|Year : 2014 | Volume
| Issue : 2 | Page : 10-14
Psychiatric morbidity and quality of life among mothers of children with orofacial cleft disorders in Enugu: A pilot study
Ifeanyichukwu I Onah1, Justin U Achor2
1 Department of Plastic Surgery, National Orthopaedic Hospital, Enugu, PMB 1294 Enugu, Nigeria
2 Federal Neuropsychiatric Hospital, Enugu State, Nigeria
|Date of Web Publication||15-Apr-2015|
Ifeanyichukwu I Onah
PMB 1294 Enugu, Enugu State
Source of Support: This research received no specific grant from any
funding agency in the public, commercial, or not-for-profit sectors, Conflict of Interest: None
Introduction: This work investigates the prevalence of psychiatric morbidity and its impact on the quality of life of mothers of children with orofacial cleft. Mothers bear stresses and care burdens of ill family members and it affects their mental health. Little is known about the psychiatric morbidity of such mothers in South-eastern Nigeria.
Materials and Methods: Participants were assessed using the Brief Screen for Depression (BSD), the EUROHIS-QOL 8-item Index, and the Self-Reporting Questionnaire (SRQ). The data was analyzed using SPSS version 15.
Results: Of the 48 participating mothers, 50% screened positive for psychiatric morbidity with the SRQ, whereas 62.5% screened positive for depression using the BSD. Psychiatric morbidity was found more among mothers with lower levels of education, having more children; older index children and with over-representation of affected female children. The mean quality of life score was 3.34 ± 0.86. Mothers that screened positive for psychiatric morbidity reported a significantly lower quality of life than those without morbidity (2.82 ± 0.90 versus 3.85 ± 0.40).
Conclusion: Features of psychosocial distress and depression are common among mothers of cleft children and exert negative effects on their quality of life.
Keywords: Cleft deformity, Nigeria, psychiatric morbidity
|How to cite this article:|
Onah II, Achor JU. Psychiatric morbidity and quality of life among mothers of children with orofacial cleft disorders in Enugu: A pilot study
. Nigerian J Plast Surg 2014;10:10-4
|How to cite this URL:|
Onah II, Achor JU. Psychiatric morbidity and quality of life among mothers of children with orofacial cleft disorders in Enugu: A pilot study
. Nigerian J Plast Surg [serial online] 2014 [cited 2022 Jul 3];10:10-4. Available from: https://www.njps.org/text.asp?2014/10/2/10/155170
| Introduction|| |
Orofacial clefts are associated with a broad range of health problems including feeding, speech, growth and development concerns and recurrent ear infections, etc. , Many of the health problems observed in orofacial cleft disorders are associated with limitations in the social and psychological functioning of the children and their families. , For the children, some of these issues include aesthetic concerns, speech and learning difficulties, social skills and self-esteem deficits, among others. ,, In addition, parents of cleft disorder patients suffer a range of stresses, care-giving burden, and financial difficulties in the course of nurturing children with cleft lip and palate disorders. ,, In fact, for the family, orofacial cleft disorders are clinically stressful conditions that require long-term adjustments and resource commitments. This is all the more so, given the need for frequent attendances for assessments, monitoring, and interventions for some of the problems that accompany cleft disorders-impaired facial growth, speech, hearing and dental impairments. ,
Given the direct influence of parental adjustment and care to the outcome of cleft disorders in children,  it is imperative to seek to understand the psychosocial impact on mothers of caring for their children with cleft disorders. Mothers bear the stresses and care burdens of ill and demanding family members , and these exert a variable toll on their mental health, wellbeing, and quality of life. ,,
Little is known about the prevalence psychiatric morbidity among mothers caring for cleft disorder patients in South Eastern Nigeria. The aim of this study was to determine the prevalence of psychiatric morbidity and its impact on the quality of life of mothers of children with orofacial cleft disorders in Enugu, South-Eastern Nigeria.
| Materials and Methods|| |
The participants were the mothers of children who presented consecutively to the cleft surgery service of the hospital between January 2010 and December 2011. Only mothers who consented to participate in the study after due explanation of its nature were recruited into the study group. There were 180 cleft surgeries in the period, isolated unilateral lip surgeries were 75 and isolated bilateral lip surgeries were 20. Combined unilateral lip and palate were 37 and bilateral lip and palate 27. Isolated cleft palate was 15. Of these 180, 123 were done in the base hospital and 57 in outreaches. Only 48 questionnaires were returned. A larger scale study of similar design is being worked out in the same institution.
The National Orthopedic Hospital (NOH) Enugu, South-eastern Nigeria is a center for free cleft services having a high volume of cleft patients yearly. The cleft team meets monthly with the patients. The standard protocol for managing clefts is to receive the patients after birth for counseling. Lip taping in cleft lip is commenced thereafter. Baseline blood counts are obtained and any anemia or infection is treated. Dietary counsel is given in the period. The weight and general health are monitored in subsequent visits. Once the patient with cleft lip is fit for general anesthesia and has attained 6 weeks surgery is scheduled. The patient for cleft palate would have attained 6 months and be fit for general anesthesia. Informed consent is obtained from all patients' attending parent/guardian. The study instruments were administered during the patients' work-up, before any corrective surgery.
The measures utilized for the study included:
• The Self-Reporting Questionnaire (SRQ) which is a 20-item screening instrument for the detection of psychiatric morbidity at the primary care setting. , It detects minor psychiatric morbidity and is suitable for use as a case finding instrument. The SRQ has been validated for use in a number of African countries, including Nigeria 
• The Brief Screen for Depression (BSD) is a brief screening instrument for depression. The BSD was designed to detect clinical levels of depression in primary care and population samples 
• The EUROHIS-QOL 8-item Index  is a brief instrument for measurement of quality of life in population studies. It assesses the psychological, physical, social and environmental dimensions of quality of life
• A socio-demographical questionnaire designed specifically for the study was used to elicit relevant socio-demographic data about the mothers and their children.
Each of the participating mothers was interviewed by a research assistant using each of the instruments. Non-English speaking participants were interviewed with a translation of the questions by the interviewer. The SRQ consists of 20 questions, which has a Yes (1) or No (0) response format. Thus, each of the 20 items is scored 0 or 1 if the symptom was present in the past one month and a cut-off score of 5/6 was utilized for this study. It is usually used as a self-administered or interviewer administered questionnaire. The interviewer administered option was selected for this study because of the variable levels of literacy in our communities.
The data analysis was undertaken by means of SPSS for Windows version 15, and entailed the calculation of rates, frequencies, and proportions. Also, measures of central tendency and dispersion were determined for relevant variables.
| Results|| |
0Prevalence of psychiatric morbidity
Of the 48 participating mothers, 50% screened positive for psychiatric morbidity on the basis of the SRQ, whereas 62.5% screened positive for depression using the BSD.
The mothers that had psychiatric morbidity had a mean age of 31.08 ± 10.52 years vs. 28.54 ± 5.65 for those without psychiatric morbidity (P = 0.303). [Table 1] shows the characteristics of the mothers.
Having psychiatric morbidity was found to be more among those with lower level of education (primary school education or none, 63.2% versus 41.4% among persons with higher levels of education (P < 0.15), higher numbers of children; having older index children and with over-representation of affected female children. The P value however is not significant.
|Table 1: Characteristics of mothers of children who presented for cleft palate treatment evaluation |
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There was no statistically significant difference between the groups on the basis of the place of residence and being involved in employment outside the house.
The mean quality of life score in the sample was 3.34 ± 0.86 (range of 1-5), with a median value of 3.63. The mothers that screened positive for psychiatric morbidity reported a significantly lower quality of life than those that had no psychiatric morbidity (2.82 ± 0.90 versus 3.85 ± 0.40). P = 0.0001.
Similarly, mothers that screened positive for depression had a significantly lower quality of life than those that were not depressed (3.03 ± 0.91 versus 3.85 ± 0.44), P = 0.001. Regarding the component items of the EUROHIS QOL, the comparisons of the means between the two groups (mothers with psychiatric morbidity vs. those without) is displayed in [Table 2]. The data show that for virtually all the items, the quality of life was significantly poorer in the group that had psychiatric morbidity.
In addition, 31.2% of all the mothers rated their quality of life as poor or very poor, 62.5% expressed satisfaction with their health status, whereas only 16.7% reported having enough money to meet their needs. Similarly, only 45.9% reported being satisfied with the conditions of their living place.
| Discussion|| |
The psychosocial impact of having cleft children has previously been documented.  In this study, 50% of the mothers of children with cleft disorders qualified as individuals with psychiatric morbidity, whereas 62.5% attained scores in the clinical range for depression symptoms. Given that these conditions are usually not detected or evaluated in the usual surgical clinic for cleft patients, their impact on the wellbeing of the mothers may have been exerting unrecognized untoward effects on the care and quality of life of the affected children. Mothers that care for these children bear the brunt of their developmental and treatment challenges and these combine with the financial and environmental inadequacies that characterize the realities of their living circumstances to contribute to the observed mental health problems. The psychological health of the mothers cannot be removed from the professional care of the children without compromising the outcome of the latter. Paying attention to the mental health of the mothers through periodic screening and interventions may likely contribute to the wellbeing of the children, especially if due consideration is given to their living conditions. The high correlation coefficient between the SRQ scores and BSD scores of 0.628 suggests a high level of co-morbidity between depression and anxiety symptoms in this sample.
Our findings of depression and anxiety compare with studies conducted among mothers of children with disabling congenital disorders, mental handicap, and psychiatric disabilities, ,, but differ from Kramer in 2007  who did not find any group specific differences in the indices of psychiatric morbidity. The differences in the findings may be related to the differing socio-economic circumstances between our sample population and Kramer's. Unlike the European context, the Nigerian environment presents a number of difficulties in providing care and accessing health services for children with orofacial cleft disorders.
Providing care to children with cleft disorders represents a source of on-going stresses that tax these mothers beyond their coping thresholds. Such may be accentuated by financial difficulties, limitations in the living environment, and perhaps despair over the developmental challenges faced by their children. Family strain, feelings of entrapment, resentment over continuing stress, and financial demands may contribute to the anxiety and depression observed among mothers caring for ill family members. ,,
The psychiatric morbidity among these mothers was associated with reduced education, having female cleft children, older index children and a higher number of children. We believe this observation may be related to a possible social disadvantage associated with less education, and higher burdens of care, as well as a possible negative impact of cleft defects on the social functioning of female children in a traditional society. It may also be that with low education access to counseling is greatly reduced, thereby giving rise to persistently unresolved questions and feelings of guilt about having a deformed child. Most cleft children in this environment are born to parents in the low socioeconomic class,  therefore most cleft mothers in this environment are affected. Earlier surgical correction when safe and practicable may be expected to have a positive impact on the maternal psychiatric wellbeing, which could affect the child's care also. Indeed many parents prefer earlier repair.  This may appear important especially for children having staged repairs, for example, cleft lip and palate patients. Such an approach though attractive to distressed parents would put the child to increased risks which may be hard to justify. It would be of greater importance to provide counseling services for mothers in resource challenged settings as ours, ensuring the patients and parents are managed by cleft teams which include counselors.
There is an association in this study between psychiatric morbidity and negative quality of life. The demand of continuing to adjust to the children's health problems in the context of financial and environmental limitations may have interacted with this morbidity to account for the observed quality of life impacts.  Enhancing the wellbeing of these mothers requires due attention to their mental health status and living conditions through periodic screening and professional interventions. 
We are aware of the study's limitations. The two instruments used for determining psychiatric morbidity (SRQ and BSD) are screening instruments. Although the BSD has a high sensitivity with regard to depressive symptoms and affect, its specificity is rather low.  Screening for unrecognized psychiatric morbidity calls for the use of very sensitive instruments that will not miss any relevant cases like the BSD.  Similarly, the SRQ, though a valid and reliable instrument, is often best used for screening purposes because of its high sensitivity.  Next, self-report data could be influenced by social desirability response set or recall bias. Also, the small sample size limits the generalizability of our findings. However, as a pilot investigation, it represents a beginning of the study of the phenomenon in the population from which this sample was drawn. We recommend comparison with mothers of non-cleft disorders.
This study contributes to understanding the mental health needs of mothers caring for cleft children in Enugu. A previous study indicates they are mostly from a low socioeconomic class.  They have high levels of unrecognized psychiatric morbidity and depressive symptoms that are adversely affecting their quality of life and social functioning. This negatively impacts the care and wellbeing of the children. The experience of psychiatric morbidity in the course of caring for cleft children may be related to the stresses, care burdens and adjustment challenges posed by the condition in a limited psychosocial living context. Studies involving more patients and centers are needed to investigate the predictive utility of the correlates of maternal psychiatric morbidity elicited. Those with features of psychiatric morbidity need to be followed up. What happens to these features after the surgery?
| Conclusion|| |
Features of psychological distress and depression are common among mothers of orofacial cleft deformity in Enugu, and associated with negative effects on their quality of life and wellbeing. A comprehensive treatment of such children will require that attention be paid to the emotional health of their mothers. More studies are indicated to determine the generalizability or otherwise of these findings.
| Acknowledgement|| |
I acknowledge the assistance of Meshack Akunekwe in data collection. Emmanuel Onyenzoputa has continued to be an inspiration.
| References|| |
Neiman GS, Savage HE Development of infants and toddlers with clefts from birth to three years. Cleft Palate Craniofac J 1997;34:218-25.
Richman LC, Eliason M. Psychological characteristics of children with cleft lip and palate: Intellectual, achievement, behavioural and personality variables. Cleft Palate J 1982;19:249-57.
Turner SR, Thomas PW, Dowell T, Rumsey N, Sandy JR. Psychological outcomes amongst cleft patients and their families. Br J Plast Surg 1997;50:1-9.
Strauss RP, Broder H, Helms RW. Perception of appearance and speech by adolescent patients with cleft lip and palate and their parents. Cleft Palate J 1988;25:335-42.
Rosanowski F, Eysholdt U. Phoniatric aspects in cleft lip patients. Facial Plast Surg 2002;18:197-203.
Richman LC, Millard T. Brief report: Cleft lip and palate: Longitudinal behaviour and achievement. J Pediatr Psychol 1997;22:487-94.
Kuehn DP, Moller K.T Speech and language issues in the cleft palate population: The state of the art. Cleft Palate Craniofac J 2000;37:348.
Baker SR, Owens J, Stern M, Willmot D. Coping strategies and social support in the family impact of cleft lip and palate and parents' adjustment and psychological distress. Cleft Palate Craniofac J 2009;46:229-36.
Maes B, Broekman TG, Dosen A, Nauts J. Caregiving burden of families looking after persons with intellectual disability and behavioural or psychiatric problems. J Intellect Disabil Res 2003;47:447-55.
Hunt O, Burden D, Hepper P, Johnston C. The psychosocial effects of cleft lip and palate: A systematic review. Eur J Orthod 2005;27:274-85.
Wong MP, Satar JG, Leong P. Cleft lip and cleft palate: Literature review. ADOHTA J 2011;7:4-11.
Hodgkinson P, Brown S, Duncan D, Grant C, Mcnaughton AT, Mattick PC. Management of children with cleft lip and palate: A review describing the application of multi-disciplinary team working in this condition based upon the experiences of a regional cleft lip and palate centre in the United Kingdom. Fetal Matern Med Rev 2005;16:1-27.
Broder HL. Using psychological assessment and therapeutic strategies to enhance wellbeing. Cleft Palate Craniofac J 2001;38:248-54.
Hastings RP. Child behaviour problems and parental mental health as correlates of stress in mothers and fathers of children with autism. J Intellect Disabil Res 2003;47:231-7.
Smith TB, Innocenti MS, Boyce GC, Smith CS. Depressive symptomatology and interaction behaviours of mothers having a child with disabilities. Psychol Rep 1993;73:1184-6.
Kramer FJ, Baethge C, Sinikovic B, Schliephake H. An analysis of quality of life in 130 families having small children with cleft lip/palate using the impact on family scale. Int J Oral Maxillofac Surg 2007;36:1146-52.
Weigl V, Rudolph M, Eysholdt U, Rosanowski F. Anxiety, depression and quality of life in mothers of children with cleft. Folia Phoniatr Logop 2005;57:20-7.
Kramer FJ, Gruber R, Fialka F, Simkovic B, Hahn W, Schliephake H. Quality of life in school-age children with orofacial clefts and their families. J Craniofac Surg 2009;20:2061-6.
Harding TW, Arango MV, Baltazar J, Climent CE, Ibrahim HH, Ladrido-Ignacio L, et al
. Mental disorders in primary health care: A study of their frequency and diagnosis in four developing countries. Psychol Med 1980;10:231-41.
Harding TW, Climent CE, Diop M, Giel R, Ibrahim HH, Murthy RS, et al.
The WHO collaborative study on strategies for extending mental health care, II: The development of new research methods. Am J Psychiatry 1983;140:1474-80.
Patel V. Culture and Common Mental Disorders in Sub-Saharan Africa. Sussex: Psychology Press; 1998.
Hakstian AR, Mclean PD. Brief screen for depression (BSD). Psychol Assess 1989;1:139-41.
Schmidt S, Muhlan H, Power M. The EUROHIS-QOL 8 item index: Psychometric results of a cross-cultural field study. Eur J Public Health 2006;16:420-8.
Bumin G, Gunal A, Tukel S. Anxiety, depression and quality of life in mothers of disabled children. Med J Suleyman Demirel Univ Turkey 2008;15:6-11.
Baker BL, Heller TL, Henker B. Expressed emotion, parenting stress and adjustment in mothers of young children with behaviour problems. J Child Psychiatry 2000;41:907-15.
Azar M, Fadr LK. The adaptation of mothers of children with intellectual disability in Lebanon. J Transcult Nurs 2006;17:375-80.
Zarit SH, Reever KE, Bach-Peterson J. Relatives of the impaired elderly: Correlates of feelings of burden. Gerontologist 1980;20:649-55.
Onah II, Opara KO, Olaitan PB, Ogbonnaya IS. Cleft lip and palate repair: The experience from two West African sub-regional centres. J Plast Reconstr Aesthet Surg 2008;61:879-82.
Olusanya AA, Oketade I Aladelusi TO. Parental adjustment to cleft lip and palate anomaly: A preliminary study. Niger J Plast Surg 2013;9:33-8.
Lipps GE, Lowe GA. Validation of the Brief Screen for Depression in a Jamaican cohort. West Indian Med J 2006;55:425-9.
[Table 1], [Table 2]