An investigation of psychological profiles and risk factors in congenital microtia patients
SummaryObjectivesAmong congenital deformities, microtia is often said to be one of the most difficult for the reconstructive surgeon. However, few reports have investigated patients' and their families' psychological profiles. This study sought to determine the prevalence of mood disorders among patients with microtia and to explore clinical features associated with mood disorders.
MethodsCongenital microtia patients were interviewed about Symptom Checklist-90 (SCL-90) and the Achenbach Child Behavior Checklist (CBCL), gender and age of patients, severity of malformation, first perceived age and approach to deformity, being teased by peers, education level of parents, family harmony or not, emotional impact of un-repaired microtia on parents and attitudes of family to patients.
ResultsThe prevalence of mood disorders among microtia patients: ‘depression’ 20.2%, ‘interpersonal sensitivity/social difficulties’ 36.6% and ‘hostility/aggression’ 26.3%. Multivariate analyses suggested that age of patients, severity of microtia, low levels of maternal education, being teased by peers, family disharmony, psychological impact on parents and overprotection from parents are significantly associated with mood disorders of patients.
ConclusionOur findings suggest that microtia patients exhibit three significant mood disorders including depression, interpersonal sensitivity/social difficulties and hostility/aggression. Some risk factors should be actively prevented and controlled, such as being teased by peers, family disharmony, psychological impact on parents and overprotection from family.
Keywords
Despite the well documented1, 2, 3 and 4 importance of surgery to improve psychological distress and self-esteem in patients with auricular deformities, questions remain regarding prevalence of mood disorders among patients who are not currently undergoing reconstructive procedures. The prevalence of microtia is estimated at 2.35 per 10 000 births. Therefore a lack of evidence regarding the prevalence of mood disorders among microtia patients may be attributed to the difficulty in recruiting significant numbers of subjects.5
The aim of our study was to assess the prevalence of mood disorders associated with microtia and the associated risk factors. We thought that determination of the prevalence of mood disorders among patients with congenital microtia may provide insight into differential risk for emotional impact. Moreover, a better understanding of the features associated with greater mood disorders might improve assessment of emotional risk and assist in the development of intervention and prevention strategies. To the best of our knowledge, this study is the first to investigate patients with microtia in terms of the prevalence of mood disorders and the clinical characteristics associated with mood disorders.
MethodsSubjectsA total of 410 subjects with congenital microtia were included in the study. The subjects were recruited from patients presenting at the Auricle Centre at the Plastic Surgery Hospital of the Chinese Academy of Medical Science, for the evaluation and treatment of microtia. The subjects included all patients presenting between January 2003 and December 2004 except those who declined to take part (n = 17, 4.0%). The mean age was 12.2 years (standard deviation 6.73). Ninety-six females (23.4%) and 314 males (76.6%) were included. All subjects were Chinese, namely Mongoloid. Written informed consent was obtained from all subjects as required by the Institutional Review Board.
Clinical assessment toolsThe profiles of the patients and their families were assembled during a clinical interview. Information gathered from patients and their families included: patients' gender, age, severity of malformation, age at which patients first perceived their deformity and level of maternal and paternal education. They were also questioned as to whether or not they had been teased by peers, whether or not the family regarded themselves as harmonious, what emotional impact the deformity had prior to reconstructive surgery, and what attitudes the wider family had to the patient. The interviews were conducted by surgeons with a master-level degree qualification. The surgeons had been trained in interviewing and administering questionnaires. Answers were recorded and collated after a consensus conference.
The psychological outcomes of the patients were assessed in detail by two different scales according to the age of the patient. The Symptom Checklist-906 (SCL-90) was used to assess mood disorders of the patients who were 13 years old and above. It is a well-established, self-report, clinical rating scale that assesses patient symptomatic psychological disturbance developed by Derogatis.1, 2 and 3 The scale assesses three main psychological problems: ‘depression’, ‘interpersonal sensitivity’ and ‘hostility’.
Mood disorders of the children with microtia under 13 years of age were measured by the Child Behavior Checklist (CBCL).7 CBCL is one of the most widely-used measures in child psychology and records the psychological problems of children, as reported by their parents or other individuals who know the child. The checklist is composed of 113 items that are all scored on a three-step scale, 0 = not true, 1 = somewhat true, and 2 = very true. The three main symptoms which were evaluated were ‘depression’, ‘social withdrawal’ and ‘aggression’.
Statistical analysisStatistical analysis was undertaken using SPSS Version 12.0 for Windows (2003) (SPSS Inc., Chicago, IL, USA). Frequencies for the responses of psychological prevalence according to scales were evaluated. A Chi-square (χ2) statistic was used to evaluate the correlation between three main psychological symptoms and independent variables. Relative risk (odds ratio (OR)) and 95% confidence interval (95% confidence interval (CI)) were calculated. Further analyses were performed using a multivariable logistic regression analysis to determine the correlation between the main psychological symptoms and other variables when there was a significant difference among the independent groups. For ranked data about risk factors, we employed a trend test using the Chi square (χ2) statistic. A value of P ≤ 0.05 was considered statistically significant. All tests were two-tailed.
ResultsDemographics of patients with microtia and their parentsIn our study 96 subjects (23.4%) were female and 314 subjects (76.6%) were male. The age ranged from 5 to 37 years with a mean age of 12.2 years. All subjects were Chinese, namely Mongoloid. A total of 66.3% of the fathers had completed education of high school or above and 60.0% of the mothers had an education level of high school or above.
Clinical features of patients with microtiaA total of 249 patients (60.7%) had right-side microtia, 141 patients (34.4%) had left-side microtia, and 20 patients (4.9%) had bilateral microtia. Referring to Marx's classification,8 the severity of deformity is classed grade 1 to 4. Ninety-six patients (23.4%) had grade 1 microtia; 260 patients (63.5%) had grade 2 microtia; 53 patients (12.9%) had grade 3 microtia and only one patient (0.2%) had grade 4. The majority of patients with microtia (Figure 1) first perceived their deformity when they were 3 or 4 years old. According to parental or patient recall, 176 patients (46.8%) found their deformation by comparing sides in front of the mirror or touching themselves, and 200 patients (53.2%) were told about their ear deformation by others. Two hundred and forty-five patients (61.1%) admitted that they had been teased by peers about the microtia when they were a child.
Emotional impact on the family When the baby with congenital microtia was born, some parents felt shocked and some felt depressed. Others described themselves as being sorry but in control of their emotions. From the parents reporting the experience, we analysed the description of the personal effects and graded the emotional impact as minimal, moderate or severe. The emotional impact was severe in 139 families, moderate in 138 families and minimal in 79. Forty-three families (10.6%) blamed family disharmony on the deformity.
Prevalence of mood disorders among patients with microtiaWe calculated the total scores of related items with CBCL or SCL-90 scales according to patients' ages respectively, and assessed prevalence of three mood disorders among patients with microtia. Prevalence of ‘depression’ in patients with microtia was 20.2% (83 patients); prevalence of ‘interpersonal sensitivity or social withdrawal’ was 36.6% (150 patients) and prevalence of ‘hostility or aggression’ was 26.3% (108 patients).
Based on the statistically significant differences uncovered in univariate analyses, we conducted a logistic regression analysis with depression as the dependent variable. The model (Table 4) showed that age (OR: 1.7; 95%CI: 1.3–2.2), severity of malformation (OR: 2.8; 95% CI: 0.2–0.6), level of maternal education (OR: 2.5; 95% CI: 0.2–0.7), being teased (OR: 2.6; 95% CI: 0.2–0.8), family disharmony (OR: 2.6; 95% CI: 0.2–0.9), severe emotional impact on parents (OR: 1.9; 95% CI: 0.3–0.8) and overprotection of children with microtia (OR: 2.5; 95% CI: 1.3–4.5) all had significant effects on depression. Gender and the perceived approach to the patient did not appear to affect the prevalence of mood disorders. In other words, being older, having a higher grade of microtia, a lower level of maternal education, being teased, coming from an inharmonious, overprotective or severely affected family all increased the risk of depression. The similar analysis with interpersonal sensitivity or social withdrawal as the dependent variable (Table 5) showed that age of patients (OR: 1.6; 95% CI: 1.3–2.0), being teased by peers (OR: 3.3; 95% CI: 0.2–0.5) and the emotional impact on parents (OR: 1.9; 95% CI: 0.4–0.7) had significant effects on this mood disorder. However factors such as gender, severity of microtia and perceived approach to the deformation did not reach statistical significance as risk factors of interpersonal sensitivity or social withdrawal. The analysis with hostility or aggression as the dependent variable (Table 6) suggested that being teased by peers (OR: 2.5; 95% CI: 0.2–0.7) and higher emotional impact on parents (OR: 1.8; 95% CI: 0.4–0.8) were significantly associated with greater hostility or aggression.
DiscussionIn addition to holding up our eyeglasses and funnelling sounds towards our ear drums to improve hearing, ears make us look better and feel much better about ourselves as a whole person. Microtia patients and their families pay more attention to the obvious aesthetic deformity. This consistently rekindles their anxiety. Naturally, patients want the deformity corrected as soon as possible. The findings from previous studies showed that auricular reconstruction has significant psychosocial benefit in the majority of children and adults despite donor-site morbidity and a range of technical results.1, 2 and 3 However, it is not technically feasible before the child reaches school age. Meanwhile, the patients and their families continuously seek guidance and support form the plastic surgeon. Understanding the psychological profile and risk factors in microtia patients will provide professionals with the necessary information to counsel and direct them.
Age effect on mood disordersOur findings showed a tendency for the prevalence of mood disorders to increase with age in patients who have not had reconstructive surgery. This would seem to reflect the increasing burden of psychosocial trials which individuals face as they grow older. The slings and arrows of school, adolescence, work and relationships must all be overcome. Brent1 and 2 has suggested that the first trial manifests in about the first year in school, when children are continually exposed to a large group of their peers for the first time. It is at this time that their self-awareness is heightened as they begin to compare, contrast and form real concepts of body image. This is when name-calling and teasing begins, and the microtia patient learns what it means to be different. From the psychological point of view, the early surgery is ideal. This presumes, however, that the quality of the result is as good in 5–6 year old children. Some argue that the volume of cartilage in such children is very limited before the age of 10 and therefore the aesthetic results which can be achieved before that age are often limited. Many surgeons therefore delay surgery until the age of 10. Moreover, presumably the potential psychological benefits of surgery are only likely to be achieved in response to a good aesthetic reconstruction. A poor result may have an adverse psychological effect. If the ear goes uncorrected or a poor result is achieved by an inexperienced surgeon, the patient tends to feel flawed, ‘less than’ others, and continues to be plagued by low self-esteem that may last a lifetime.
Correlation between severity of malformation and psychological morbidityInterestingly, contrary to prior research, in the univariate analysis, the degree of disfigurement was significant associated with depression in our analysis. Multivariable logistic regression analysis also identified it as a risk factor for depression. While some prior research has suggested the degree of facial disfigurement is not directly correlated with the number of psychological disorders.9 and 10 We presumed that contradictory results may be attributed to patients' perception to mild ear deformity. Many children with a mild deformity may think they were born with one big ear and one little one, and that when they are older, the little one can be made larger to match the other. This is related to the reduction in psychological morbidity of the patients with mild microtia.
Initial perception of deformityOur results suggested that the child will discover that he/she is different at around the age of three to four (Figure 1), which is consistent with Brent's findings.1 and 2 The manner in which patients came to perceive their microtia was rated as passive or active. Usually, the parents found their child actively comparing sides in front of a mirror. Others were passively told of their ear deformation. Our study suggests that the earlier the patient is aware of his/her ear deformation, the lower prevalence of psychological disorders. Interestingly, the manner of discovery and assimilation of the microtic ear(s), be it active or passive, did not appear to impact significantly on future psychological wellbeing. Therefore, we would encourage parents to be honest with their child, to give him or her reasonable explanation early. They should reassure the child that the ear can be repaired and made to look more normal in the future. Persistent hiding or avoidance of the truth, results in a more severe emotional impact on both parents and children.
Teasing and mood disordersOur results demonstrate a correlation between teasing and psychological morbidity. Teasing resulted in significantly higher levels of all three mood disorders uncovered in both univariate and multivariate analyses. Two hundred and forty-five patients (61.1%) admitted that they had been teased about their microtia by peers as a child. Other studies3 have shown that teasing was a prominent problem in both children (88%) and adults (85%) with auricular deformity. Thus, we believe childhood teasing to have a significantly detrimental effect on the patients' wellbeing.
The family situationBoth univariate analysis and multivariable logistic regression analysis all identified the following parental parameters to be significant risk factors: low level of maternal education, emotional impact, family disharmony and ill conceived attitudes towards the patient. Because the ear deformity consistently rekindles parents' guilt, the parents are also faced with many emotional tribulations. The emotional impact upon parents was classified as severe in 34.7%, moderate in 45.6% and mild in 19.7% of cases. Brent2 believes that the major determinant of microtia-related disturbance before the age of six or seven is transmission of parental anxiety. When parents make a fuss about the deformity, the child feels upset and self esteem drops. If name-calling and teasing by his peer groups are added to the situation, the afflicted child is likely to be plagued by self perpetuating feelings of low self-esteem. Thus, the family should play a major role in building and bolstering self-image, creating a normal life, and encouraging normal, productive engagement with society. The child with microtia should be treated normally. Time should be given to discussing the situation in an objective manner without making a fuss. This study demonstrates that in 54.7% of cases parents had overprotected and compensated with special care. This may lead to loss of opportunities for learning and social interaction. If the family gives the child chances to try, he will develop enough self confidence.
LimitationsThe groups studied were self selected by virtue of their request for surgery. Any generalisations of these findings to the entire population of congenital microtia patients should be made with caution. Another limitation concerning our sample size is that our microtia group contained a higher proportion of males (n = 314) than females (n = 96). But epidemiological studies 11 report that females and males are equally affected by microtia. The findings reported in our study should be considered preliminary because no control population is studied. We have no idea what the relevant levels of depression, etc. are in the control population. This will be clarified in a future prospective study.
In conclusion, an apparently high prevalence of mood disorders amongst patients with microtia was identified. These included depression, interpersonal sensitivity/social difficulties and hostility/aggression. Moreover, we identified the risk factors to be associated with mood disorders. Being subjected to teasing by peers, or growing up in a disharmonious or overprotective family are all risk factors, which may be amenable to early intervention by healthcare or education professionals. Certainly if a team approach can be adopted with a view to reducing the psychological impact of the deformity upon the parents then the patient may suffer less in the long term.
AcknowledgementThe authors thank Kenneth Stewart, M.D., for his editorial assistance with the manuscript.
References
SummaryObjectivesAmong congenital deformities, microtia is often said to be one of the most difficult for the reconstructive surgeon. However, few reports have investigated patients' and their families' psychological profiles. This study sought to determine the prevalence of mood disorders among patients with microtia and to explore clinical features associated with mood disorders.
MethodsCongenital microtia patients were interviewed about Symptom Checklist-90 (SCL-90) and the Achenbach Child Behavior Checklist (CBCL), gender and age of patients, severity of malformation, first perceived age and approach to deformity, being teased by peers, education level of parents, family harmony or not, emotional impact of un-repaired microtia on parents and attitudes of family to patients.
ResultsThe prevalence of mood disorders among microtia patients: ‘depression’ 20.2%, ‘interpersonal sensitivity/social difficulties’ 36.6% and ‘hostility/aggression’ 26.3%. Multivariate analyses suggested that age of patients, severity of microtia, low levels of maternal education, being teased by peers, family disharmony, psychological impact on parents and overprotection from parents are significantly associated with mood disorders of patients.
ConclusionOur findings suggest that microtia patients exhibit three significant mood disorders including depression, interpersonal sensitivity/social difficulties and hostility/aggression. Some risk factors should be actively prevented and controlled, such as being teased by peers, family disharmony, psychological impact on parents and overprotection from family.
Keywords
- Congenital microtia;
- Risk factor;
- Cross-sectional study;
- Mood disorders
Despite the well documented1, 2, 3 and 4 importance of surgery to improve psychological distress and self-esteem in patients with auricular deformities, questions remain regarding prevalence of mood disorders among patients who are not currently undergoing reconstructive procedures. The prevalence of microtia is estimated at 2.35 per 10 000 births. Therefore a lack of evidence regarding the prevalence of mood disorders among microtia patients may be attributed to the difficulty in recruiting significant numbers of subjects.5
The aim of our study was to assess the prevalence of mood disorders associated with microtia and the associated risk factors. We thought that determination of the prevalence of mood disorders among patients with congenital microtia may provide insight into differential risk for emotional impact. Moreover, a better understanding of the features associated with greater mood disorders might improve assessment of emotional risk and assist in the development of intervention and prevention strategies. To the best of our knowledge, this study is the first to investigate patients with microtia in terms of the prevalence of mood disorders and the clinical characteristics associated with mood disorders.
MethodsSubjectsA total of 410 subjects with congenital microtia were included in the study. The subjects were recruited from patients presenting at the Auricle Centre at the Plastic Surgery Hospital of the Chinese Academy of Medical Science, for the evaluation and treatment of microtia. The subjects included all patients presenting between January 2003 and December 2004 except those who declined to take part (n = 17, 4.0%). The mean age was 12.2 years (standard deviation 6.73). Ninety-six females (23.4%) and 314 males (76.6%) were included. All subjects were Chinese, namely Mongoloid. Written informed consent was obtained from all subjects as required by the Institutional Review Board.
Clinical assessment toolsThe profiles of the patients and their families were assembled during a clinical interview. Information gathered from patients and their families included: patients' gender, age, severity of malformation, age at which patients first perceived their deformity and level of maternal and paternal education. They were also questioned as to whether or not they had been teased by peers, whether or not the family regarded themselves as harmonious, what emotional impact the deformity had prior to reconstructive surgery, and what attitudes the wider family had to the patient. The interviews were conducted by surgeons with a master-level degree qualification. The surgeons had been trained in interviewing and administering questionnaires. Answers were recorded and collated after a consensus conference.
The psychological outcomes of the patients were assessed in detail by two different scales according to the age of the patient. The Symptom Checklist-906 (SCL-90) was used to assess mood disorders of the patients who were 13 years old and above. It is a well-established, self-report, clinical rating scale that assesses patient symptomatic psychological disturbance developed by Derogatis.1, 2 and 3 The scale assesses three main psychological problems: ‘depression’, ‘interpersonal sensitivity’ and ‘hostility’.
Mood disorders of the children with microtia under 13 years of age were measured by the Child Behavior Checklist (CBCL).7 CBCL is one of the most widely-used measures in child psychology and records the psychological problems of children, as reported by their parents or other individuals who know the child. The checklist is composed of 113 items that are all scored on a three-step scale, 0 = not true, 1 = somewhat true, and 2 = very true. The three main symptoms which were evaluated were ‘depression’, ‘social withdrawal’ and ‘aggression’.
Statistical analysisStatistical analysis was undertaken using SPSS Version 12.0 for Windows (2003) (SPSS Inc., Chicago, IL, USA). Frequencies for the responses of psychological prevalence according to scales were evaluated. A Chi-square (χ2) statistic was used to evaluate the correlation between three main psychological symptoms and independent variables. Relative risk (odds ratio (OR)) and 95% confidence interval (95% confidence interval (CI)) were calculated. Further analyses were performed using a multivariable logistic regression analysis to determine the correlation between the main psychological symptoms and other variables when there was a significant difference among the independent groups. For ranked data about risk factors, we employed a trend test using the Chi square (χ2) statistic. A value of P ≤ 0.05 was considered statistically significant. All tests were two-tailed.
ResultsDemographics of patients with microtia and their parentsIn our study 96 subjects (23.4%) were female and 314 subjects (76.6%) were male. The age ranged from 5 to 37 years with a mean age of 12.2 years. All subjects were Chinese, namely Mongoloid. A total of 66.3% of the fathers had completed education of high school or above and 60.0% of the mothers had an education level of high school or above.
Clinical features of patients with microtiaA total of 249 patients (60.7%) had right-side microtia, 141 patients (34.4%) had left-side microtia, and 20 patients (4.9%) had bilateral microtia. Referring to Marx's classification,8 the severity of deformity is classed grade 1 to 4. Ninety-six patients (23.4%) had grade 1 microtia; 260 patients (63.5%) had grade 2 microtia; 53 patients (12.9%) had grade 3 microtia and only one patient (0.2%) had grade 4. The majority of patients with microtia (Figure 1) first perceived their deformity when they were 3 or 4 years old. According to parental or patient recall, 176 patients (46.8%) found their deformation by comparing sides in front of the mirror or touching themselves, and 200 patients (53.2%) were told about their ear deformation by others. Two hundred and forty-five patients (61.1%) admitted that they had been teased by peers about the microtia when they were a child.
Emotional impact on the family When the baby with congenital microtia was born, some parents felt shocked and some felt depressed. Others described themselves as being sorry but in control of their emotions. From the parents reporting the experience, we analysed the description of the personal effects and graded the emotional impact as minimal, moderate or severe. The emotional impact was severe in 139 families, moderate in 138 families and minimal in 79. Forty-three families (10.6%) blamed family disharmony on the deformity.
Prevalence of mood disorders among patients with microtiaWe calculated the total scores of related items with CBCL or SCL-90 scales according to patients' ages respectively, and assessed prevalence of three mood disorders among patients with microtia. Prevalence of ‘depression’ in patients with microtia was 20.2% (83 patients); prevalence of ‘interpersonal sensitivity or social withdrawal’ was 36.6% (150 patients) and prevalence of ‘hostility or aggression’ was 26.3% (108 patients).
Based on the statistically significant differences uncovered in univariate analyses, we conducted a logistic regression analysis with depression as the dependent variable. The model (Table 4) showed that age (OR: 1.7; 95%CI: 1.3–2.2), severity of malformation (OR: 2.8; 95% CI: 0.2–0.6), level of maternal education (OR: 2.5; 95% CI: 0.2–0.7), being teased (OR: 2.6; 95% CI: 0.2–0.8), family disharmony (OR: 2.6; 95% CI: 0.2–0.9), severe emotional impact on parents (OR: 1.9; 95% CI: 0.3–0.8) and overprotection of children with microtia (OR: 2.5; 95% CI: 1.3–4.5) all had significant effects on depression. Gender and the perceived approach to the patient did not appear to affect the prevalence of mood disorders. In other words, being older, having a higher grade of microtia, a lower level of maternal education, being teased, coming from an inharmonious, overprotective or severely affected family all increased the risk of depression. The similar analysis with interpersonal sensitivity or social withdrawal as the dependent variable (Table 5) showed that age of patients (OR: 1.6; 95% CI: 1.3–2.0), being teased by peers (OR: 3.3; 95% CI: 0.2–0.5) and the emotional impact on parents (OR: 1.9; 95% CI: 0.4–0.7) had significant effects on this mood disorder. However factors such as gender, severity of microtia and perceived approach to the deformation did not reach statistical significance as risk factors of interpersonal sensitivity or social withdrawal. The analysis with hostility or aggression as the dependent variable (Table 6) suggested that being teased by peers (OR: 2.5; 95% CI: 0.2–0.7) and higher emotional impact on parents (OR: 1.8; 95% CI: 0.4–0.8) were significantly associated with greater hostility or aggression.
DiscussionIn addition to holding up our eyeglasses and funnelling sounds towards our ear drums to improve hearing, ears make us look better and feel much better about ourselves as a whole person. Microtia patients and their families pay more attention to the obvious aesthetic deformity. This consistently rekindles their anxiety. Naturally, patients want the deformity corrected as soon as possible. The findings from previous studies showed that auricular reconstruction has significant psychosocial benefit in the majority of children and adults despite donor-site morbidity and a range of technical results.1, 2 and 3 However, it is not technically feasible before the child reaches school age. Meanwhile, the patients and their families continuously seek guidance and support form the plastic surgeon. Understanding the psychological profile and risk factors in microtia patients will provide professionals with the necessary information to counsel and direct them.
Age effect on mood disordersOur findings showed a tendency for the prevalence of mood disorders to increase with age in patients who have not had reconstructive surgery. This would seem to reflect the increasing burden of psychosocial trials which individuals face as they grow older. The slings and arrows of school, adolescence, work and relationships must all be overcome. Brent1 and 2 has suggested that the first trial manifests in about the first year in school, when children are continually exposed to a large group of their peers for the first time. It is at this time that their self-awareness is heightened as they begin to compare, contrast and form real concepts of body image. This is when name-calling and teasing begins, and the microtia patient learns what it means to be different. From the psychological point of view, the early surgery is ideal. This presumes, however, that the quality of the result is as good in 5–6 year old children. Some argue that the volume of cartilage in such children is very limited before the age of 10 and therefore the aesthetic results which can be achieved before that age are often limited. Many surgeons therefore delay surgery until the age of 10. Moreover, presumably the potential psychological benefits of surgery are only likely to be achieved in response to a good aesthetic reconstruction. A poor result may have an adverse psychological effect. If the ear goes uncorrected or a poor result is achieved by an inexperienced surgeon, the patient tends to feel flawed, ‘less than’ others, and continues to be plagued by low self-esteem that may last a lifetime.
Correlation between severity of malformation and psychological morbidityInterestingly, contrary to prior research, in the univariate analysis, the degree of disfigurement was significant associated with depression in our analysis. Multivariable logistic regression analysis also identified it as a risk factor for depression. While some prior research has suggested the degree of facial disfigurement is not directly correlated with the number of psychological disorders.9 and 10 We presumed that contradictory results may be attributed to patients' perception to mild ear deformity. Many children with a mild deformity may think they were born with one big ear and one little one, and that when they are older, the little one can be made larger to match the other. This is related to the reduction in psychological morbidity of the patients with mild microtia.
Initial perception of deformityOur results suggested that the child will discover that he/she is different at around the age of three to four (Figure 1), which is consistent with Brent's findings.1 and 2 The manner in which patients came to perceive their microtia was rated as passive or active. Usually, the parents found their child actively comparing sides in front of a mirror. Others were passively told of their ear deformation. Our study suggests that the earlier the patient is aware of his/her ear deformation, the lower prevalence of psychological disorders. Interestingly, the manner of discovery and assimilation of the microtic ear(s), be it active or passive, did not appear to impact significantly on future psychological wellbeing. Therefore, we would encourage parents to be honest with their child, to give him or her reasonable explanation early. They should reassure the child that the ear can be repaired and made to look more normal in the future. Persistent hiding or avoidance of the truth, results in a more severe emotional impact on both parents and children.
Teasing and mood disordersOur results demonstrate a correlation between teasing and psychological morbidity. Teasing resulted in significantly higher levels of all three mood disorders uncovered in both univariate and multivariate analyses. Two hundred and forty-five patients (61.1%) admitted that they had been teased about their microtia by peers as a child. Other studies3 have shown that teasing was a prominent problem in both children (88%) and adults (85%) with auricular deformity. Thus, we believe childhood teasing to have a significantly detrimental effect on the patients' wellbeing.
The family situationBoth univariate analysis and multivariable logistic regression analysis all identified the following parental parameters to be significant risk factors: low level of maternal education, emotional impact, family disharmony and ill conceived attitudes towards the patient. Because the ear deformity consistently rekindles parents' guilt, the parents are also faced with many emotional tribulations. The emotional impact upon parents was classified as severe in 34.7%, moderate in 45.6% and mild in 19.7% of cases. Brent2 believes that the major determinant of microtia-related disturbance before the age of six or seven is transmission of parental anxiety. When parents make a fuss about the deformity, the child feels upset and self esteem drops. If name-calling and teasing by his peer groups are added to the situation, the afflicted child is likely to be plagued by self perpetuating feelings of low self-esteem. Thus, the family should play a major role in building and bolstering self-image, creating a normal life, and encouraging normal, productive engagement with society. The child with microtia should be treated normally. Time should be given to discussing the situation in an objective manner without making a fuss. This study demonstrates that in 54.7% of cases parents had overprotected and compensated with special care. This may lead to loss of opportunities for learning and social interaction. If the family gives the child chances to try, he will develop enough self confidence.
LimitationsThe groups studied were self selected by virtue of their request for surgery. Any generalisations of these findings to the entire population of congenital microtia patients should be made with caution. Another limitation concerning our sample size is that our microtia group contained a higher proportion of males (n = 314) than females (n = 96). But epidemiological studies 11 report that females and males are equally affected by microtia. The findings reported in our study should be considered preliminary because no control population is studied. We have no idea what the relevant levels of depression, etc. are in the control population. This will be clarified in a future prospective study.
In conclusion, an apparently high prevalence of mood disorders amongst patients with microtia was identified. These included depression, interpersonal sensitivity/social difficulties and hostility/aggression. Moreover, we identified the risk factors to be associated with mood disorders. Being subjected to teasing by peers, or growing up in a disharmonious or overprotective family are all risk factors, which may be amenable to early intervention by healthcare or education professionals. Certainly if a team approach can be adopted with a view to reducing the psychological impact of the deformity upon the parents then the patient may suffer less in the long term.
AcknowledgementThe authors thank Kenneth Stewart, M.D., for his editorial assistance with the manuscript.
References
- 1
- B. Brent
- Auricular repair with autogenous rib cartilage grafts: two decades of experience with 600 cases
- Plast Reconstr Surg, 90 (1992), pp. 355–374
- [SD-008]
- 2
- B. Brent
- The pediatrician's role in caring for patients with congenital microtia and atresia
- Pediatr Ann, 28 (1999), pp. 374–383
- [SD-008]
- 3
- N. Horlock, E. Vogelin, E.T. Bradbury et al.
- Psychosocial outcome of patients after ear reconstruction: a retrospective study of 62 patients
- Ann Plast Surg, 54 (2005), pp. 517–524
- [SD-008]
- 4
- E.T. Bradbury, J. Hewison, M.J. Timmons
- Psychological and social outcome of prominent ear correction in children
- Br J Plast Surg, 45 (1992), pp. 97–100
- [SD-008]
- 5
- ICBDMS
- Congenital malformations worldwide. A report from the International Clearinghouse for Birth Defects Monitoring Systems
- Elsevier, Amsterdam (1991)
- [SD-008]
- 6
- L.R. Derogatis, R.S. Lopman, L. Covi
- SCL-90: an outpatient psychiatric rating scale preliminary report
- Psychopharmacology, 9 (1973), pp. 13–28
- [SD-008]
- 7
- Xu Taoyuan
- Achenbach child behavior checklist
- Chin Ment Health J, 7 (Suppl.) (1993), pp. 54–61
- [SD-008]
- 8
- H. Marx
- Die missbildungen des ohres
- F. Henke, O. Lubarsch (Eds.), Handbuch der spez path aanat hist, Springer, Berlin, Germany (1926), pp. 620–625
- [SD-008]
- 9
- D.B. Sarwer, T.A. Wadden, M.J. Pertschuk et al.
- The psychology of cosmetic surgery: a review and reconceptualization
- Clin Psychol Rev, 18 (1998), pp. 1–22
- [SD-008]
- 10
- R. Lansdown, J. Lloyd, J. Hunter
- Facial deformity in childhood: severity and psychological adjustment
- Child Care Health Dev, 17 (1991), pp. 165–171
- [SD-008]
- 11
- J. Zhu, Y. Wang, J. Liang et al.
- An epidemiological investigation of anotia and microtia in China during 1988–1992
- Zhonghua Er Bi Yan Hou Ke Za Zhi, 35 (2000), pp. 62–65
- [SD-008]