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European Journal Orthodontics 20 1998) 407-415

Psychological aspects of cleft lip and palate 1998 European Orthodontic Society

S. Turner , N. Rumsey and J. SandyDivision of Child Dental Health, Bristol University Dental School and Faculty of Healthand C ommunity, U niversity of the West of England, Bristol, UK

SUMMARY In addit ion to the inf luences of family dynamics, educational and vocational factors on the social development and rehabilitation of CLP patients, psychological problems,such as lowered self-esteem and difficulties during social interaction, are also experiencedby CLP individuals. As only 20 per ce nt of cl eft t ea ms world wide carry out a psychologicalassessment for their patients, it is l ik ely that the prevalence of psychological problems ishigher than the l iterature suggests. To maximize the chances of a posit ive outcome in thecare of cleft affected individuals, CLP patients who are concerned about their appearance orwho experience psychosocial problems need to be identif ied by cleft teams. Interventions,such as c ouns el ling or social inter ac tion skills training, s hould be offered in order that thepatient s self-esteem and social self-confidence can be increased.Current research surrounding patient and parent satisfaction with cleft care suffers fromseveral areas of methodological weakness.

IntroductionCleft lip and palate CLP) is the most commonlyoccurring craniofacial developmental abnormality, affecting one in seven hu nd red live births Co up lan d and Coupla nd, 1988; G re gg et al.1994). The incidence ,of cleft lip and palateanomalies varies according to race, gender andcleft type, being more common among Indianand Oriental populations 2.3 per thousand totalclefts) and least common among Afro-Caribbeangroups 0.6 per t hou san d t ot al clefts; Gorl inet al. 1971 .Following the birth of a baby with a cleftanomaly, primary corrective surgery is usuallyperformed within the first few months of life. Inthe United Kingdom lip repairs. are performedusually at around 3 months, with the cleft palaterepair following at 6 months Rob ert s- Ha rryand Sandy, 1992). Existing multi-speciality careis primarily aimed at physical rehabilitation,with the psychological issues of care often beingneglected. The parents and patients perceptionsand needs are a critical c om po ne nt of e ven tua loutcome, yet they are frequently overlooked Broder et al. 1992 .

Psychological factors in the rehabilitationof P affected individualsThe family environment is an important factor inthe rehabilitation of a child with a facial cleft.The attitudes, expectations and degree of supportshown by parents are likely to have an enormousinfluence on a child s perception of their cleftimpairment Bull and Rumsey, 1988; Lansdownet aI. 1991). The parents feelings about theirchild s cleft defect are thought to be paramountin developing the child s self-esteem Schonfeld,1969;Broder et al. 1992).The birth of a baby witha cleft anomaly israrely predicted, despite the useof ultrasound scanning techniques, so the expectation is always for a normal birth. The initiale mo ti on al reactions from p ar en ts can be thoseof shock, confusion, grief, and guilt, althoughthese are not necessarily universal Slutsky,1969;Clifford, 1973;Shakespeare, 1975;Bradbury,1993). Families rarely discuss the cleft anomalyand often the issues surrounding the child s cleftmay only surface duri ng visits to the cleft careteam Clifford, 1987). The parents may experience a mental crisis that is handled according totheir own character strengths and weaknesses.

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4 8T hese r eactions in part d ep en d on the p are nt sp revio us b ack gro un d, existing ability towith stress and personal philosophy of living McWilliams, 1982).The baby s facial appearancemay i nt er fe re with early mother child bonding Field and Vegha-Lahr, 1984) which is thought tobe an impor tant deter minant of per sonality findadjustment in adult life Clifford, 1973). There is,however, no evidence that this bonding is alwaysaffected. Subsequent to the neo natal period,m ot he rs of b ab ie s with CLP ex pres s m or e conc er n and anxiety a bo ut t hei r b ab y t ha n m ot her sof non-cleft babies Spriestersbach, 1973). Similarly, mothers of babies with a cleft find theyexperience a higher degree of personal stress andfamily conflict, with less family cohesiveness compared with families of non-cleft babies Ramstadet al. 1995 .

Pare nts of children with clefts report theiroffspring to be m or e shy and socially i nh ib it edc om pa re d with non-cleft children . As a result,parents may be more tolerant of misbehaviour intheir child Tobiasen and Hiebert, 1964). Somep ar en ts of facially disfigured c hi ld re n are notonly over protective and likely to spoil their child Knudson-Cooper, 1981),but they are also moreprone to experiencing stress, anxiety and depression themselves Broder and Strauss, 1991). Howparents deal with their child s cleft may vary fromt ot al d en ial of psychological p ro bl em s withinthemselves or their child, to pre-occupation withth ei r child s perceived problems B ro de r andStrauss, 1989). Increasing a child s social skills,educational, and sporting achievements may compensate both p ar en t and child for the p ro ble msexper ienced as a result of the child s appearance Bernstein, 1976). This compensation provides avaluable m ean s for the family to cop e with thecleft anomaly and provides a mechanism of promoting self-esteem within the family Lefebvreand Arndt, 1988).

Children with CLP may find their mothersexert psychological control and are more intrusive than children with other congenital facialan om al ies or non-cleft c hi ld ren R ic hm an andHarper, 1978). Facially disfigured children maydetect negative reactions from their parents at anearly age, but fortunately children also discernthat their parents take pride in them despite

S. R. TURNER ET AL

any family anxieties and stresses during theirupbringing Kok and Solman, 1995).T he re are few studies on family issues alo ne

and tho se findings which have b ee n publishedare usually secondary and coincidental to the mainresearch questions. As an example, Lefebvre andMunro 1978) fo un d 12 per cent of parents ofCLP children were s ep ara ted or divorced and6 per cent were suffering from mental ill-healthproblems. The authors inclusion of seeminglyperipheral statistics infers that marital discord isa result of family stress surrou nd ing their disfigured child, although the issue is not exploredf ur ther. Winick 1967) suggests that as many as50 per cent of marriages fail where a baby hasseriou s con genital pro blem s. The divorce r at eamongst adult CLP-affected individuals 14 percent) approximates t ha t of t hei r non-cleft siblings 12 per cent), but is lower th an non-cleftcontrols 18 per cent; Peter and Chinsky, 1974).Approximately half of divorced individuals including those with CLP) later remarry Peterand Chinsky, 1974).

tigm experienced by cleft lip nd p l teffected individu lsAn individual s perception of their facial attractiveness and their ability to communicate verballyhas an impor tant influence upon an individual spsychological well-being Goffman 1968; Fitts,1972; Kapp-Simon, 1979). How we perceive ourselves is influenced by how others respond tous socially. A negative response from outsiders,act ual or p erceiv ed, may ad versely affect ourown self-image Videbeck, 1960; Goffman, 1968;Charon, 1979). The links between physicalattractiveness, and the likelihood of personala ch ie ve men t and social acceptab ility are nowwell established. Even amongst children as youngas three years, attractive children are moreaccepted as peers Dion et at. 1972; Dion, 1973).Amongst adults, positive personality characteristics are more frequently attributed to attractivepeople compared with the unattractive Dion,1973; Bull and Dav id, 1986). At tra ct iv e ad ul tsalso t en d to be m or e socially skilled G ol dm anand Lewis, 1977). These links between physicalb ea uty and social acceptability underline the

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potential disadvantages for CLP affected individuals who may have an abnormal facialappearance (Bull and Rumsey, 1988).Social interactionsAn imperfect appearance may initiate overtteasing, bullying and unwanted questioning.Social responses may also take the form of moresubtle changes in normal patterns of verbal andnon-verbal interaction such as facial expression(Bull, 1990).These unfavourable social responsesare the result of stigma, where outsiders subconsciously judge an individual negatively becauseof their imperfect appearance. The unfavourablesocial responses may be interpreted as a form ofsocial unacceptability which may reduce feelingsof self-worth within the individual (Bernstein,1976; Lefebvre and Munro, 1978; Macgregor,1982; Bull and Rumsey, 1988; Bull, 1990). Anindividual with a disfigurement may be at risk ofdeveloping psychological problems if feelings ofself-worth are consistently low (Spriestersbach,1973).Social rejection from outsiders is predictedand noticed by people with CLP (Lefebvre andMunro, 1978; Rumsey and Bull, 1986). Fearfulanticipation of these antisocial responses withinany disfigured individual will affect how theyfunction socially. These fears may result in psychosocial adjustment problems (Shaw,1981,1986)because unfavourable responses are recalled atthe next encounter (Bernstein, 1976;Macgregor,1982).Characteristics other than the direct visualimpact of the cleft may also influence the degreeof stigmatism experienced. For instance, theability with which a CLP affected individual isperceived to be handling their imperfect appearance can favourably alter an outsider s judgement of the individual (Stricker et al 1979 .Broder and Strauss (1989) have demonstratedthat it is not only individuals with visible cleftdefects who feel they are under scrutiny by thepublic, but also those with invisible defects (cleftplate only) who may feel self-conscious. Thereis some speculation that milder disfigurementscause as much, if not more, anxiety than severedisfigurements (Lansdown et al 1991). The

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social response towards individuals with milderdefects is less predictable than that towards severely disfigured individuals. t is the unpredictability of the social response that is thought toraise anxiety levels (Epsteen, 1958; Macgregor,1970; Lansdown et al 1991). CLP affectedindividuals who are dissatisfied with or who areunrealistic about their appearance need to beidentified. Once found, these individuals a triskfor developing low self-esteem, could be offeredsome social skills training to improve their selfconfidence and increase their self-esteem (Rumseyet al 1986; Kapp-Simon, 1995). This routinepsychological assessment of individuals withCLP is likely to contribute to a more completerehabilitation (Broder and Strauss, 1989; KappSimon et al 1992;Bradbury, 1993).SpeechConcerns regarding speech are thought to be lesssignificant than appearance in contributing tolow self-esteem amongst cleft affected individuals (Richman, 1983). Little else is known aboutthe opinions of cleft lip and palate patientsregarding their speech, and where opinions aresought, the majority are largely satisfied with thisaspect. On e study, however (Strauss et al. 1988reported that 28 per cent (a significant minority),judged themselves to be either moderately intelligible or else not understood at all. Parents andchildren fail to agree on satisfaction with speech.This is important because speech ranks highly inaspects which are likely to attract teasing (Thomaset al 1997; Turner et al 1997). parents fail toagree with the child on how severe the speechproblem is then they may not recognize a causeof significant distress.Incidence of psychosocial problemsThere appear to be no guidelines as to the levelof psychosocial problems in CLP affected individuals who need psychiatric referral. In somestudies, where the occurrence of psychologicalproblems is not the main research issue, apatient s psychological well-being is definedaccording to psychometric tests only (KappSimon, 1979, 1986; Broder and Strauss, 1989).

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410Based on examinations carried out by m ental

health professionals, 56 per cent of patients withclefts have problem s warranting a psychosocialreferral Broder and Strauss, 1991). The incide nc e i nc re as es with age 6 -1 2 y ea rs 62 pe r cent,12-18 yea rs 72 pe r cent) Broder and Strauss,1991). Problem s are more frequently founda mo ng m al es 69 per cent) than females 42 percent; Broder and Strauss, 1991). These figuress ee m high bu t this includes behavioural, cognitive, emotional and family problem s. There issalutary preliminary evidence which suggests thesuicide rate in a dult individuals with a cleft lipis twice that of the normal population Herskindet al. 1993 .Where d ir ec t c om pa ris on s of psychosocial

adjustment between different age groups aremade, poor a dj us tme nt in y ou ng p at ie nt s isoften expressed outwardly as antisocial behaviour. Older patients are more likely to internalizet he ir p ro bl em s and experience more anxietyand depression Pertschuk and Whitaker, 1982;Pillemer and Cook, 1989). Sigelman and Singleton 1986) postulate that psychological problemsincrease with age beca use of an increased sensitivity towards physical impairment from n on cleft subjects. Alternative reasons could be thatyo un ge r p atie nts are better at denying theirproblems or that appearance is of less perceivedimportance in young childr en compared withadolescents. The differences observed betweenage groups could also simply reflect variation inthe methods used for measuring psychologicaladjustment. Finally, younger children have relatively stable friendship groups whereas adolescents are constantly forming new relationships,which may account for any increase in problem s Clifford, 1987).Whatever the mechanism for this observed

increase in psychosocial maladjustment with age,there are important implications for the timingof any surgery for cleft affected patients. is suggested that surgical procedures are less psychologically traumatic if performed at an early ageor as needs arise Macgregor, 1982; Pertschukand Whitake r, 1982). Howe ve r, cleft lip andpalate surgery other t ha n p ri ma ry lip, p ala te ,and a lv eo la r r ep air ) sh oul d idea lly be minimaluntil growth in the facial region has r ea che d

S. R. TURNER ET AL.

a dult levels because scarring, as a result of thesurgery, restricts mid-facial growth Ross, 1987;Mars and Houston, 1990; Semb, 1991). Thegreater the e xt en t and number of surgical procedures then the greater the facial growthrestriction Ross, 1987). Clearly, this is an area ofpotential conflict for cleft care teams whosepatients psychosocial development would, intheory, benefit from corrective surgical procedures being carried out during growth. Conflictssuch as this underline the need for detailed casediscussion between different specialists within acleft lip and palate team as well as the imm ediatefamily Field and Vegha-Lahr, 1984; Canady,1995).

Educational and vocational issuesCleft-affected children experience increased frequency of speech and learning problems Lefebvreand Arndt , 1988), as well as lo we r IQ scores forverbal and language deficiency compared withnormative data Richman and Eliason, 1983).These problems are compounded by teachers whofrequently underestimate a child s intellectualability Dion, 1973; Richman, 1978). Despite theapparent disadvantages encountered by individuals with CLP during school education, ones tud y has reported that a significantly higherproportion achieve a job status within the higherprofessional, managerial and skilled trade groups,compared with the non-cleft population. However, other studies suggest CLP affected individuals have an overall lower socio-economic statuscompared with non-cleft patients Broder andStrauss, 1991), although their job satisfaction ishigh Clifford et al. 1972 .

Patient and parent satisfaction with cleft careoutcomeSelf-perception of the cleft anomaly is an important contributor to a CLP affected individual sself-esteem and psychosocial adjustment Videbeck, 1960; Fitts, 1972; Strauss et al. 1988 .Enhancement of patie nts self-esteem andp ar en ta l acceptance of their child s cleft aretherefo re important goals for craniofacialteams Schonfeld, 1969). Only a few studies have

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examined levels of patient satisfaction as ameasure of cleft care outcome Lefebvre andMunro, 1978; Richman et al. 1985; Strauss et al.1988; Noar, 1991;Broder et al. 1992 .

Satisfaction with surgical resultsSurgery for disfigurement usually results inincreased self-esteem, self-confidence, and satisfaction with appearance, irrespective of whetheran objective im prov emen t is no ticed by independent observers Lefebvre and Munro, 1978).The major ity of disfigured patients report highlevels of satisfaction with their surgical results Clifford et al. 1972; Strauss et al. 1988; Noar,1991; Broder et al. 1992). This level of expressedsatisfaction may be attributable to a need forfamilies to justify th eir emotional, and sometimes financial investment in treatment Broderand Richman, 1987). Unrealistically high expectations for surgical improvement end in dissatisfaction with post-surgical results so familiesshould be counselled extensively pre-operativelyto identify cases where this may be a problem Macgregor, 1971; Canady, 1995). Dissatisfactionmay also occur when par ents feel they are beingpressured into agreeing to surgery for their childd urin g a p er io d when they are d en yi ng to th em selves t ha t t he ir child is disfigured or in n ee d oftreatment. If p arents deny to themselves thattheir child is disfigured, th er e are p rob ably nobenef its to be gained from surgical inter vention Berscheid and Gangestad, 1982).Although the major ity of cleft aff ected individuals are r ep ort ed ly very satisfied with t hei ro ve ral l a pp ea ra nc e, t he ir c le ft -r el at ed facialf ea tu res such as lip scars, are o ft en the focus fordissatisfaction Richman et al. 1985; Strausset al. 1988; Noar, 1991). Par ents consistentlyreport more disappointment in their child s facialappearance than their children, irr espective ofcleft type Broderet al. 1992). These differencesmay be due to under-reporting of concerns bych ild ren who may be ret ice nt a bo ut expressingd isapp oin tment whilst in the pres ence of theirp aren ts and specialists Br od er et al. 1992 .Recently, it was d em on st ra te d t ha t in d ifferen tage g ro ups 10-, 15-, and 20-year-olds) it is the15-year-olds who disagree most with their

4parents about their overall facial appearance.They expressed most dissatisfaction with theappearance of their lips and teeth Thomaset al.1997; Turner et al. 1997 .

Pare nts of girls perceive t hei r children to bemore concerned about their appearance thanp ar en ts of boys B ro de r et al. 1992). There areconflicting data surrounding gender differencesin satisfaction with cleft care. Some studies reportthat females with clefts are more dissatisfied withappearance than males Berscheid and Gangestad,1982; Broder and Strauss, 1989). Others suggestthat males and females have similar levels ofsatisfaction Broder et al 1992 .

Methodological weaknesses within currentcleft psychology researchThe challenge of psychometric testing is toidentify ways in which subjective experiences ofp ati en ts can be made objective. is, however,difficult to identify how people think and react tofacial disfigurement. In order to address thesequestions complex statistical tools are needed toisolate and identify the u nd erl yi ng s tr uc tu re ofan individual s perceptions. It would be naive toassume that psychometric tests alone can identify adversity in experience of cleft lip and palate.These tests are important in the treatment ofthese patients, but cannot be used in isolation. Inthe last 25 years there have been advances in thequ ality of s tu dy design used to inv es tig ate psychosocial issues. Prior to the 1970s,studies were,at best, theoretically speculative. Case r epor tswere common with no solid data to substantiateclaims Stricker, 1970). C om pa ri so n b et we enstudies was impossible due to lack of agr eementamongst researchers on methodology and sampling Bradbury, 1993). Clifford 1988) suggestedth at this had resu lted in c on cep tu al ly naiveattempts to describe a set of patients sharing thesame anomaly in familiar psychological terms .Investigative links between physical appearanceand the individual s psychosocial functioning aredifficult because although facial appearance canbe measured in terms of impairment Tobiasenand Hiebert, 1993) and, to some extent, attractiveness Howells and Shaw, 1985; RobertsHarry et al. 1992), it is impossible to measure the

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412though ts of a disfigured pe rson . Furthermore,people v ar y in t he ir perception of their physicalself-image and their emotional reactions to theseperceptions Richman et al. 1988). Attemptingto e va lu at e the thoughts and feelings of a disfigured individual is possible using standardizedpsychometric questionnaires that have beendeveloped and validated by social scientists andpsychologists. For example, the P ie rs Harri schildr en s self-concept scale is an objectivemeasure consisting of 80 statements about theindividual to which the respondent replies yes ,or no Piers, 1969). However, opinion concerning the usefulness and applicability of differents ta nd ar di ze d m ea su re s var ie s widely a mo ng stresearchers in this field. Although such a questionnaire provides a basis for com parison this isonly possible in a limited sense. Even when datahave been obtained, problems exist concerninganalysis. Behavioural scientists have investigatedproblems of analysis and interpretation overthe last few years, sometimes advocating the useof com plex statistical tools such as factor , andcluster analyses Stricker et al. 1979). Theseanalyses are more frequently used for marketresearch purposes and are viewed sceptically byhealth care statisticians. Methods of analysingpsychometric data therefore remain a con tro versial topic.

Future study designsMany studies investigating psychological issuesof cleft lip and p al at e use s el f- re po rt ed data Harper and Richman, 1978; Kapp-Simon, 1979,1986; Richman, 1983; Richman et al. 985;Strauss et al 1988; Broder and Strauss, 1989). Todate these studies have only been cross-sectionalfor d if fe re nt age groups. In f ut ur e lo ngi tud ina lstudies of subjects will be needed to investigate ifintra-individual self-perception changes with age Broder et aI 1992). fcleft teams are to usepatient questionnaire data as a measure of treat-ment outcome, then information regarding changes.in self-perception with time will be needed usingcleft and non-cleft populations Broder and Strauss,1991).

The opinions of patients and parents satisfaction with treatment are usually based their

s R. TURNER ET AL .experiences from one centre Lefebvre andMunro, 1978; Richman et al. 1985; Strauss et al.1988; Broder et al. 1992). To avoid biasedresponses from the subjects regarding satisfaction, t he ir o pi ni on s s ho ul d ideally be co lle cte dfrom several different cleft lip and palate centresusing standardized data collection methodsadministered by independent examiners. Noar 1991}used data from five centres within London.Superficially, this represents a multi-centre study,but as only 8patients responded, the samplesize precludes any meaningful comparisons.

reblelllSwith samples in cleftpsychology studiesDespite CLP being relatively common comparedwith other craniofacial anomalies GorIin et al.1971) there is still a tendency to use small sam plesizes Richm an et al. 1985; Noar, 1991). Thismay be a reflection of the t ime consuming datacollection required to complete psychometricassessments Pertschuk and Whitaker, 1982).Alternatively,. small sample sizes may reflect theproblem of using only one centre with a lim itedcatchment area for subjects. Some have usedcom bined groups of different cleft anomalies inorder to i nc re ase the s am pl e size L ef eb vr e andMunro, 1978; Richman et al. 1985; Strauss et al.1988). The validity of r es ult s for sa tis fa cti onwith cleft outcome may be reduced if all clefttypes are combined within the analysis. As anexample, in R ic hma n s study of se lf- repor tedspeech concerns, no indication was given of theincidence of palatal and pharyngeal surgery withinthe sample Richman, 1983). These subjects werecom bined with others who had r ece ive d nop al at al or p ha ry ng ea l surgery. As a re sult, t he irobser va tions r ega rdi ng sp ee ch concerns arelikely to be over optimistic. Self-selection factorsmay skew a sample in those studies wheresubjec ts are asked to volunteer for assessment Clifford et al. 1972 .

Adtlitieaal methodological problemsResearchers rarely refer to the period of timeover which investigations into satisfaction areundertaken. This s ho ul d be taken into account,

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PSYCHOLOGICAL A SPE CT S O F C LP

as the success of procedures undertaken by cleftspecialists may increase with their experience.This may have a bearing on how satisfied apatient is with, for example, a lip repair. Similarly, if responses to interview questions havebeen categorized by an interviewer over severalyears of da ta collection, it is possible t ha t thereliability of the categorization procedure willdrift with the interviewer s experience andenthusiasm. Strauss et al 1988) collected dataover 11 years, yet inter-examiner calibration andre-calibration were not undertaken during thestudy. Several other methodological problemsalso need to be addressed. Retrospective investigations asking for opinions on past treatmentmay be subject to recall and memory bias, especially where adults are involved Clifford et al1972). The expression of satisfaction from anadult regarding surgery undertaken during childhood may under- or over-estimate, childhooddissatisfaction. Using one standardized psychometric test for a sample with a large age rangemay reduce the sensitivity of the results becausethe test has to be modified to suit the differentages of the subjects. For example, one study Lefebvre and Munro, 1978) examined subjectsfrom ages 6 to 37 years using the same questionnaire. may be more appropriate to analysesamples in their different age groups rather thancombining all of the results for the sake ofincreasing sample size.ddress for correspondenceDr R. SandyDivision of Child Dental HealthUniversity of Bristol Dental SchoolLower Maudlin StreetBristol BS1 LY UKcknowledgementWe would like to thank Miss Jane Western forher secretarial skills involved in the preparationof this paper.eferencesBernstein N 1976Emotional care of the facially burned anddisfigured Little. Brown and Company. Boston

413Berscheid E, Gangestad S 1982 The social psychologicalimplications of facial physical attractiveness. ClinicalPlastic Surgery 9: 289-296Bradbury E 1993Psychological approaches to children andadolescents with disfigurement: a review of the literature.Association for Child Psychology and Psychiatry, Review

and Newsletter 15: 1-6Broder H L, Richman L C 1987 An examination of mentalhealth services for cleft and craniofacial patients. CleftPalate and Craniofacial Journal 24: 158-163Broder H L, Strauss R P 1989Self-concept of early primaryschool age children with visible or invisible defects. CleftPalate Journal 26: 114-118Broder H L, Strauss R P 1991 Psychological problems andre fe rra ls among oral-facial t ea m patients. Jour nal ofRehabilitation 57: 31-36B rod er H L, Smith F B, Strauss R P 1992 Habilitation ofpatients with clefts: Parent and child ratings of satisfactionwith appearance and speech. Cleft P alate and Cranio

facial Journal 29: 262-267Bull R 1990 Society s reactions to facial disfigurements.Dental Update 17: 202-205Bull R, David I 1986 The stigmatising effect of facialdisfigurement. Journal of Cross Cultural Psychology 17:99-108Bull R, R ums ey N 1988 The social psychology of facialappearance. Springer-Verlag, New YorkCanady J W 1995 Emotional effects of plastic surgery onthe adolescent with a cleft. Cleft Palate and CraniofacialJournal 32: 120-124Charon J M 1979Symbolic interactionism: an introduction,

an interpretation, an integration. Prentice Hall, EnglewoodCliffs, New JerseyClifford E 1973Psychosocial aspects of orofacial anomalies:Speculations in search of data. Report No 8 AmericanSpeech and Hearing Association, RockvilleClifford E 1987The cleft palate experience: New perspectives on management Springfield, IllinoisClifford E 1988 The state of what art? Cleft Palate andCraniofacial Journal 25: 174-175Clifford E, Crocker E. Pope B A 1972 Psychological findings in the adulthood of 98 cleft lip and palate children.Plastic and Reconstructive Surgery 50: 234-237Coupland M A. Coupland A I 1988 Seasonality. incidence.

and sex distribution of cleft lip and palate births in Trentregion 1973-1982. Cleft Palate Journal 25: 33-37Dion K K 1973 Young children s stereotyping of facialattractiveness. Developmental Psychobiology 9: 183-188Dion K K. Berscheid E. Walster E 1972What is beautiful isgood. Journal of Personal Social Psychology 24: 285-290Epsteen C 1958 Psychological impact of facial deformities.American Journal of Surgery 96: 745-748Field T M, Vegha-Lahr N 1984 Early interactions betweeninfants with craniofacial anomalies and their mothers.Infant Behaviour and Development 7: 527-530

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414Fitts W H 1972The self-concept and behaviour. Counsellorrecordings and tests.Research Monograph No.1, Nashville,TennesseeGoff man E 1968 Stigma: Notes on the management ofspoiled identity. Prentice-Hall, Englewood Cliffs, NewJerseyGoldman W, Lewis P 1977Beautiful is good: Evidence thatthe physically attractive are more socially skilled. Journalof Experimental Social Psychology 13: 125-130Gorlin R J, Cervenka J,Pruzinsky S 1971Facial clefting andits syndromes. Birth Defects 7: 3-49Gregg T, Boyd D, Richardson A 1994 The incidence ofcleft lip and palate in Northern Ireland from 1980-1990.British Journal of Orthodontics 21: 387-392Harper D C, Richman L C 1978 Personality profiles ofphysically i mpai red adolescents. J our nal of ClinicalPsychology 34: 636-642H er sk in d A M, C hri st ens en K, Juel K, F ogh -A nd er son P

1993Cleft lip: a risk factor for suicide. International Congress on Cleft Palate and Related Craniofacial Anomalies,Australia, p. 156 Abstract)Howells D G, Shaw W C 1985 The validity of reliability ofratings of dental and facial attractiveness for epidemiological use. American Journal of Orthodontics 88:402-408Kapp-Simon K A 1979Self-concept of the cleft lip and/orpalate child. Cleft Palate Journal 16: 171-176Kapp -Si mon K A 1986 Self-concept of pri ma ry schoolchildren with cleft lip, cleft palate, or both. Cleft PalateJournal 23: 24-27Kapp-S imon K A 1995 Psychological interventions for

the adolescent with cleft lip and palate. Cleft PalateCraniofacial Journal 32: 104-108Kapp-Sirnon K A, Simon D J, Kristovich S 1992 Selfperception, social skills, adjustment and inhibition inyoung adolescents with craniofacial anomalies. CleftPalate and Craniofacial Journal 29: 352-356Knudson-Cooper M S 1981 Adjustment to visible stigma:the case of the severely burned. Social Sciences Medicine15:31-44Kok L L, Solman R T 1995 Velocardiofacial syndrome:learning difficulties with intervention. Journal of MedicalGenetics 32: 6 2 6 8La nsdow n R, Lloyd J, H un te r J 1991 Facial def orm ity in

childhood: severity and psychological adjustment. ChildCare Health Development 17: 165-171Lefebvre A M, Ar ndt E M 1988 Working with faciallydisfigured children a challenge in prevention. CanadianJournal of Psychiatry 33: 453-458Lefebvre A M, Munro I 1978 The role of psychiatry in acraniofacial team. Plastic and Reconstructive Surgery 61:564-569Macgregor F C 1970 Social and psychological implicationsof dentofacial disfigurement. Angle Orthodontist 40:231-233

S. R. TURNER ET ALMacgregor F C 1971Selection of cosmetic surgery patients:Social and psychological considerations. Surgical Clinicsof North America 51: 289-293Macgregor F C 1982 Social and psychological studies ofplastic surgery. Clinical Plastic Surgery 9: 283-288Mars M, Houst on W 1990 A preliminary study of facialgrowth and morphology in unoperated male unilateralcleft lip and p al at e subjects over 13 years of age. CleftPalate Journal 27: 7-10McWilliams B J 1982 Social and psychological problemsassociated with cleft palate. Clinical Plastic Surgery 9:317-326Noar J H 1991 Questionnaire survey of attitudes andconcerns of p at ie nt s with cleft lip and palate and theirparents. Cleft Palate Journal 28: 279-284Pertschuk M J,Whitaker L A 1982Social and psychologicaleffects of craniofacial deformity and surgical reconstruction. Clinical Plastic Surgery 9: 297-306Peter J Chinsky R R 1974 Sociological aspects ofcleft palate adults: I Marriage. Cleft Palate Journal 11:295-309Piers E V 1969 The P iers-Harris children s self-concept

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