It is important that healthcare providers understand the difference between the fathers' and mothers' worries about their child with a cleft lip and palate. Specific support services should be offered to fathers with a high level of resilience, in terms of the acceptance of reality and problem-solving, which could increase their parenting ability.

Aim: As patients with cleft lip and/or palate grow older, the main decision-making process for treatment is likely to shift from a parent-centered to a patientcentered process. However, many adolescent patients have difficulty in treatment decision-making. This study aimed to clarify the decision-making process regarding undergoing surgery among adolescent patients with cleft lip and/or palate. Methods: Participants were adolescent patients with cleft lip and/or palate aged 14-18 years who were admitted to a hospital in Japan for surgery. Fourteen patients (six boys, eight girls) and their parents agreed to participate in this study. Data were collected in face-to-face semi-structured interviews. Data were analyzed qualitatively with inductive content analysis. Results: Fifteen categories were classified into three themes for adolescent patients' decision-making processes regarding undergoing surgery. The three themes were: (a) a doctor's recommendation for surgery, (b) psychological conflict about surgery, and (c) a final decision about surgery. Conclusion: This study's findings suggest that adolescent patients with cleft lip and/or palate were not adequately involved in the decision-making process before undergoing surgery. Medical staff need to explain other treatment options, the risks and benefits of surgery with materials and methods that adolescent patients can understand as part of "a doctor's recommendation for surgery." Medical staff and parents need to encourage adolescent patients to communicate their preferences and values to reduce patients' "psychological conflict about surgery" and adolescent patients' intentions should be considered in "a final decision about surgery." K E Y W O R D S adolescent, cleft lip, cleft palate, decision-making, surgery 1 | INTRODUCTION Cleft lip and/or palate is a craniofacial anomaly and common birth defect, with an overall worldwide prevalence of 9.92 per 10,000 live births (International Perinatal Database of Typical Oral Clefts Working Group, 2011). Cleft lip and/or palate affects speech and language development, dental development, and facial appearance. Patients with cleft lip and/or palate usually undergo a combination of surgical interventions, speech therapy,

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With a worldwide prevalence of approximately 9.92 per 10,000 newborn births, 1 cleft lip and/or cleft palate (CL/P), which includes cleft lip only (CL), cleft lip and palate (CLP), and cleft palate only (CP), is one of the most common congenital orofacial anomalies in humans. 2 Japan reports the highest prevalence worldwide (20.4 per 10,000 births). 1 Children with CL/P experience effects on their speech, hearing, appearance, and cognition that can lead to long-lasting adverse outcomes for their health and social integration. 3 Recent research into the psychological influence of these adversities, such as behavioural problems,