Bridging Faces and Minds: Integrating Psychiatry into a Cleft Lip and Palate Clinic in India
By: Dr. Ajay Aditya A.M., Senior Resident in Psychiatry, Institute of Psychiatry and Human Behaviour, Goa Medical College, India.
INTRODUCTION
“Behind every repaired lip lies a story that stitches together not just tissue, but trauma, resilience, and hope.”
Cleft lip and palate are among the most common congenital anomalies worldwide, affecting approximately 1 in every 700 live births. While surgical advances have significantly improved cosmetic and functional outcomes, the psychosocial and developmental needs of children with cleft conditions often remain in the shadows particularly in low- and middle-income countries (LMICs), where access to mental health care is limited and stigma persists.
In India, children with cleft conditions frequently carry a double burden: one visible, the other invisible. Alongside facial differences, they face bullying, disrupted schooling, emotional distress, and silent struggles. Recognising these challenges-and responding to a thoughtful invitation from our surgical colleagues-our psychiatry team joined hands with the cleft care unit to develop an integrated model of mental health support. What began as a pilot has grown into a compassionate, person-centred model that looks beyond the surgical scar to the life story it conceals.
Beyond the Surface: Psychosocial and Developmental Challenges
“While a surgeon may close the cleft, the emotional and developmental gaps often remain wide open.”
Children with cleft conditions frequently face a constellation of psychosocial and developmental challenges. These include stigma and peer rejection, particularly in school environments; low self-esteem and body image concerns often linked to speech difficulties or visible facial differences; and anxiety or mood disturbances that are sometimes misinterpreted as personality traits or temperament. Parents, too, often experience guilt and helplessness, influenced by cultural myths and social isolation. Perhaps most concerning is the frequent oversight of neurodevelopmental comorbidities – such as learning disorders, ADHD, and language impairments-that may significantly impact academic performance and long-term adjustment. Despite undergoing multiple corrective procedures, these children often remain unsupported in domains beyond the operating room.
“Fixing the face is only part of the picture-supporting the mind completes the frame.”
Figure 1: Inauguration of the integrated cleft lip and palate clinic at our institute, uniting families, community members, and the multidisciplinary care team.
From Concern to Collaboration
The journey began in 2022, when surgeons in the cleft care team approached our department with concerns about children struggling with anxiety, social withdrawal, and school refusal in the perioperative period. Their openness to mental health input laid the foundation for a collaborative, whole-child approach.
A psychiatry-led pilot screening at a tertiary cleft care centre in South India revealed a high burden of emotional and behavioural concerns. What followed was the formal integration of child psychiatry into the multidisciplinary team, shifting the paradigm from single-focus treatment to holistic care.
Key Components of the Model
- Multidisciplinary case discussions, bringing psychiatry into weekly rounds with surgery, ENT, speech therapy, paediatrics, and orthodontics
- Routine mental health and developmental screening, using tools such as the Strengths and Difficulties Questionnaire (SDQ) and child behaviour checklists
- Focused psychiatric consultations, for concerns like selective mutism, behavioural dysregulation, trauma, or school refusal
- Play-based assessments and narrative tools, to explore body image, fears, and emotional narratives in younger children
- Caregiver psychoeducation sessions, addressing grief, adjustment, expectations, and parental self-blame
- Neurodevelopmental screening, to identify comorbidities like intellectual disability, ADHD, and specific learning disorders-particularly when academic difficulties, inattention, or delayed milestones were flagged.
In essence, we stopped asking just “What can be fixed?” and started asking, “What else needs to be understood?”
Figure 2: The integrated team consisting of: plastic surgeon, psychiatrist, paediatrician, and psychiatric social worker.
Figure 3: Therapeutic space for play-based engagement with young cleft patients.
Case Vignettes: More than a Diagnosis
| Case 1 – Social Anxiety and Mutism Post-Surgery: An 8-year-old girl, post multiple surgeries, remained mute in school despite age-appropriate speech abilities. She was diagnosed with selective mutism and social anxiety. With play therapy and gradual school exposure, she began expressing herself and rebuilding social confidence. |
| Case 2 – Behavioural Issues and Academic Struggles: A 10-year-old boy presented with persistent aggression and school refusal. Developmental screening revealed underlying ADHD and borderline intellectual functioning. Behavioural interventions, caregiver training, and school liaison facilitated improvement in emotional regulation and re-engagement with academics. These cases reminded us that what appears as resistance is often distress–- waiting to be named, understood, and supported. |
Written informed consent was obtained from the parents for the case vignettes described.
Acceptance in Action
From the outset, the cleft surgical team demonstrated remarkable openness to including mental health in their care model. Their early recognition of the emotional challenges children faced-especially around surgery-laid the foundation for meaningful collaboration. While some professionals and families were initially uncertain, the benefits soon became evident. Surgeons observed improved cooperation in anxious children; speech therapists reported better engagement. Most affirming, however, were the families who began referring others-sharing that, for the first time, their child felt not only treated, but truly understood.
Lessons Learned
Several key lessons emerged through this integration. Cultural adaptation-using local metaphors, familiar language, and play-based approaches-was vital in building trust. The visible presence of psychiatry within the clinic reduced stigma and normalized mental health care. Involving families as co-therapists strengthened engagement and outcomes. Most importantly, early developmental screening allowed timely identification of comorbidities, often changing the course for children who might otherwise have been overlooked.
Scaling the Vision
Buoyed by the success of this model, efforts are underway to replicate it in other paediatric domains, including:
• Developmental delay and paediatric neurology units
• Spina bifida and craniofacial anomaly support services
In parallel, advocacy has begun at the policy level to incorporate mental health and developmental screening as a standard part of cleft care pathways in India.
Conclusion
Cleft care has come a long way in restoring faces-but it’s time we do more to restore minds. Children born with cleft lip and palate journey through far more than operating rooms – they navigate questions of identity, belonging, and self-worth. Mental health care is not a luxury add-on; it is a core necessity. Integrating psychiatry into cleft services ensures that no child is reduced to a procedure or diagnosis.
“In bridging faces and minds, we inch closer to the true meaning of holistic care-where healing is not only seen, but also felt.”
This article represents the view of its author(s) and does not necessarily represent the view of the IACAPAP's bureau or executive committee.
