undergo in the future [65].

#### **8.7 Limitations of the study**

In our study, the cleft type of patients was not classified because of the limited number of isolated palatal or lip cleft cases. Further studies with increased number of patients would be better to investigate the impact of the type of cleft on the psychosocial functioning of both patients and their parents. In addition, the mothers of individuals with CL/P should be compared with control group mothers. Finally, this study identifies the psychosocial functioning among patients with CL/P and their mothers at only one point of time study. Long-term evaluation will provide us better understanding of whether issues regarding psychosocial functioning change over time.

### **9. Conclusion**

In this study, the following results were obtained:

There was no significant difference in terms of quality of life between the groups of children and adolescents with CL/P, and the mothers of children and adolescents. Quality of life levels were found to be close to the mean values for both individuals with CL/P and their mothers.

Low self-esteem levels were determined in both children and adolescents with CL/P. Self-esteem level of the adolescent group was significantly lower than the children group.

Self-esteem levels were not found to be significantly different between the mothers of children and the mothers of adolescents. High self-esteem levels were observed in both groups.

No significant difference was found between the children and adolescents in terms of depression scores.

Beck Depression Inventory scores were higher in the mothers of children than the mothers of adolescents. This result indicates that the mothers of children with CL/P are more prone to depression.

Psychosocial and behavioral problems may occur in children and adolescents with CL/P due to their deformities. In addition to treatment for the deformities and functions of individuals with CL/P, good psychological support is needed to improve their psychosocial status. In addition, healthy individuals should be informed appropriately in order to prevent situations such as mocking, bullying and stigmatization that cause psychosocial and behavioral problems and to change society's perspective and prejudice against these individuals with CL/P.

While each family needs to be evaluated within itself, mothers who take care of individuals with CL/P should be properly and thoroughly informed by the multidisciplinary team about the situation and care of their children. Appropriate psychosocial support is required to reduce stress and depression levels in mothers.
