title: Social response in children with severe cognitive impairments: factors in craniofacial surgery decision-making.
abstract: BACKGROUND
  The controversy over whether certain pediatric craniofacial operations primarily address "functional" versus "aesthetic" goals has fostered tensions among insurance companies, patients and families, and treatment teams. The authors posit that such operations have objectives and outcomes that can be categorized as "functionally aesthetic" and describe the empirical basis for this assertion. Furthermore, the authors apply this concept to the difficult surgical decision-making process associated with treating children with severe cognitive impairments.
  
  
  METHODS
  When patients have severe cognitive impairments, the social benefits of treatment may be less clear than for other patients, increasing the complexity of surgery decision-making. The authors discuss the nature of cognitive impairment, its prevalence in patients with craniofacial anomalies, links between social functioning and both cognitive development and appearance, and the importance of social integration for psychological and cognitive functioning. Special issues involved in working with cognitively impaired children are covered, including parent and patient expectations for surgical outcome and the difficulties involved in pain assessment and control. Potential linkages are described for craniofacial surgery, appearance, social functioning, and cognitive development.
  
  
  CONCLUSIONS
  A craniofacial operation directed at reconstruction of a congenital defect in a child should not be dismissed as simply and purely cosmetic. The authors document and outline the potential ethical issues and social and cognitive benefits that should be considered by insurance companies, patients and families, and treatment teams when determining treatment options for cognitively impaired children with craniofacial anomalies.
authors.affiliation: Department of Physical Medicine and Rehabilitation, Craniofacial Anomalies Program, University of Michigan, Ann Arbor, Michigan, USA. jbkay@umich.edu
authors.forename: Joshua B
authors.initials: JB
authors.lastname: Kay
authors.forename: Marie
authors.initials: M
authors.lastname: Van Tubbergen
authors.forename: Seth
authors.initials: S
authors.lastname: Warschausky
authors.forename: Steven R
authors.initials: SR
authors.lastname: Buchman
mesh_terms: D002648:Child; D003072:Cognition Disorders / Q000453:epidemiology / Q000523:psychology*; D015897:Comorbidity; D019465:Craniofacial Abnormalities / Q000453:epidemiology / Q000601:surgery*; D003657:Decision Making; D006801:Humans; D007223:Infant; D008607:Intellectual Disability / Q000453:epidemiology / Q000523:psychology; D008297:Male; D010147:Pain Measurement; D012086:Reoperation; D018570:Risk Assessment; D012919:Social Behavior; D012922:Social Change