Psychological adjustment of Children with Microtia
Before and After Ear Reconstruction Surgery
Alexis Johns, PhD
Daniel Im, BS
Sheryl Lewin, MD
Microtia is a congenital external ear malformation which can be treated by means of reconstructive surgery. Currently, autologous costal cartilage is the most commonly used and preferred material for ear reconstruction (Beahm, 2002). The primary factors considered in determining the most appropriate timing for an auricular reconstruction via the cartilage method are the age of external ear maturity and the availability of adequate donor-site rib cartilage (Tanzer, 1971). This requires a child to wait till he or she is of at least 6 to 10 years of age before receiving the surgery (Tollefson, 2006). A newer technique combines the concepts of prosthesis with implantation; a high density polyethylene implant (e.g. Medpor) provides the auricular size, shape, and contours. This Medpor technique permits earlier surgery—as early as age 3 (Eavey, 2006). It has been hypothesized that the preschool-age child may benefit from earlier treatment based on the premise that this minimizes the social stigma of a congenital deformity such as microtia (Tollefson, 2006).
The study will take place with two groups of participants. The first group will be a prospective investigation of participants born with isolated microtia who are receiving the Medpor technique ear reconstructive surgery for the first time and their parents. The second group will be retrospective with participants also born with isolated microtia who have already completed Medpor ear reconstruction. The participants will between 3 to 21 years of age and speak and understand English or Spanish. The first group of participants will complete questionnaires prior to surgery as well as a year following their ear reconstruction. For the children, an age-specific questionnaire will be administered with questions about their surgery, friends, social skills, confidence, appearance, teasing, school, and family. Parents will complete a parallel questionnaire, along with questions about history of microtia diagnosis. The second group of participants and their parents will complete similar questionnaires, with questions about their functioning before and after their surgery. In addition, all children and their parents will complete the Pediatric Quality of Life Inventory (PedsQL) and the Behavior Assessment System for Children (BASC-II).
The measures completed by both groups of participants will provide important descriptive data about their current psychosocial adjustment and the developmental course of their self-image, peer relations, and social skills. It is expected that older children will have experienced significantly more teasing than younger children and consequently the older children will report lower positive adjustment and higher negative adjustment. For the prospective group, the study will also provide a better understanding of surgery expectations, how the surgery process is experienced, and their satisfaction with the outcome. In the year follow-up, it is expected that all children will report improvements and that earlier ear reconstruction will predict better psychosocial adjustment.
Although no substantial research exists studying the psychosocial benefits of earlier microtia reconstruction, it has been conceived that the preschool age child (around age 3) may benefit from minimizing the social stigma of a congenital deformity such as microtia by utilizing either a prosthetic ear or reconstruction with alloplast (e.g. Medpor). With the Brent (age 6) or Nagata (age 10) methods, the child must wait before sufficient costal cartilage can be harvested, and the child will have already faced the psychosocial consequences of peer derision (Tollefson, 2006). A patient who reaches approximately 10 years of age before having reconstruction may already have permanent psychological sequelae as a result of harassment from peers (DellaCroce, 2001).
Children with craniofacial anomalies, such as microtia, experience significant teasing, rejection, and other negative social responses, such as social avoidance from others. These occurrences show trends toward social withdrawal, likely as a reaction to the negative reactions of others (Snyder, 2005). Children with craniofacial anomalies are treated differently than children without such defects; the affected children consequently have been shown to be more introverted and to express a more negative self-concept than unaffected children (Weinstein, 2005). These negative events may also result in decreased self-esteem, increased anxiety, behavioral problems, and difficulty with social integration. The patients who request ear reconstruction often complain of diminished self-consciousness and being teased by peers. Children born with microtia tend towards social isolation, they play less with other children, meet less people, and hide more commonly from certain people, and avoid school. The longer the individual has to cope with microtia, the greater the psychosocial morbidity is likely to become. With increasing age, the teasing and the unpopularity becomes increasingly fixed in the children’s mentality and less amenable to external positive influences (Horlock, 2005).
There has not been a substantial amount of research completed regarding the psychological effects of teasing on children born with microtia; however, a great deal of work has been done related to children born with other craniofacial anomalies such as cleft lip and palate (CLP) and hemangiomas. Teachers rate children with CLP as having more internalizing behaviors and being more inhibited in the classroom. A study found that having CLP was not the main cause of psychosocial morbidity, but rather the experiences that often accompany the presence of CLP, most significantly, teasing (Hunt et al., 2007). The experience of being teased is associated with depressive symptoms, general anxiety, fear of negative evaluation, and loneliness. It is believed that age is significantly related to behavioral problems and happiness with facial appearance; older subjects had more behavioral problems and were less happy with their appearance than younger subjects were (Hunt et al., 2006). With hemangiomas, studies have found that children with craniofacial hemangiomas had a consistently negative perception of how they were valued by others and that these children often identified with pictures of children playing alone and less often picked themselves as the child their parents liked. One study reported that a child’s social sensitivity about their hemaniogioma began around 4 years of age, and therefore, before this realization of social awareness, the children are too young to appreciate any difference or have any behavioral change due to the presence of the lesion (Weinstein, 2005).
The existing literature has not adequately investigated at what approximate age a child born with microtia becomes aware of his or her difference and, more importantly, at what age a child born with microtia begins to suffer the negative psychosocial consequences associated with the social stigma of microtia. Therefore, the aim of this study is to identify the approximate age when a child first becomes self-aware of his or her microtia, as well as the age when a child first begins to suffer negative psychosocial effects, most likely due to peer derision and teasing. Also, this study will examine if earlier microtia reconstruction is predictive of longitudinal psychosocial benefits. It is thought that surgery at a younger age (three to six years old) will mitigate or prevent the negative effects of receiving surgery at an older age (seven years or older), when the child has already started school and experienced the social stigma of being born with a physical defect. As earlier positive psychosocial adjustment contributes to healthier development of social skills and self-esteem, undergoing ear construction at a young age is hypothesized to minimize the negative effects of the years of social stigma and teasing associated with later surgery. It is expected that children older than seven years old will have experienced more teasing and social disapproval compared to children younger than seven years old and thus consequently will report lower self-esteem, social skills, self-confidence, and satisfaction with appearance. It is expected that the more positive outcomes with earlier surgical intervention will be seen in the prospective and retrospective groups of participants.