|Year : 2017 | Volume
| Issue : 3 | Page : 88-93
Effectiveness of early intervention on awareness and communication behaviors of mothers of toddlers with repaired cleft lip and palate
M Pushpavathi, Kavya Vijayan, Akshatha Vishwanath
Department of Speech-Language Pathology, All India Institute of Speech and Hearing, Mysuru, Karnataka, India
|Date of Web Publication||21-Nov-2017|
Department of Speech-Language Pathology, All India Institute of Speech and Hearing, Manasagangothri, Mysuru - 570 006, Karnataka
Source of Support: None, Conflict of Interest: None
Objective: The present study is aimed to provide an insight on the causative factors on expressive language delay in toddlers with repaired cleft lip and palate (RCLP). Participants: The present study considered mothers of ten toddlers with RCLP with a mean age of 2.8 years who underwent surgery within 1.5 years. Method / Interventions: The mother-child dyads were enrolled for Early Language Intervention Program (ELIP). The mothers were assessed for the awareness about CLP through a questionnaire and home training was assessed through Mohite's Inventory. Speech and non-speech behaviors of the mothers were assessed using a check list based on an interactional video. These three measures were done before initiating speech and language therapy. Post-therapy measurement was done after 20 sessions. Main Outcome Measures - Pretest post-test design was used to compare the differences in measures for the pre-therapy and post-therapy conditions. Results: Mothers showed greater awareness regarding causes, assessment, treatment, associated problems and issues related to speech therapy in CLP post-orientation (p≤ 0.05). Results also indicated improved home-training abilities of parents on parameters such as language stimulation, physical environment, variety of stimulation and maternal attitude (p≤ 0.05). A statistically significant difference was also noted for speech and non-speech behaviors of the mother (p≤ 0.05). Conclusions: Extensive counseling and orientation helped mothers to gain effective knowledge about cleft lip and palate and focused stimulation approach enabled them to deliver the intervention reliably.
Keywords: Awareness, cleft palate, early intervention, home training
|How to cite this article:|
Pushpavathi M, Vijayan K, Vishwanath A. Effectiveness of early intervention on awareness and communication behaviors of mothers of toddlers with repaired cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:88-93
|How to cite this URL:|
Pushpavathi M, Vijayan K, Vishwanath A. Effectiveness of early intervention on awareness and communication behaviors of mothers of toddlers with repaired cleft lip and palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2019 Jul 18];4, Suppl S1:88-93. Available from: http://www.jclpca.org/text.asp?2017/4/3/88/218885
| Introduction|| |
Cleft of lip and palate (CLP) is one of the most common congenital anomalies which occurs due to multifactorial condition resulting in various associated problems. Several studies have reported that before 3 years of age toddlers with repaired cleft of lip and palate (RCLP) demonstrate various language deficits such as delayed onset, limited vocabulary, restricted sound inventories, and compensatory articulation., Expressive language delay (ELD) is one of the most common conditions in children with RCLP, wherein a severe delay is observed in the expressive language, whereas the receptive language skills and cognitive abilities are reported to be age appropriate.
The various language issues in children with RCLP could be attributed to the lack of extensive counseling and orientation regarding the issues related to speech and language rehabilitation which would result in inadequate knowledge about CLP. The other reasons can be attributed to less positive mother–child interaction and stimulation patterns in the home environment. Due to the limitations in the child's oromotor structures, they may not respond adequately to the mother's effort to communicate. This would in turn affect the mother's responsiveness as well as the type and amount of linguistic input. Other factors such as extended hospital stays, hearing loss related to middle-ear infections, and repeated exposure to surgical pain may interfere with the readiness to learn, and thus may cause a delay in expressive language.,
The necessity for early language intervention soon after surgery for children with CLP has been documented in some studies, and it has been established that early language intervention programs (ELIP) are successful in facilitating speech and language output., The role of maternal speech stimulation and the inclusion of a parent-implemented schedule in such early intervention programs have been intensively studied., It has been seen that mothers who were enrolled in a parent-implemented program were able to improve their abilities in providing speech and language stimulation to their children after the scheduled series of training sessions., The American Cleft Palate Association also encourages “ensuring that the family/caregiver and patient have opportunities to play an active role in the treatment process.”
Although the incidence of CLP has been on the rise in the Indian context, the health-care facilities and benefits provided have not been utilized solely due to the lack of awareness among the parents or the various health-care providers themselves. Research over the past decade has indicated that parents of children with disabilities including orofacial clefts have been seen to demonstrate various psychosocial concerns such as depression, anxiety, and stress which in turn affects the growing parent-child relationship., Thus, the family environment is an important factor in the rehabilitation of a child with a facial/orofacial cleft. The attitudes, expectations, and degree of support shown by parents are likely to have an enormous influence on a child's perception of their cleft impairment.,
A survey on parents of children with CLP showed that the rehabilitation program should also help with issues such as financial management of having a child with a birth defect, recreation for the child and child care, along with counseling options for the family members. It is also advocated that the professionals should provide adequate information to the parents early in the course of treatment and in multiple sessions which in turn increases parental retention of information and promotes the process of coping., The parental attitudes toward the treatment of their child's cleft palate was evaluated and it was found that 36% of parents wished for more participation in their children's treatment decisions and a large percentage (65%) thought that their help was insignificant or ineffective. This clearly indicates the lack of awareness among parents about the extent of their involvement in the rehabilitative process of their child during the early years. Due to the transcultural factors in India such as ignorance, transportation problems, difficulties in meeting the expenses, neglect of the child, and gender bias often the medical and nonmedical treatments get delayed. A recent Indian study highlighted that the mothers of children with RCLP showed a belief in some myths with respect to causes and treatment although they had some awareness regarding the associated problems of CLP.
Over the years, various inventories have been developed in the Indian context to measure the effects of home and family environment on the child's speech and language development. Mohite Home Environment Inventory is one such inventory which measures the effect of home and family environment on the child's development. Research conducted in India by making use of this inventory have highlighted that the home environments which provide less linguistic and cognitive stimulation to the child resulted in the children demonstrating a language delay.
The incidence of CLP is on the rise in the recent years which calls for a thorough investigation into the contributing factors leading to linguistic deficits in this population as studies related to the same are limited. Thus, there is a need to carry out an explorative study to assess the knowledge and attitudes of Indian parents about the issues related to CLP, which could also throw light on the factors which could be involved in causing ELD in toddlers with CLP. The objectives of the present study are as follows:
- To study the influence of orientation and counseling on the parental awareness levels and the quality of home training
- To examine the changes if any, in the speech and nonspeech behaviors of mothers before and after the intervention program.
| Methods|| |
Ten toddlers in the age range of 1–4 years who were diagnosed to have ELD secondary to RCLP, along with their mothers, served as participants for the study and is provided in [Table 1]. The mothers were in the age range of 20–35 years, had passed atleast 12th grade, were in the middle-to-high socioeconomic status and had Kannada as their native language. The language evaluation of the toddlers was carried out by a qualified Speech Language Pathologist (SLP) using Receptive-Expressive Emergent Language Scale (REELS). Children aged below 4 years and diagnosed as ELD secondary to RCLP were enrolled for the ELIP at our institute. The participants had not received any speech and language therapy before enrollment. The other inclusionary criteria included normal hearing and cognitive abilities. Any history of neurological or psychological illness was ruled out. An informed consent (approved by the Ethical Committee) was obtained from the parents before their participation in the study.
Three different materials were used for the purpose of investigating the factors contributing to ELD in the CLP population. They have been mentioned below.
- Questionnaire on Awareness of parents on Issues Related to CLP – The questionnaire contained eight domains such as attitude of parents, causative factors, associated problems, treatment (general and surgical), speech therapy, and general nature of CLP. Each domain had ten statements which consisted of five myths and five facts. Thus, there were a total of 80 statements. The response for each of the question was close-ended and binary choice of response was provided
- Mohite Home Environment Inventory – This inventory was developed to assess home environment for speech and language stimulation. It consists of five domains such as “language stimulation,” “physical environment,” “encouragement of social maturity,” “variety of stimulation,” and “maternal attitude and disciplining.” It consists of a total of 24 statements. The response for each of the question was close-ended and binary choice of response was provided
- Checklist to assess speech and nonspeech behavior of the mother – A checklist was prepared after conducting a thorough review of literature with respect to the behaviors adopted by a mother while providing speech stimulation to her child. The checklist consists of a total of 37 statements segregated under three domains. The three domains are “speech behaviors” which assesses the quality of speech stimulation provided by the mother, “nonspeech behaviors” which assesses the pragmatic skills of the mother while giving therapy and “other behaviors” which assesses the activeness of the mother during the session. The aspects of each domain were arrived at by observing and noting down the speech and nonspeech behaviors of mothers in various videos which were recorded during free play and interaction between mothers and toddlers with RCLP. During analysis, the appropriate behaviors were marked off by the SLP, by observing the interaction session between the mother and child with CLP.
In the preliminary stage, the mothers were enrolled for the ELIP program and following this, their awareness about CLP was assessed through the parental awareness questionnaire and each item was scored. This was followed by a detailed pretherapeutic evaluation which was conducted to establish the baseline of the children and mother's speech and language behaviors. The quality of home training was assessed through Mohite's Inventory. Subsequently, the speech and nonspeech behaviors of the mothers were assessed using the developed checklist and scored. The scores of Mohite inventory and behavior checklist were based on mother-child interactional video of 45-min duration.
A detailed counseling and orientation session was provided to the mothers regarding the classification, causes, team approach, evaluation, and various management issues in children with CLP. Speech and language therapy was initiated for toddlers soon after orientation. After 20 sessions of intensive therapy by the SLP, wherein mother was also an active participant, the questionnaire and checklists were readministered to find out the disparity in scores between the pre- and post-test measurements. The 20 therapy sessions were carried out over a period of 2 months. Audio-video recording was carried out for each child during the initial sessions and after 20 sessions of therapy to ascertain the amount of stimulation provided by the mother before and after therapy.
Focused stimulation approach was used which was also shown to the mother during therapeutic sessions. A multisensory approach was used to increase the oromotor movements. A corpus of vocabulary was prepared in the master lesson plan which contained the most commonly used functional words by toddlers. The positive behaviors of the child were reinforced appropriately. The mother was told to carry out a similar training program at home in the absence of direct supervision of the SLP.
The scores obtained under different domains in the questionnaire, inventory, and checklist were tabulated and subjected to statistical analysis. The data from the participants were analyzed using SPSS software (Statistical Package for the Social Sciences) was acquired by IBM Corp. in 2009 (version 21). Results of Kolmogorov–Smirnov test and Shapiro–Wilk test revealed that the data did not follow normal distribution. Thus, nonparametric measures were employed in the study. Wilcoxon signed rank test was administered to check the statistical significance between pre-test and post-test scores.
| Results|| |
The present study serves as a prefatory endeavor to highlight the factors which may be responsible for the delay in speech and language stimulation in toddlers with RCLP. The mean scores obtained under different domains in the questionnaire, inventory, and behavioral checklist were tabulated and subjected to statistical analysis. The results obtained are discussed under different heads below.
Awareness of parents on issues related to cleft of lip and palate
The awareness levels present in mothers before attending therapy and after the intervention was assessed, and the mean values obtained under each domain are presented in the table below.
[Table 2] clearly depicts the fact that mothers showed a lesser amount of awareness regarding causes, assessment, treatment, associated problems, and issues related to speech therapy in CLP before orientation. During the posttherapy condition, it was observed that the mothers showed a greater level of awareness in all the eight domains. To statistically analyze the data, Wilcoxon Signed Rank test was administered which revealed a significant difference (*P ≤ 0.05) between the pre-test and post-test scores under each domain.
|Table 2: The mean scores and P value of the mother's response for parental awareness questionnaire under different domains during pre- - and post-test conditions|
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Quality of home training
The quality of home training was assessed using the Mohite Home Environment Inventory. The results exemplify that the home training provided by the parents of children with RCLP was poor. The maternal attitude and disciplining were observed to be poor during the pretest. Furthermore, the amount of language stimulation and the variety of stimulation were found to be reduced. Posttherapy and with counseling a significant difference was seen in language stimulation and in the variety of stimulation provided. Maternal attitude and disciplining also showed an improvement as depicted in [Table 3] below.
|Table 3: The mean scores and P values for Mohite home environment inventory under different domains during pre-and post-test conditions|
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Checklist to assess speech and nonspeech behaviors of the mother
The speech and nonspeech behaviors of the mother were assessed using a checklist. The results depict that during pretest the scores for speech behaviors of the mothers during speech stimulation were poorer than that of nonspeech and other behaviors. However posttherapy, an enhancement was observed for speech behaviors, nonspeech, and other behaviors which are illustrated in the table below.
[Table 4] illustrates the mean scores and P values obtained under the different domains of the checklist, both pre- and post-therapy. Statistical analysis using Wilcoxon signed rank test showed a significant difference (*P ≤ 0.05) between the pre-test and post-test scores under speech, nonspeech, and other behavioral domains.
|Table 4: The mean scores and P values for mother's behavioral checklist under different domains during pre- - and post-test conditions|
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| Discussion|| |
The results of the present study clearly portray that there was a remarkable increase in the awareness and home training of the mothers from the baseline to posttherapy. Although, it was noticed that before therapy, the mothers had better knowledge regarding problems associated with CLP and the importance of speech therapy, the awareness regarding the treatment for associated problems of CLP was poor. However, postorientation, the mothers showed an increased awareness regarding overall causes, assessment, and treatment of CLP.
The results of the present study are in consonance with the previous studies which directs a greater need for the parents to know the facts on various domains of CLP.,,,,,,, Thus, the post-test results showed a greater improvement on all domains after detailed counseling. The significant difference in language stimulation and maternal attitude indicated a progress which has enabled them to deliver a qualitative intervention. The findings of the present study support the previous findings which reported that mothers who received training program for a sustained duration were significantly better in providing stimulation to their children. These emphasizes the role played by the family members, especially the mothers in shaping the linguistic development of children with CLP.
With respect to speech and nonspeech behaviors, it was seen that the mothers demonstrated positive patterns of interaction during post-test. The above changes were observed as mothers had become more accepting of the cleft condition because of orientation and extensive counseling provided regarding issues related to management of CLP. Furthermore, the demonstration of focused stimulation helped the mothers in organizing the environment and activities that suit the child's needs. This study is also in consonance with the earlier findings which revealed that mothers who participated in a parent-implemented program were able to provide better speech and language stimulation to their children after the scheduled series of training sessions.,
The changes in the behaviors, attitudes, and knowledge of mothers would also evidently reflect changes in the child's speech and language performance. The findings of the present study corroborate the findings of the previous studies which have highlighted that mothers of children with RCLP who attend regular and intensive language intervention programs showed a tendency to use better patterns of interaction wherein they learnt to adapt and use nonverbal modes, gestures, and actions to help their children communicate in a better way. These changes in the mother's communication patterns would enhance the toddler's speech and language abilities in terms of increased phonetic inventory, greater vocabulary and better oromotor skills. Studies taken up in future along these lines would depict the positive effects of the mothers communicative patterns on the child's speech and language abilities.
| Conclusions|| |
The present study emphasizes that extensive counseling and orientation helps mothers to gain effective knowledge about issues related to the management of a child with cleft lip and palate. It also highlights that ELIP enabled the parents to deliver the language intervention reliably. This study also provided an insight toward the changes in language stimulation and maternal attitude after the demonstration of focused stimulation approach.
This is a part of the ongoing research on “Efficacy of Early Language Intervention Program for Children with Repaired Cleft lip and Palate”, funded by the Department of Science and Technology (DST - No. SB/SO/HS/02/2014), Government of India. The authors would like to thank DST for funding the project. The authors would also like to thank Dr. S. R. Savithri, Director, All India Institute of Speech and Hearing, Mysuru, for providing the infrastructure to carry out the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Murray JC. Costs of cleft lip and palate: Personal and societal implications. In: Wyszynski DF, editor. Cleft lip and palate-From origin to treatment. Oxford University press; 1995. p. 458-59.
Sunitha R, Jacob M, Jacob MS, Nagarajan R. Providing intervention services for communication deficits associated with cleft lip and/or palate-A retrospective analysis. Asia Pac Disabil Rehabil J
D'Antonio LL, Scherer NJ. Communication disorders associated with cleft palate. In: Losee J, Kirschner R, editors. Comprehensive Cleft Care. McGraw: Hill; 2008. p. 64-78.
Broen PA, Devers MC, Doyle SS, Prouty JM, Moller KT. Acquisition of linguistic and cognitive skills by children with cleft palate. J Speech Lang Hear Res 1998;41:676-87.
Thammaiah I, Lydia J, Pushpavathi M. Awareness of parents on the nature of cleft lip and palate: An exploratory study. J All India Inst Speech Hear 2011;30:15-22.
Savage HE, Neiman GS, Reuter JM. A developmental perspective on assessment in infants with clefts and related disorders. Infant-Toddler Intervention: A Transdisciplinary Journal 1994;4:221-34.
Scherer NJ, Kaiser A. Early intervention in children with cleft palate. Infants Young Child. 2007;20:355-66.
Chapman KL, Hardin MA. Language input of mothers interacting with their young children with cleft lip and palate. Cleft Palate Craniofac J 1991;28:78-85.
Manocha A, Narang D, Balda S. Role of intervention in improving maternal stimulation level. J Soc Sci 2008;17:181-4.
American Cleft Palate-Craniofacial Association. Standards for Cleft Palate and Craniofacial Teams; 2008. Available from: http://www.acpa-cpf.org/
. [Last accessed on 2017 July 28].
Shrivatsav S. Parents still don't bring cleft lip, palate kids for treatment. Nagpur: Times of India; 2013.
Thamilselvan P, Kumar MS, Murthy J, Sharma MK, Kumar NR. Psychosocial issues of parents of children with cleft lip and palate in relation to their behavioral problems. J Cleft Lip Palate Craniofacial Anomalies 2015;2:53-7.
Grollemund B, Danion-Grilliat A, Kauffmann I, Bruant-Rodier C. Relationships between parents and children with labio-palatal clefts: The importance of a delay preceding the first surgical repair. J Dentofacial Anom Orthod 2011;14:304-12.
Bull R, Rumsey N. The social psychology of facial disfigurement. J Cross Cult Psychol 1988;17:99-108.
Lansdown R, Lloyd J, Hunter J. Facial deformity in childhood: Severity and psychological adjustment. Child Care Health Dev 1991;17:165-71.
Dölger-Häfner M, Bartsch A, Trimbach G, Zobel I, Witt E. Parental reactions following the birth of a cleft child. J Orofac Orthop 1997;58:124-33.
Broder H, Trier WC. Effectiveness of genetic counseling for families with craniofacial anomalies. Cleft Palate J 1985;22:157-62.
Horner MM, Rawlins P, Giles K. How parents of children with chronic conditions perceive their own needs. MCN Am J Matern Child Nurs 1987;12:40-3.
Pannbacker M, Scheuerle J. Parents' attitudes toward family involvement in cleft palate treatment. Cleft Palate Craniofac J 1993;30:87-9.
Venkatesan S. Socio-cultural dimensions of cleft lip and palate in India. Glob J Interdiscip Soc Sci 2015;4:72-7.
Mohite P. Mohite's home environment inventory: Child's observation technique. Agra: National Psychological Corporation; 1989.
Malhi P, Sidhu M, Bharti B. Early stimulation and language development of economically disadvantaged young children. Indian J Pediatr 2014;81:333-8.
Bzoch KR, League R. Receptive Expressive Emergent Language Scale. Gainesville, Florida: Anhinga Press; 1971.
Young JL, O'Riordan M, Goldstein JA, Robin NH. What information do parents of newborns with cleft lip, palate, or both want to know? Cleft Palate Craniofac J 2001;38:55-8.
Weatherley-White RC, Eiserman W, Beddoe M, Vanderberg R. Perceptions, expectations, and reactions to cleft lip and palate surgery in native populations: A pilot study in rural India. Cleft Palate Craniofac J 2005;42:560-4.
Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: A qualitative study. Acad Med 2008;83:292-7.
Girolametto LE. Improving the social-conversational skills of developmentally delayed children: An intervention study. J Speech Hear Disord 1988;53:156-67.
Wasserman GA, Allen R, Linares LO. Maternal interaction and language development in children with and without speech-related anomalies. J Commun Disord 1988;21:319-31.
[Table 1], [Table 2], [Table 3], [Table 4]
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