Jeremiah Maller Partner Organization: Operation Smile The Impact of Cleft Surgery on Academic and Cognitive Outcomes for Teens in India Jeremiah Maller Partner Organization: Operation Smile

Research Question What is the impact of cleft lip and palate surgery on cognitive and academic outcomes for teenagers born with orofacial clefts in India?

Causal Chain - Implicit Assumptions Unrepaired Cleft Bullying at School School Absence/Dropout Low Math & Reading Ability Last link assumes attending school is correlated with math and reading ability

Background and Study Motivation First study attempting to identify the causal impact of cleft surgery on outcomes using a plausible counterfactual $796 USD = mean cost per surgery (Thakkar et al., 2010, Alkire et al., 2015) Comprehensive impact of cleft surgery factors into allocation of public health resources

Magnitude of Unrepaired Cleft in India India has a backlog of ~ 1 Million cleft patients Every year in India 27,000 to 33,000 are born with cleft Current capacity in India: 50,000 cleft surgeries each year

Repaired Cleft is correlated with: Prevalence of reading disorders in children with cleft is 30-40% vs. 10% to 15% in the non-cleft population (Richman et al., 2005) Abnormal brain development, significantly lower full scale, performance, and verbal IQ scores (Nopoulos et al., 2002) Lower high school GPA and graduation rates (Persson et al., 2008; ibid 2012) Developmental delays and deficits in language, vocabulary expression, perceptual-motor skills, rapid naming, verbal memory, and fluency (Kapp-Simon & Krueckeberg, 2000) “adult males with oral clefts manifest a specific pattern of cognitive deficits. As the development of the face is highly interdependent with the development of the brain, it is theorized that the etiology of these cognitive deficits is a primary problem with abnormal brain development.” (Nopoulos et al., 2002).

Cleft Severity: Number of Surgeries Required CL/P Conditions Average # of Required Surgeries Incomplete unilateral or bilateral CL, no CP = 2 Incomplete unilateral or bilateral CP, no CL = 3 Complete unilateral or bilateral CL, no CP = 4 Incomplete CL and incomplete CP = 5 Complete unilateral CL and CP = 6 Complete bilateral CL and CP = 7 Complete bilateral CL and CP w/ deviated premaxilla = 8

Outcome Variables: Math Ability (ASER)

Outcome Variables: Reading Ability (ASER)

Outcomes: Digit Span Memory Test

Empirical Strategy Differences-in-differences OLS regression Fixed effects at the household level (Removes factors like household income, level of parental education) SE clustered at the household level A differences-in-differences estimation method is used to to identify the causal impact of the surgical intervention by comparing the life outcomes of teens that received surgical treatment to their nearest age (non-cleft) siblings and in turn comparing this difference to the difference between teens with cleft who did not have access to the surgery at a young age and their own (non-cleft) siblings. Still, households whose children received the surgery at a younger age during earlier waves of Operation Smile outreach, might differ systematically from those who did not. This raises concerns about endogeneity in any simple comparison of treated and untreated patient groups. The differences-in-differences estimation method controls for systematic differences between treatment and control groups and employs fixed effect controls at the household level. This eliminates time-invariant unobservable parental characteristics (socioeconomic status, education, income, etc.), and geographically determined economic, institutional, and social characteristics; such as the quality of local schools, local economic variables, the efficacy of local social support networks, and the local level of social stigmatization of cleft.

Identifying Assumption Identifying Assumption: In the absence of cleft surgery for treated cleft teens, the difference between treated cleft teens and their siblings would be the same as the difference between untreated cleft teens and their siblings.

Empirical Specification What is the impact of cleft severity level? What is the restorative impact of each additional surgery, on average?

Alternate Specification What is the impact of being born with any cleft, regardless of severity? What is the restorative impact of receiving one or more surgeries?

Outcome Variables Patient-Sibling Surveys: ASER Math Ability ASER Reading Ability Cognitive Ability Parent Survey: Parental perception of academic ability Anderson Indices

Conclusion & Discussion Key Result: Cleft severity and surgery have no clear impact on cognitive/academic outcomes and school attendance/completion. Across the board low quality public schools in India make make it difficult to distinguish the treatment effect Failure at any point in causal chain ->> Failure to reject the null hypothesis Larger sample needed

Dedicated to Saugata Gupta