OBSERVATIONS AND COMMENTARY The State of What Art? EDWARD CLIFFORD, Ph. D. Psychological studies need to meet contemporary standards of research design and theoretical relevance within the mainstream of its behavioral science. The use of a clinical-scientist model for psycholo- gists with greater emphasis on clinician than on scientist results in an impoverishment of psychological research and a paucity of stimulat- ing theoretical speculation. Sporadic and pedestrian studies cannot ex- plain why a necessary and sufficient relationship should exist between the presence of a cleft and the dependent measures used. As a result, psychological studies about cleft palate have managed to achieve a state of invisibility as far as most psychologists are concerned. As long as the present status remains at the current level, real progress is impos- sible, and we will be content with mediocrity. In this highly personal essay, I want to exa- chological time devoted to patients with cleft mine what has been accomplished by psycholo- palate. gists and what the future may hold for advancing Support must come from already strained cleft psychological knowledge about cleft lip and pa- palate center budgets or from external funding late. As a behavioral scientist, I believe I must in the form of grants. This, I believe, leads psy- be accountable to two general audiences. First chologists in most centers to exist in an at- of all, my psychological endeavors must have mosphere I characterize as casual neglect or meaning and value to my colleagues in other dis- benign indifference. Centers may believe in the ciplines concerned with cleft palate. Secondly, desirability of having psychological participation; and no less important, my work should be wi- they may even be interested in providing access thin the mainstream of my behavioral science, to their patients for psychological research, as- using contemporary standards of research design suming that psychologists should have a natural and theoretical relevance. Neither of these can and inherent interest in investigating cleft lip and be accomplished in a vacuum; appropriate sup- palate. However, centers may be unable or un- port and encouragement are needed. willing to provide the long-term financial sup- Psychologists working in cleft palate centers port necessary to mount research endeavors that accept for themselves, and are expected to ac- produce more than the sporadic and pedestrian cept, the clinician-scientist model. This model studies so often found in the literature. serves well for the primary disciplines of most I believe that almost exclusive reliance on the centers-audiology, orthodontics, plastic sur- clinical model, with greater emphasis on clini- gery, speech pathology-because the direct clin- cian than on scientist, actually results in an im- ical services provided to patients with clefts form poverishment of psychological research and a | a relatively secure base of operations. Regular, paucity of stimulating theoretical speculation. ongoing psychological services rarely are pro- Static application of the clinical psychologist vided (or needed?), nor are they viewed as cen- model resulted in a proliferation of reports about tral to the mission of the cleft palate team. This intelligence, personality, and psychopathology. deprives the psychologist of a secure foundation, These, by the way, have been examined by clin- and he or she must seek support elsewhere, fre- ical psychologists for almost every known clini- quently resulting in less, rather than more, psy- cal population. Such approaches frequently represent initial, and at times, conceptually naive attempts to describe a set of patients sharing the Dr. Clifford is Professor and Co-Director of the Facial same anomaly in familiar psychological terms. Rehabilitation Center at Duke University Medical Center, In other words, the psychologist-clinician does Durham, North Carolina. ‘ what he or she is used to doing-administers psy- 174 OBSERVATIONS AND COMMENTARY 175 chological tests routinely used in clinical prac- relevance to other psychologists. Perhaps few tice. Unfortunately, this is what their nonpsycho- studies have been submitted to psychological logical colleagues on the cleft palate team expect journals because the investigator assumed the ef- them to do. While descriptive studies are neces- forts would be judged by a more critical psycho- sary and valuable, the empirical results cannot logical audience. Apparently psychological explain why a necessary and sufficient relation- studies about cleft palate have managed to ship should exist between the presence of a birth achieve a state of invisibility as far as most psy- defect (more specifically cleft lip and palate) and chologists are concerned. performance, based on these tests. In examining the "'state of the art,"" I am The cleft palate literature is replete with studies forced to conclude that the state is rudimentary overtly or covertly assuming that having a cleft and further that psychological research has results in a behavioral deficit; no one posits, for lagged behind developments in psychology. Only example, that having a cleft results in improved recently, for example, have psychologists begun interpersonal relationships or problem solving. to address issues of physical attractiveness that I find it fascinating that the accumulation of evi- have been the concern of social psychologists for dence forces us to reject the equation that cleft the past 15 years. Similarly, we may be con- equals behavioral deficit. Since we have demon- cerned with speech production, yet little or noth- strated, contrary to expectations, that the intel- ing appears in the cleft palate literature about ligence of our patients is within the normal range, interpersonal communication. Intelligence and that no specific personality patterns are exclu- perceptual-motor skills have been examined, yet sively associated with cleft lip and palate, and cognitive processes or the consideration of a that our patients are noted for absence, rather cognitive-development growth model largely are than presence, of psychopathology, where do we ignored. Considerable emphasis has been placed go from here? Nowhere. Nowhere-unless the on the effect on mothers of giving births to a baby role model of the investigator changes. with a cleft, yet studies related to mother-infant Nowhere-until an adequate support base is es- attachment are difficult to find. Some work has tablished for psychological research within cleft appeared on self-concept and body image, again palate centers. Nowhere-as long as the research examined for the negative effects of having a is produced almost exclusively for nonpsycho- cleft; no attention has been given to how a defect, logical audiences. and its sequelea, are incorporated into the self- I find it significant that few studies about cleft system. palate appear in psychological journals and at- The "state of the art'' is rudimentary. Unfor- tract psychological audiences. Because so few tunately, I see nothing on the horizon that would psychologists are active in research in this area, impel progress or facilitate change. As for ex- a lack of familiarity about cleft palate among psy- citement, creativity, vibrancy, and relevance, I chologists in general may be the result. Perhaps can only return to the title of this essay, the state the meager number of studies published has no of what art? 176 Cleft Palate Journal, April 1988, Vol. 25 No. 2 Tonsillectomy and Pharyngeal ing pharyngeal flap surgery (Kravath et al, 1980). Flap Operation Should not be By adding a tonsillectomy to the pharyngeal flap, Performed Simultaneously the potential for upper airway obstruction as a postoperative complication is increased. Two of We would like to express some concern regard- the Reath et al subjects had upper airway obstruc- ing the publication of a recent article (July 1987) tion as a postoperative complication. in Cleft Palate Journal, "Simultaneous Posterior The authors mention that both nasopharyn- Pharyngeal Flap and Tonsillectomy'' by Reath, goscopy and multiview videofluoroscopy were LaRossa, and Randall. We are of the firm opin- not done in the cases they have reported, but that ion that tonsillectomy should not be performed these techniques would have improved diagnostic in the same operation with a pharyngeal flap for efforts. But they go on to state that they have several reasons, each important. found nasopharyngoscopy to be almost imposs- The first objection relates to two recent reports ible to do in "2-, 3-, and 4-year-old children..." alluded to, but not cited by the authors. These This line of reasoning provides other concerns reports were presented at the annual meeting of for us. The first is the concept of doing pharyn- _ the American Cleft Palate Association and else- geal flaps in 2 year olds and most 3 year olds, where and were brought to the attention of Reath especially combined with tonsillectomy. Our et al in a verbal response to their presentation of preference would certainly be to avoid pharyn- this paper in New York. Both Shprintzen et al gel flap surgery until after speech and language (1988) and MacKenzie-Stepner et al (1988) have development was a bit more complete. The se- documented that hypernasal speech can be caused . ~ cond is the notion of performing pharyngeal flap by hypertrophic tonsils and relieved by tonsillec- surgery before adequate diagnoses can be ob- tomy alone. In such cases, hypertrophic tonsils tained by endoscopy and fluoroscopy. Finally, can impair the movements of the lateral pharyn- even though nasopharyngoscopy can be per- geal walls, the velum, or both. The 20 cases formed successfully in the majority of 4-year-old reported by Shprintzen et al (1988) show that this children, MacKenzie-Stepner et al (1988) illus- is not a rare phenomenon and may be underdiag- trated that the effects of tonsillar hypertrophy can nosed. In such cases, pharyngeal flap becomes be detected by multiview videofluoroscopy, which an unnecessary operative procedure. Of interest, can be easily performed even in very young four (20 percent) of the cases reported by Reath children.