Letter to the Editor

Perrson M, Beck M, Svensson H. Academic achievement in individuals with cleft: a population-based register study. Cleft Palate Craniofac J. 2012;49:153–159.

Persson, Becker, and Svensson recently published a study of academic performance by children with clefts based on the use of the Swedish national birth registries and school grade registries. They presented data showing that children with clefts had higher rates of failure to complete compulsory education and lower grades in selected subjects than children without clefts. In their discussion, the authors speculate that chidren with clefts may have “lower cognitive ability” that could be related to impaired academic achievement (Persson et al., 2012).

Studies such as this one can be considered “push-button research,” and this kind of publication is increasingly common. Push-button research is performed by investigators who pose questions to collective or institutional databases. Such studies have the advantedges of investigator conveinience and large, preanalyzed populations. These studies may, however, be compromised by cateorical flaws and omissions in the databases themselves, as well as compounded errors introduced by the investigators' queries. Database problems have recently been discussed by Koch et al. (2012), who found significant differences in complication detection between administrative and clinical databases. Examples of investigator abberations have been described by Haider et al. (2012). In their study, the authors found that clinical reports based on the National Trauma Database (United States) frequently used incomplete covariate analyses, rarely used clustering to evaluate facility variations, and often included the medical nonsensical category of race (Oberlin and Lineaweaver, 2012).

The study by Persson et al. appears to contain database limitations, some of which are mentioned by the authors and can be summarized as follows:

In addition, the authors may have placed undue functional significance on some of their findings. For example, they claim “strong evidence” for a lower grade point average (GPA) in their cleft population. Examination of the data shows that the cleft children had a GPA of approximately 5% lower than the noncleft children. How meaningful can that difference be when all the groups actually fall into “grade 3,” defined as “pass”?

With these problems, did the authors act responsibily in publishing their data at this stage and proposing “lower cognitive ability” as a possible explanation for their findings in cleft children? Their analysis seems seriously incomplete, while their conclusion could contribute to a simplistic association between clefts and intellectual impairment.

In his novel The Book of Illusions, Paul Auster (2002) creates a character with a deformity, a facial hemangioma. The character describes the concept of the deformity to another character, who becomes her lover.

Other people carried their humanity inside of them, but I carried mine on my face…. I wasn't allowed to hide who I was. That was the difference between me and everyone. I wasn't allowed to hide who I was. Every time people looked at me, they were looking right into my soul. I wasn't a bad looking girl—I knew that—but I also knew I would always be defined by the purple blotch on my face…. I was never going to have an ordinary kind of happiness, but… I realized I had something almost as good. I knew what people were thinking. All I had to do was look at them, study their reactions. When they saw the left side of my face, I could tell whether they could be trusted or not. The birthmark was the test of their humanity. (Auster, 2003, p. 121–122)

This passage remarkably illustrates the complex, reflective interface that an individual with a facial deformity has with his or her social interactions. The study by Persson et al. introduces an ambiguous element into the interface. Should caregivers and educators consider that “lower cognitive ability” is a characteristic of children with clefts? Should children with clefts recognize this preconception in their interactions with caregivers and educators? If Persson and coworkers can bring their studies into useful analysis of correctable factors, they should promply proceed. If they have introduced a simplistic association between clefts and “lower cognitive ability,” one that could be clumsily misused by caregivers, educators, and gatekeepers, then they should reflect in their future works about the possible consequences of premature, pejorative conclusions.

Peter Randall, MD, has offered the following portrait of children with clefts:

With the added trials of surgery in infancy, numerous trips to the hospital, facial incisions, and difficulty hearing, the troubles are seen to go on and on. School age can be particularly difficult with teasing, taunting, and lack of acceptance. Yet after all of this we usually find an individual who has learned the valuable ability to rise above the problem. These children have learned that they can face adversity and come through in spite of it. They have learned how to “take it,” to be goal oriented, to “stick with it,” and usually to emerge with a smile on their face … with encouragement from their parents and teachers, and from us, these children should do well. (Randall, 2009, p. XIX–XX)

Although lacking data, Randall may have given a more thorough description of the academic context of children with clefts than the study by Persson et al.

We disclose a possible conflict of interest that could have influenced our reaction to this article. M.F. has a bilateral cleft lip and palate, and W.C.L. has a unilateral cleft lip and palate.