Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 953e958

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Journal of Cranio-Maxillo-Facial Surgery

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Children with a cleft lip and palate: An exploratory study of the role of
the parentechild interaction
Volker Gassling a, *, Caroline Christoph a, Kristina Wahle a, Bernd Koos b, Jörg Wiltfang a,
Wolf-Dieter Gerber c, Michael Siniatchkin d
a
Department of Oral and Maxillofacial Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
b
Department of Orthodontics, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
c
Institute of Medical Psychology and Medical Sociology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
d
Clinic for Child and Adolescent Psychiatry, Johann Wolfgang Goethe-University, Frankfurt, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Having a child with an orofacial cleft may be associated with a specific pattern of parenting.
Paper received 4 September 2013 In order to investigate the parenting style, the present study assessed parentechild interactions during a
Accepted 3 January 2014 problem-solving task performed under pressure.
Material and methods: Parentechild interactions were video recorded for 15 families with a child with a
Keywords: cleft lip and palate (CLP), which were then compared to 20 healthy families and 20 families with a child
Cleft lip and palate
suffering from migraines. The children had to solve a puzzle within a specified time with either their
Parentechild interaction
mother or father.
Craniofacial malformation
Family
Results: In families with a child with CLP, mothers tried to support their children more often and children
demonstrated more autonomous behaviour towards both parents than children in healthy and migraine-
affected families. Moreover, the children with CLP relied less on their fathers for help and interrupted
their fathers less frequently.
Conclusions: Autonomous behaviour among children with CLP which is supported by their parents may
represent psychosocial compensatory mechanisms in the family environment.
Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction compromise the affected individuals and lead to psychosocial dif-

Non-syndromic cleft lip and palate (CLP) represents the most
common malformation of the midfacial region worldwide. In
Europe, the incidence varies between 0.69 and 2.35 per 1,000
newborns depending upon the geographic location and ethnic
identity (Gundlach and Maus, 2006). Today, treatment requires
multidisciplinary care including maxillofacial surgery, orthodon-
tics, otolaryngology, speech therapy, and dentistry. Owing to great
efforts, particularly in the field of plastic-surgical treatment during
the last few decades, the health outcome of affected patients seems
to be good, particularly in developed countries (Hakim et al., 2013;
Mossey et al., 2009; Wermker et al., 2013). However, the multiple
burdens occurring from birth through to adulthood may
* Corresponding author. Department of Oral and Maxillofacial Surgery, University
Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 26,
24105 Kiel, Germany. Tel.: þ49 431 597 2791; fax: þ49 431 597 4084.
E-mail address: gassling@mkg.uni-kiel.de (V. Gassling).
ficulties in various aspects of life. Individuals with CLP present more
often with behavioural problems, suffer from depression, and are
unhappy because of their facial appearance and speech compared
with subjects without a cleft (Hunt et al., 2006). It is unclear,
however, how the disability impacts the social abilities and inter-
personal relationships of patients with CLP and what consequences
in the social environment may result from the malformation.
For example, adolescents with craniofacial anomalies (CFA)
initiated contact less often, received positive responses from peers
less frequently, and were engaged in conversations which were
shorter in duration than healthy control subjects (Kapp-Simon and
McGuire, 1997). Children with CFA were less responsive in socially
reciprocal interactions and were rated personally as less attractive
with regard to social contact (Krueckeberg et al., 1993). Further-
more, the severity of the cleft deformity was shown to have a sig-
nificant impact on social competence in childhood, e.g., on the
development of friendships. Given these examples, it is not sur-
prising that even adult siblings with repaired clefts were less
frequently married than their non-cleft siblings (Tobiasen and

1010-5182/$ e see front matter Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jcms.2014.01.016
954 V. Gassling et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 953e958
Hiebert, 1993). Accordingly, parents of CLP-affected children rated
them less socially competent regarding patterns of social in-
teractions (Slifer et al., 2004). Furthermore, subjects with CLP did
not differ from healthy individuals with respect to emotional and
behavioural problems as well as hyperactivity. However, patients
were six times more likely to report difficulties with respect to
social abilities (Brand et al., 2009). In this context, the surgeon’s
assessment of facial aesthetics after cleft surgery seems to be of
minor relevance and thus emphasize the role of social support of
affected individuals (Cochrane and Slade, 1999; Gkantidis et al.,
2013).
There may be different explanations for the described psycho-
social problems of subjects with CLP. On the one hand, psychosocial
deficits may have developed following a disability-related malad-
aptation in the psychosocial environment. On the other hand, they
may be associated with a specific style of parenting in families with
a CLP child. The birth of a child with a facial disfigurement is a
profound experience for the affected parents. One investigation of
parental reactions following the birth of a child with a CLP has
provided evidence for negative parental emotions towards the CLP-
affected child, e.g., frustration, disappointment, rejection, and
feelings of guilt, sorrow, and pain resulting in less trust in and
happiness about their children (Dolger-Hafner et al., 1997). It can be
assumed that the pattern of social interactions within families with
a CLP-affected child in general may be compromised by “stigma-
tization” and a negative attitude towards CLP children (Nelson
et al., 2012). Based on these observations, it can be hypothesized
that parents may demonstrate a negative pattern of parentechild
interaction with more criticism and less positive reinforcement
along with more direct control and less assurance which encour-
ages the autonomous behaviour of a child with CLP.
The present study was aimed at testing this hypothesis. Dyadic
parentechild interactions were studied using a standardized
experimental design which enabled the microanalysis of commu-
nication patterns structured under laboratory conditions. This
design has been successfully used in a number of studies which
have demonstrated an abnormal pattern of parentechild in-
teractions in families with children suffering from migrainous
headaches and asthma (Gerber et al., 2002; Lykaitis, 1985;
Siniatchkin et al., 2003, 2010). The construct allows for a detailed
evaluation of the procedural side of interactions and describes fa-
milial relations in terms of the learning theory. Thus, the construct
focuses on parental control of the child’s activities either directly or
by linking changes with specific consequences. In order to inves-
tigate the sensitivity and specificity of dyadic parentechild in-
teractions in families with a CLP-affected child, actual interactions
with the CLP-affected child were compared to previously recorded
interactions with a healthy (sensitivity) and migraine-suffering
(specificity) child (Siniatchkin et al., 2003, 2010).
2. Material and methods
2.1. Study participants
Only complete families including both the mother and father
were studied. Fifteen families with a non-syndromic CLP-affected
child were recruited from craniofacial malformation consultation
appointments with the Department of Cranio-Maxillofacial Sur-
gery, University Hospital of Schleswig-Holstein, Kiel Campus, Kiel,
Germany. There was no recruitment bias and we had no refusals
since all families which were consecutively asked to participate
consented to inclusion in the study. All participating children had a
repaired unilateral or bilateral CLP. According to our treatment
protocol, the lip closure is performed at the age of 4e6 months, the
soft and hard palate closure at the age of 10e12 months, and the
secondary alveolar bone grafting at the age of 8e11 years. The
control groups consisted of 20 families with a healthy child and 20
families with a child suffering from migraines. Healthy and
migraine-suffering children were investigated previously within
the framework of a German Research Foundation project (Ge 500/
4-2). Therefore, the clinical and demographic characteristics of the
healthy and migraine-affected group and parameters of the
parentechild interactions in healthy and migraine-affected families
have been published elsewhere (Siniatchkin et al., 2003, 2010).
There were no significant differences between parents and children
from each group according to age, gender, and other demographic
characteristics (see Table 1). None of the recruited families refused
participation in the study. All children from migraine-affected
families suffered from migraines without aura (mean frequency
of migraine attacks: 2.24  2.5 day/months; mean attack duration:
8.17  6.3 h; mean duration of disease: 5.5  2.19 years). Structured
headache interviews were performed with all participants.
Migraine diagnosis was performed by an experienced neurologist
according to the revised criteria of the International Headache
Society based on an interview and prospective headache diaries
(International Classification of Headache Disorders; (IHS, 2004)).
Migraine diagnosis was excluded in families with a CLP-affected
child and healthy families. There was no divorce in the histories
of all families included in the analysis. None of the subjects inves-
tigated were undergoing psychiatric or psychological treatment nor
were they taking any medication. Psychiatric comorbidity was
excluded through the clinical interview with the parents and a
psychiatric examination of the children. None of the children pre-
sented with symptoms which would fulfil the diagnostic criteria for
any psychiatric disorders according to ICD-10. Although cognitive
abilities were not tested in the children, all of them attended reg-
ular primary and secondary schools and demonstrated an average
school performance (according to school report cards). All partici-
pants were Caucasians. Parents were informed about the course of
the experimental procedure and gave written informed consent
before the examination began. The study design complied with the
Declaration of Helsinki, was approved by the local ethics board (AZ:
D 433/10), and was registered in the German Clinical Trials Register
(registration code: DRKS00004281; https://drks-neu.uniklinik-
freiburg.de/drks_web/setLocale_EN.do).
2.2. Study of parentechild interactions
2.2.1. Paradigm
Observations were performed under laboratory conditions. The
interactive behaviour was assessed by an achievement-oriented
task: a puzzle adhering to the method described by (Lykaitis,
1985) and validated for clinical groups by (Gerber et al., 2002;
Siniatchkin et al., 2003, 2010) was administered. All recordings
were made in quiet, soundproof rooms free from outside distur-
bances. The child had to solve the puzzle autonomously with the
mother or father, respectively. The order concerning the interaction
with the mother or the father was counterbalanced between fam-
ilies. The puzzle was divided into 2 equal parts each with 53 pieces.
Each half was to be solved within 15 min. The following in-
structions were given: (1) Only the child was permitted to touch
Table 1
Demographic characteristics of the groups (mean and SD for age and m:f for gender).
CLP group Healthy group Migraine group Difference
Age of mother 37.9  6.7 40.6  5.4 39.3  4.1 n.s.
Age of father 40.4  8.4 41.1  4.2 43.7  7.1 n.s.
Age of child 9.00  1.25 10.6  2.6 10.55  1.5 n.s.
Gender of child 7:8 8:12 12:8 n.s.
 V. Gassling et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 953e958
the puzzle pieces and solve the task. However, the child was not
aware of the puzzle picture and had to rely on the parent for in-
formation. (2) The parent had a picture of the completed puzzle and
was told to verbally help the child without showing the picture or
individual pieces. Furthermore, no physical help was allowed (i.e.,
no pointing with hands, eyes, nose, or elbows). (3) The child was
allowed to ask about the picture. After giving the instructions, the
investigator turned on the video camera and left the room. Once
the allotted time expired, time was stopped and the puzzle pieces
which were solved were counted. The families were observed un-
der pressure and stress during the task, which was induced by
limiting the time allowed and by giving a special instruction indi-
cating that the aim of the study was to determine with which
parent the child could solve the puzzle most quickly. Care was
taken to randomize the sequence of participation for different
family members in the task.
2.2.2. Evaluation of the family interaction
The specific interactive behaviour was recorded with a video
camera and analysed sentence-by-sentence and movement-by-
movement afterwards for verbal and non-verbal aspects of the
interaction according to the frequency of the predefined parame-
ters listed below. The analysis of the intra-familial interaction was
based on the behavioural concept described by Lykaitis (Lykaitis,
1985) and Innerhofer (Innerhofer, 1982). The interactive se-
quences were structured in observation units, such that a unit of
person 1 was followed by a unit of person 2 and conversely. The
observation unit was defined as a “change in the control behav-
iour,” whereby the verbal and non-verbal behaviours of a subject
were evaluated in terms of the support or suppression of the ac-
tivities of the partner. The observation unit was not time-restricted,
but was defined by content-related aspects. A unit of meaning
could be a word (“Yes”), a sentence (“I am happy”), or a longer
segment when the content remained constant. All statements and
phrases which were not related to the puzzle were rated as dis-
tractions. All types of observations were defined within the context
of the process of puzzle solving. The observation units were rated
according to the extent of “effective puzzle solving.” Non-verbal
behaviour was excluded from the analysis because of poor inter-
rater reliability for non-verbal codes.
2.2.3. Dimensions of types of observations
The dimensions of the observed interactions were related to the
following:
a) The consequence dimension (indirect emotional
consequence-directed control) included positive reinforce-
ment (compliments, eulogy, and expression of positive
emotions) or punishment (criticism, threats, expression of
negative emotions, sarcasm, frantic behaviour, disappoint-
ment, and ignorance of instruction).
b) The goal dimension (direct objective purpose-related con-
trol) included codes requiring an immediate change in
behaviour: specific instructions (commands, instructions,
comments, and questions which provided a detailed
description of the expected behaviour) and blocking and
interruption of the partner’s activity (direct obstruction,
active ignoring of the instruction, active deliberate inter-
ruption, or rejection of a suggestion).
c) The solution dimension (instrumental procedural realiza-
tion) included verbal feedback and self-comments which
were task-relevant, but not directed at the partner.
d) The help dimension included attempts to improve the
quality of communication or understanding. It consisted of
descriptions of the picture and general remarks on the task-
955
solving process or comments without a detailed description
of the expected behaviour.
e) The autonomous problem-solving or control dimension by
the children consisted of self-comments from the children as
well as independent and autonomous puzzle solving.
Detailed descriptions of the types of observations have been
published elsewhere (Gerber et al., 2002; Siniatchkin et al., 2003,
2010).
The evaluation was performed by two independent “raters”
(psychology students) who had been given appropriate and rele-
vant training as well as intensive supervision of the rating process.
The training sessions were delivered by the last author who served
as a principal investigator on the development of the assessment
system and in the evaluation of parentechild interactions in fam-
ilies with a child who experiences migraines and in healthy fam-
ilies. Each rater used a specially written code manual developed for
the coding process. Questions concerning difficult interactions
were solved together with the criterion rater (last author) after
training was completed. Verbatim transcripts were not used during
evaluation. Four randomly selected videotapes were coded at the
beginning of the study. The percentage agreement between the two
coders was 82%. The fixed-effect intraclass correlation coefficients
(ICCs) between raters according to the relative frequencies of the
different categories ranged from 0.69 to 0.91. In addition, Cohen’s k
coefficient was computed yielding k ¼ 0.78 (p < 0.0001) for the
entire dataset. Altogether, the reliability of the evaluation system
for the frequency analysis seems to be sufficiently high. Ten mi-
nutes of each parentechild interaction were coded (in some fam-
ilies, the interaction finished quickly, but lasted at least 10 min for
all families). We found great variation in the number of codable
behaviours observed. It was necessary to correct the raw frequency
of each coding category by the total number of codable behaviours
observed for a particular person. Therefore, the score for each code
was expressed as a proportion of codable units for that person
(relative frequencies as outcome measures).
2.3. Statistical analysis
All dependent variables revealed a normal distribution (non-
significant KolmogoroveSmirnov tests) and homogeneity of vari-
ances (F-test). The differences between the group of children with
CLP and healthy children as well as children with migraines were
evaluated using ANOVA statistics according to the relative fre-
quencies of categories obtained for the parentechild interactions.
Interactions with a mother and with a father were assessed sepa-
rately. The specific differences between the groups were analysed
using post hoc Scheffe tests. The significance level was kept at
p < 0.05 and corrected for multiple comparisons.
3. Results
Fig. 1 illustrates the results of parentechild interaction in fam-
ilies with a CLP-affected child, families with a child who experi-
ences migraines, and healthy families. The interactions with both
parents were analysed in all healthy and migraine-affected families.
In two families with a CLP-affected child, the interaction with the
father was not included because the fathers could not participate in
the study.
For interactions with the mother, the analysis of variance
revealed significant differences between the groups for the
purpose-related control (specific instructions, F2,54 ¼ 7.185;
p ¼ 0.002), positive reinforcement (F2,54 ¼ 10.514; p < 0.001) from
the mother as well as through questions (F2,54 ¼ 13.144; p < 0.001),
interruptions (F2,54 ¼ 4.553; p ¼ 0.015), and autonomous problem
956 V. Gassling et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 953e958

Interaction with a mother in families with CLP-affected children, the children interrupted their
mothers and demonstrated more autonomous behaviour (control)
0,7 significantly more often than was observed in migraine-affected
0.002 n.s. <0.001 n.s. n.s. n.s. <0.001 0.015 0.013
families (p ¼ 0.012 and p ¼ 0.012, respectively).
For interactions with the father, ANOVA revealed significant
0,6
CLP child differences between the groups for help (F2,52 ¼ 9.370; p < 0.001)
Healthy child from the father as well as questions (F2,52 ¼ 8.378; p < 0.001), in-
0,5 Migraine child
terruptions (F2,52 ¼ 9.404; p < 0.001), and autonomous problem
solving, i.e., control (F2,52 ¼ 4.693; p ¼ 0.014) as demonstrated by
relative frequencies

0,4 the children. Post hoc tests demonstrated the following interaction
patterns: 1) fathers used help strategies less frequently towards a
0,3 CLP-affected child compared with healthy children (p < 0.001); 2)
in families with a CLP-affected child, children asked fewer ques-
0,2 tions and interrupted their fathers less often than in healthy
(p ¼ 0.008 and p < 0.001, respectively) and migraine-affected
(p ¼ 0.001 and p ¼ 0.026, respectively) families; and, 3) CLP-
0,1
affected children demonstrated more autonomous behaviour
(control) when interacting with their fathers compared with
0,0
migraine-suffering children (p ¼ 0.011). Compared with healthy
children, there was a significant tendency towards more autono-
mous behaviour among CLP-affected children (p ¼ 0.12).
trol tion ent ent ack help child on ch l child
con errup orcem nishm feedb ns pti tro
int reinf pu stio nterru con
que i 4. Discussion

The current exploratory study investigated parentechild in-

Interaction with a father teractions in families with a CLP-affected child. This study reveals
the following main findings: 1) in families with a CLP-affected child,
0,7 mothers tried to reinforce their children more often and children
n.s. n.s. n.s. n.s. n.s. <0.001 0.001 <0.001 0.014
demonstrated more autonomous behaviour towards both parents
0,6 CLP child than in healthy and migraine-affected families; 2) children with
Healthy child CLP relied less often on help from their fathers and interrupted
Migraine child their fathers less frequently than was the case in healthy and
0,5
migraine-affected families; and, 3) migraine-suffering children
relative frequencies

0,4 were exposed to more purpose-related control and showed more

submissive behaviour (more questions, fewer interruptions) to-
wards their parents than children affected by CLP and healthy
0,3
children.
The main assumption of this study is that the pattern of parente
0,2
child interactions in families with a CLP-affected child is influenced
by the malformation and the possible “stigmatization” of their
0,1 children. Based on results from previous studies (Dolger-Hafner
et al., 1997), we hypothesized that parents in families with a CLP-
0,0 affected child may demonstrate a negative pattern of parente
child interaction with more criticism and less reinforcement, more
direct control and less reassurance encouraging autonomous
trol tion ent ent ack help child on ch l child behaviour towards a CLP-affected child. However, we were unable
con errup orcem nishm feedb ns pti tro
int reinf pu stio nterru con to confirm this hypothesis. In contrast, the CLP-affected children
que i
were more independent when interacting with their parents and
Fig. 1. Relative frequencies of parentechild interactions in families with a CLP-affected parents from families with CLP-affected children were more
child, families with a migraine-suffering child, and healthy families (note: control by encouraging and less directive and restrained when compared with
parents ¼ specific instructions, punishment ¼ negative reinforcement, control by healthy and migraine families. It seems likely that the malforma-
children ¼ autonomous problem solving).
tion is associated with a more cautious, patiently, and encouraging
parenting style which promotes greater initiative in the CLP-
solving, i.e., control (autonomous problem solving, F2,54 ¼ 4.743; affected child. A systematic search of the literature concerning
p ¼ 0.0133) as demonstrated by the child. Post hoc tests revealed the “parentechild interaction” and “cleft lip and palate”, respectively,
following interaction patterns: 1) mothers exerted significantly along with “malformation” revealed only a few studies which have
more purpose-related control over their children in migraine- included direct observation of parentechild interactions. Wasser-
affected families compared with healthy families (p ¼ 0.002) and mann et al. investigated parentechild interactions in families with
families with a CLP-affected child (p ¼ 0.046); 2) in families with a children presenting with mixed physical deformities by analysing
CLP-affected child, mothers tried to reinforce their children signifi- videotaped recordings in a semi-structured situation and found
cantly more often than in both families with a healthy child that mothers of disabled children tended towards an ambivalent
(p < 0.001) and with a child suffering from migraines (p ¼ 0.001); 3) parenting style both encouraging and ignoring their toddlers
in families with a migraine-suffering child, the children asked their (Wasserman et al., 1985). The greater degree of reinforcement of
mothers questions more often than children from healthy families CLP-affected children among their mothers in the present study
(p ¼ 0.007) and families with a CLP-affected child (p < 0.001); and, 4) partially resembles the earlier findings, while the age group and
 V. Gassling et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 953e958
type of impairment in both studies differed. Note that the extent of
social competence in children with craniofacial abnormalities was
associated with parental encouragement, which was more often
expressed in families with a CLP-affected child (Pope and Ward,
1997). It is well known that a less performance-oriented and
more child-directed attitude of mothers leads to a positive self-
esteem in children later in life. Thus, the mothers’ reinforcement
of the children in the present study may represent a particular kind
of child-directed attitude among mothers towards their CLP-
affected children. It may be that the encouraging parental style
can be attributed to attempts by the parents to compensate for
emotional problems in their CLP-affected children which may be
related to the malformation. This suggestion needs to be supported
through further study.
The CLP-affected children tended to solve the puzzle indepen-
dently and single handedly, relied less on instruction from their
parents, and interrupted their mothers more frequently. There
could be a number of explanations for the autonomous behaviour
of the children. Firstly, the less restrictive behaviour of the parents
towards their CLP-affected children may facilitate the more
autonomous behaviour of the children. Accordingly, the parents of
children with a CLP were more tolerant towards oppositional
behaviour in their children as found previously (Tobiasen and
Hiebert, 1984). Having a child with a CLP may lead to feeling a
relative loss of control by the parents. The birth of a child with a
facial disfigurement is a profound experience for the affected par-
ents. The investigation of parental reactions following the birth of a
CLP-affected child provides evidence of negative parental emotions
towards the child, e.g., frustration, disappointment, rejection, and
feelings of guilt, sorrow, and pain (Dolger-Hafner et al., 1997).
Feelings of guilt, shame, denial, and mental defence amongst others
are of particular importance. These feelings may aggravate the need
for overprotection and excessive care on the one hand and cause
estrangement and alienation on the other. Both attitudes may lead
to the restraint of parents in interactions with their children
because of either an intention to encourage and protect the au-
tonomy of the children or indifference towards their children
resulting in a lack of control during the interaction. The second
explanation is less likely since mothers encourage their children
excessively and fathers exert sufficient control in the interactions.
Secondly, the explanation for the observed pattern of parentechild
interactions may be found in the behaviour of the children. Here,
children aged between 7 and 9 years old were studied. At that age,
the abilities to cope with stress and the malformation have already
been developed. These abilities and behavioural strategies may be
dysfunctional and even compromise the adjustment. As shown
previously, CLP-affected children are more likely to have psycho-
social deficits: they initiate fewer contacts with their peers, receive
positive responses less frequently, demonstrate less reciprocity in
social interactions, are less able to build friendships, and frequently
report difficulties with respect to social abilities (Brand et al., 2009;
Kapp-Simon and McGuire, 1997; Krueckeberg et al., 1993; Slifer
et al., 2004). Because of their malformation and the possible shame
associated with it, CLP-affected children may have learned to rely
more on themselves and to look less for social support in the sur-
rounding environment. This lack of reciprocity in social situations
may result in the expressed autonomous behaviour. Because of the
type of correlation analysis applied in our study, it is difficult to
determine a causal explanation for the interaction pattern. In-
teractions are always reciprocal. This can be observed in our study
as well: the mothers of CLP-affected children used less direct in-
structions than the fathers used and were interrupted more
frequently by their children than the fathers were, whereas the
more autonomous behaviour of the children with more frequent
interruptions causes the behaviour of the mothers to be more
957
restrained or vice versa. Future studies should focus on the causal
relationships in the complex pattern of human communication.
Note that parentechild interactions with infants and toddlers
with CLP either did not differ from those in healthy families
(Endriga and Speltz, 1997; Maris et al., 2000; Speltz et al., 1993) or
were associated with less nurturing behaviour by mothers than in
healthy families (Barden et al., 1989; Hentges et al., 2011; Murray
et al., 2008). Moreover, at the age of 3 years, children with
congenital anomalies (most of which were CLP children) were more
resistant and compliant than their healthy peers in interactions
with their parents (Allen et al., 1990). However, those children were
only 3 years old and suffered different kinds of congenital anom-
alies, e.g., craniofacial and other kinds of malformations. These
findings are in contrast with the results of this study, which was
performed in families with children aged 7e9 years old. It seems
likely that the observed pattern of parentechild interactions in our
study may result from the long history of adjustment. Thus, in-
teractions with infants and toddlers and those with school children
may differ and may be associated with a greater degree of
estrangement among parents at an early age and greater over-
protection later in childhood.
How specific is the described pattern of parentechild in-
teractions in families with a CLP-affected child? We suggest that
this interaction pattern may be observed generally in families
with children suffering from a chronic disease. Thus, having a
child with a chronic illness, e.g., spina bifida or congenital heart
disease may be associated with substantial parental stress and
affect the parenting style (Kazak and Wilcox, 1984; Pelchat et al.,
1999). However, the described pattern of parentechild interaction
seems to be fairly specific for families with a CLP-affected child.
Studies of school-aged children and adolescents with physical or
cosmetic abnormalities have shown that children behave
passively, dependently, and are less extroverted in interactions
with their parents (see Wasserman et al. (1985) for a review). In
order to investigate the specific types of behaviours, interactions
in families with a CLP-affected child were compared to in-
teractions in families with a child suffering from migraines. In
migraine-affected families, parents showed a high degree of
dominance and control towards an affected child. Moreover,
children with migraines demonstrated more submissive and
passive behaviour characterized by a higher degree of assistance
and feedback: i.e., assurance that the child’s own decision is
correct (Siniatchkin et al., 2003, 2010). In such a way, the pattern
of parentechild interactions in migraine-affected families re-
sembles those in families with a child suffering from a chronic
illness or physical disability (Wasserman et al., 1985). However, in
families with a CLP-affected child, the opposite was the case:
those children were more active and autonomous and parents
were less directive and dominant during the interaction. It seems
likely that different chronic illnesses and disabilities may result in
different patterns of parentechild interactions which should be
specified for each particular condition.
5. Conclusions
Autonomous behaviour among children with CLP which is
supported by their parents may represent psychosocial compen-
satory mechanisms in the family environment.
Role of the funding source
The present study was financed internally by the author’s
institution.
Conflict of interest statement
The authors have declared no conflicts of interest.
958 V. Gassling et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 953e958
Acknowledgements
We thank all participating patients and their families. Further-
more, we offer special thanks to the persons in the control group for
their cooperation.
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