The psychologist provides evaluation of, and treatment for, emotional, learning, developmental, and adjustment disorders. This generally occurs within the context of the patient's family. Particular attention is focused on the manifestations of appearance and speech on the patient's self esteem and coping strategies for the patient and family in dealing with issues related to multiple operations. The clinical social worker may also focus on many of these concerns as well as using their expertise to obtain services when needed for patients.

View a PowerPoint presentation about family dynamics and social issues.

View a PowerPoint presentation about interventions and well-being initiatives.

1. Prenatal
   Assist with prenatal counseling regarding future expectations of development and coping with the unexpected intrauterine diagnosis of a child with a cleft or craniofacial anomaly.
2. Neonatal
   1. May assess high risk infants for risk of developmental disorders.
   2. May also assist parents with stresses related to children with facial deformity or other developmental problems.
   3. Family support groups such as groups of parents of children with clefts or craniofacial anomalies can be very important to some parents in helping them cope with the birth of a child with a cleft or craniofacial anomaly. This can continue throughout childhood and adolescence.
   4. In children with high risk for developmental problems, early referral to an infant program may be beneficial.
3. Infant
   1. Infant assessment includes developmental assessment of motor and language development, and social responsiveness.
   2. Continue to assess the family.
4. Toddler
   1. Toddler assessment of self help skills, social development, and motor/language development.
   2. Continue to assess the family.
5. Preschool Development
   1. Evaluate language and intellectual development.
      1. Expressive vs. Association language disorders are frequent and need to be carefully monitored.
      2. Early verbal IQ deficits are common and may affect overall IQ scores.
   2. Early Social Interactions.
      1. Parent-child interactions.
      2. Overprotectiveness may be present in parents of children with facial deformities and this should be monitored and counseling provided when needed.
   3. Developmental Assessment.
      1. Need for early assessment due to high frequency of early delay.
      2. Validity problems of early assessment make it necessary to avoid rigid establishment of intellectual ability.
   4. During the preschool years delays in development frequently first manifest themselves. The psychologist and speech language pathologist are the team members most likely to diagnose and recommend specific interventions to maximize the patient's potential development when delay is present.
6. School-Aged Child
   1. Learning disorders in children with clefts and craniofacial anomalies.
      1. Reading disorders
         1. Need for early screening intervention and remediation
         2. Reading problems related to speech problems are common
         3. Reading comprehension problems related to language problems may occur, thus reading evaluation should include assessment of both word recognition and reading comprehension
      2. Memory disorders
         1. Late development of auditory memory
         2. Learning problems related to short term memory are frequent, therefore screening of short term memory or word finding problems is important (dysnomia)
      3. Language disorders (common types)
         1. Dysnomia (word finding problem)
         2. Expressive Dysphasia (verbal expression of ideas problem)
         3. Associative Dysphasia (understanding of language problem)
         4. Behavioral Problems
      4. Acting out behaviors
         1. Related to early parent overprotection
         2. Related to language disorders
      5. Behavioral inhibition
         1. Anxious withdrawal
         2. Passivity (non-anxious) to avoid teasing
   2. Teacher Expectations
      1. Teacher perceptions of ability is often underestimated.
      2. Self fulfilling academic expectations of teachers translates to underachievement.
   3. It is during this time that children and their peers become aware of how they look. Deformities can lead to problems with teasing and self esteem in patients with clefts and craniofacial anomalies. The psychologist can help with coping strategies for patients and their families and can give the surgeon advice about the timing of operations for appearance during this critical time. The clinical social worker can aid in appropriate placement within the educational system.
7. Adolescents
   1. Self-esteem
      1. Realistic vs. unrealistic self perception of appearance and/or speech.
      2. Social skills training may help to overcome hypersensitivity.
   2. Behavioral Inhibition and Social Introversion
      1. Depression/anxiety treatments may be indicated.
      2. Social introversion as a way of life may result in lowered self expectation.
   3. Dating and Self-Concerns
      1. Cognitive behavior modifications may help through the use of self talk to provide strategies for coping with anxiety-provoking social situations.
      2. Group counseling can be especially helpful with groups of peers with similar conditions.
   4. During adolescence there is a heightened self-awareness of body image and greater existential worry about "who am I?", "what is my identity". Most adolescents experience these issues; however, the adolescent with facial differences or speech problems may experience a greater sense of "being different", leading to greater emotional turmoil.

      Also, adolescence is a period when there is often a decrease in open communication with parents and other adults. Therefore, it is important for the team psychologist, and/or social worker, to communicate and screen adolescents for possible emotional/social concerns. Monitoring of school achievements, peer activities, and social interactions may reveal when problems are occurring.

8. Adulthood
   1. Social Adaptation
      1. Marriage aspirations
      2. Activities
   2. Educational/Vocational Aspirations
      1. Achievement motive
      2. Work aspirations

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