Children of the Philippines: Attitudes Toward Visible Physical Impairment

DENNIS C. HARPER, PH.D.

DAVID B. PETERSON, PH.D.
Objective: This pilot study was designed to evaluate childrens attitudes and
understanding of physical disabilities with special reference to those with craniofacial anomalies in the Philippines. Children with and without craniofacial
anomalies were studied.
Design: This was a two-group correlational design with additional statistical
assessment of subgroup differences. Each group was interviewed and information obtained on a standard disability preference task, attributions for playmate choice, and frequency of contact with disabilities. Parents completed a
structured interview.
Setting: Participants were 122 children recruited from Negros, Philippines.
Participants: Fifty-four children with craniofacial anomalies (aged 7 to 12
years) were enrolled in the study, and 68 children without any disabilities were
recruited from a local school in Bacolod City, Negros, Philippines.
Main Outcome Measures: Participants completed a picture-ranking interview
of specific physical disabilities and provided their reasons for their play choices and their contact with physical disabilities.
Results: The Kendall W correlation was significant for the children with craniofacial anomalies and for those without physical disabilities. Both groups
reported lower preferences for disabilities that interfere with play and social
interactions. Children depicted with facial anomalies received lower preference, compared with other physical disabilities. Children with craniofacial
anomalies who have experienced surgical repair reported more positive rankings for the child depicted with a facial cleft. Sex differences in disability preference were noted.
Conclusions: Children in the Philippines with and without craniofacial differences revealed similarities in preferences to children in several Western
(United States) and non-Western countries. Children depicted with facial anomalies received lower preference than other visible physical differences. Children reported both positive and negative explanations for their disability play
preferences. Facial differences may result in illogical and negative explanations for social avoidance among children. Similar reactions are noted in other
parts of the world.
KEY WORDS: adjustment, attitudes, children, cleft lip, cleft palate, Philippines

Substantial evidence reveals that children with visible physical differences (facial dysmorphism, orthopedic-mobility impairments, amputations, or obesity) often experience a hostile,
rejecting, and ambiguous social milieu (Harper and Richman,
1978; Wright, 1983; Gerrard, 1991; Harper, 1991, 1995). Such
visible differences may lead to the following sequence: children with visible physical differences receive negative social
feedback, and such feedback often reduces self-esteem and
limits the childs future likelihood of approaching peers socially. These cyclical negative peer interactions can place chil-

dren at risk for social discomfort, rejection, and potential adjustment problems throughout their life span. Results from a
variety of studies (Kapp, 1979; Kapp-Simon, 1986; Broder and
Strauss, 1989; Leonard et al., 1991; Padwa et al., 1991; King
et al., 1993; Broder et al., 1994; Eder, 1995) exploring selfconcept, adjustment, self-perception, anxiety, depression, behavioral difficulties among children with varying degrees of
facial disfigurement, and types of cleft and palate disorder have
yielded very mixed results. Furthermore, key researchers
(Richman, 1991; Kapp-Simon, et al., 1992; Broder et al., 1994)
have noted that there was limited solid evidence for significant
psychopathology because many children and adolescents report positive adjustment and positive self-esteem. Differences
in adjustment and behavior that exist often do not reach
levels that warrant formal psychiatric diagnosis or noticeable
behavioral dysfunction. Nevertheless, there is evidence that
those with facial dysmorphism, both children and adults, may

Dr. Harper is from the University of Iowa College of Medicine, Iowa City,
Iowa. Dr. Peterson is from New York University, New York, New York.
Submitted April 2000; Accepted November 2000.
Reprint requests: Dennis C. Harper, Ph.D., Department of Pediatrics, University of Iowa Hospitals and Clinics, 100 Hawkins Drive, 341 University
Hospital School, Iowa City, IA 52242-1011. E-mail dennis-harper@uiowa.edu.
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Harper and Peterson, ATTITUDES TOWARD IMPAIRMENT

experience lower self-esteem and discomfort in social interactions. Although these personal reactions may not reach levels of psychiatric morbidity, they are distressing and likely
impact the quality of life (Pillemer and Cook, 1989; Bennett
and Stanton, 1993).
The social-psychological impact of chronic visible disabilities is well documented for adults and children (Bull and Rumsey, 1988; Lavigne and Faier-Routman, 1992; Harper, 1999.
Physical disabilities have been investigated by social scientists
in two general ways: their functional and adaptive impact on
a persons life skills and the potential social rejection of appearing different (Wright, 1983). Looks or appearance can
have a significant impact on the individuals perceived value
(Harper, 1991, 1997, 1999). In particular, clefts of the lip and
palate can place the person in a vulnerable position for adjustment and social problems (Harper and Richman, 1978;
Richman and Harper, 1978; Shaw, 1981b; Rumsey, 1983;
Richman and Eliason, 1993). Adjustment in this population is
not related in a simple or direct fashion to visibility of facial
differences or the concept of attractiveness (Pertschuk and
Whitaker, 1987, 1988; Bennett and Stanton, 1993; Ries and
Hodgins, 1995). Katz (1981) and Jones et al. (1984) described
a complicated social interpersonal interaction to individuals
with physical stigmata. Harper (1999) also discussed how children may conceptualize and think about peers with visible
physical differences and how this often impacts their play experiences. Clinical observations and existing research on children with facial impairments raise concerns about their future
adjustment (Bull and Rumsey, 1988); however, presently few
empirical data exist documenting the actual peer reactions and
peer views of their interactions with children with facial dysmorphisms in this social-interpersonal process. In brief, what
do peers say and think about their peers with these facial differences and what do children with facial differences say and
think about such personal differences?
In a series of worldwide studies (Harper et al., 1985, 1986,
1994; Harper and Bhattarai, 1989; Sanchez and Harper, 1994;
Harper, 1995, 1997, 1999), investigators explored nondisabled
childrens expressed attitudes toward children with a variety
of visible physical impairments (orthopedic-mobility, amputation, facial cleft, and obesity). The methodology and interviews used in these studies has been extensively validated and
replicated in five different countries by Harper (1999) and
based on 25 years of prior research by Richardson (1983).
Individual interviews by Harper with more than 1400 children
identified significant and consistent preferences toward particular visible disabilities, Western versus non-Western cultural
preferences toward particular disabilities, and childrens attitudes toward disabilities to reflect both negative and positive
social attitudes often related to the type and frequency of prior
social contact (Harper, 1999). Those depicted with facial clefts
in these studies characteristically received low social play preference, were frequently chosen last as playmates in contrast to
other childhood physical disabilities, and received more negative and illogical personal evaluative remarks from their
peers, and the facial appearance appeared to engulf the chil-

567

dren spreading a negative cast on their play skills and social

acceptability (Harper, 1995, 1997, 1999).
Children in the Philippines with cleft of the lip and palate
have limited access to surgical repair or oral prosthetics. Consequently, many children continue with craniofacial problems
well into their adolescence and adulthood. Repairs, when available, have often been provided by Operation Smile International. The Philippines are an archipelago in Southeast Asia.
The inhabitants are closely related to Southeast Asian groups
(e.g., Indonesians, Thais, and Vietnamese). With the exception
of Manila, the economy is largely agriculture and commercial
fisheries. Bacolod City is a large city (population 300,000) on
Negros, a south central island of the Philippines, the location
of the present study. Operation Smile International is a volunteer organization providing in-country surgical correction
for patients and education for local health care workers worldwide. Its annual missions throughout the Philippine Islands for
over 10 years enable a unique opportunity to complete clinical
and epidemiological studies.
Murray and associates (1997) have provided comprehensive
studies of clinical and epidemiological findings regarding the
prevalence of cleft lip and palate (1.94 per 1000 live births)
in the Philippines. These findings report a high incidence of
cleft lip and palate in native-born Filipinos. In conjunction
with these surgical rehabilitative services, a pilot project was
proposed and accepted attempting a qualitative child-focused
attitude study of children with clefts and their families. The
following research questions were proposed. How do children
in the Philippines with clefts of lip or palate view physical
disabilities of children? Are there any differences in their
views of disability toward facial disfigurement or other types
of physical impairments following a surgical repair by Operation Smile personnel? What can we learn from attitudes of
their nondisabled Filipino peers toward these physical disabilities? This was a pilot study to explore attitudes toward physical disability of children in the Philippines and focus on how
those with a craniofacial impairment view physical impairments of their peers. Children without disabilities were also
interviewed to form a normative background for these findings.
METHOD
Subjects
Children were selected during a 3-day general medical
screening program from approximately 450 children and families with a variety of craniofacial and genetic disorders. The
number of children that could be enrolled (sample size) was
limited by the amount of time (3 days) available during the
Operation Smile initial health screening. These children and
families were seeking the assistance of Operation Smile International in Bacolod City, Negros, Philippines in February and
March 1995. Parents completed a research consent document,
and children gave their assent. Children of both sexes between
the ages of 8 and 12 years were selected. From a potential

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Cleft PalateCraniofacial Journal, November 2001, Vol. 38 No. 6

FIGURE 1 Boy and girl with a facial cleft.

group of 450, 65 were approached, and 57 children and families agreed to participate during their initial medical screening
by Operation Smile medical staff resulting in an acceptance
rate of 87.6%. Children who met the age requirements (between 8 and 12 years) and were judged healthy by the medical
staff and agreed to participate were selected. Three children
were subsequently dropped from consideration because they
displayed other noncleft facial dysmorphic features leaving 54
(83.1%) children in the study sample. Of the eight who did
not participate, all had no prior surgical repairs. These remaining 54 children displayed a variety of craniofacial differences voluntarily seeking surgical assistance from the personnel of Operation Smile International. These families were from
throughout Negros, and the majority of children were attending
school on an infrequent basis.
In addition to children with clefts of the lip and palate, a
control group of children who were not physically impaired
were obtained from a large public school in Bacolod City. This
control group participated only in the child interviews. Of the
78 children approached, 68 (87%) agreed to participate. Discussion with teachers did not indicate any noticeable differences between participants and nonparticipants. Sixty-eight
children of both sexes, between the ages of 8 and 12 years
were selected from four classrooms in a local elementary
school in Bacolod City. This was based on voluntary participation following a review of local school authorities and parent
representatives according to local standards.
In summary, 125 children were interviewed, and 54 parents
of children with clefts of the lip or palate were also interviewed. All interviews were completed over 5 10-hour days
by three bilingual adult interviewers from Bacolod City.
Materials and Procedures
Three female adult interviewers from Bacolod City were
recruited through the assistance of Project Hope. Project Hope
is a local civic support group providing volunteer and financial
assistance to Operation Smile International personnel. Project
Hope provides the local logistics to coordinate all aspects of
these medical services in Bacolod City. All adults were conversant in Illongo (local dialect) and English. Interview procedures were reviewed and practiced under supervision.
Parents and children were approached and asked for their
participation through these interviewers during initial medical
screening by Operation Smile staff. All parents observed the
child interviews and were physically present at all times.

FIGURE 2 Children with visible physical differences.

Each child was presented with a series of line drawings (8

by 11) depicting common visible physical impairments consistent with existing facial or cultural and physical characteristics of Filipino children living in Negros. Drawings were
initially developed consistent with physical and cultural features as has been done previously by Harper in previous studies (1995, 1999). Drawings were developed with consultation
of local professionals. Each child (own sex) was shown a series of pictures in random order depicting the following physical disabilities: a child with crutch or brace, a child in a wheelchair, a child with hand missing, a child with obesity, a child
with a facial cleft, and a child without any physical disability
(Figs. 1 and 2). Children were asked to express their play
preferences (who would you like to play with?) for the children depicted in the drawings. Each child reported preference
ranks (e.g., first to last, 1 through 6). Following this picture
interview, children indicated their reasons verbatim for their
first and last play selection (e.g., why did you choose this one
first; why did you choose this one last?). All children reported
their contact or familiarity with all physical differences depicted on the basis of a structured contact interview. Children
reported their frequency and familiarity (name) of these social
contacts.
Finally, parents were asked a series of structured questions
focusing on their views of what caused the childs medical
problem, the effect on the child and the family, and the type
of assistance needed and how surgical assistance has helped
or will help the child. This interview is available by contacting
the first author. These data are not reported here.
Following methodology by Richardson (1983), Harper
(1997), and Harper et al. (1986), Kendalls statistic rank correlation coefficient (Seigel, 1956) was used to determine
whether there were consistent patterns in the childrens preference rankings. This analysis was chosen because it does not
assume an equal interval scale and does not require a normal

Harper and Peterson, ATTITUDES TOWARD IMPAIRMENT

569

TABLE 1 Preference Ranking of Children with Cleft Lip or Palate

Boys
Mean
10.67
Age

Rank
1
2
3
4
5
6

N
W
O
F
H
C

(n 5 37)

Mean
2.67
3.00
3.51
3.83
3.86
4.10

Girls
SD
1.84

Mean
10.88

SD
1.70
1.82
1.46
1.70
1.68
1.50

N
H
F
W
O
C

Kendall W .09*

SD
2.36
(n 5 17)

Mean
1.94
2.94
3.47
4.00
4.05
4.58
Kendall W .26*

American
Normative

Total
(n 5 54)

SD
1.59
1.14
1.73
1.87
1.39
1.22

N
W
H
O
F
C

Mean
2.44
3.31
3.57
3.68
3.72
4.25

SD
1.68
1.88
1.58
1.45
1.70
1.42

Confidence
1.992.89
2.803.82
3.144.00
3.294.08
3.254.18
3.874.64

N
C
W
H
F
O

Kendall W .10*

Data from Richardson and colleagues (1983).

95% upper and lower confidence intervals for each total mean.
N 5 no disability; W 5 wheelchair; O 5 obese; F 5 face; H 5 hand; C 5 crutch/brace.
* p # .001.

distribution of rankings. The statistical analysis, a nonparametric association measure, evaluated the significance and degree of association of each groups overall rankings of the
disabilities depicted. This measure evaluates whether the rank
ordering by the children was statistically significant from a
random rank order. Kendall coefficients of concordance (W)
reported here are generally low reflecting the diversity of individual reasons for rankings. This methodology has been used
in prior investigations (approximately 30 studies) with approximately 4800 children.
Descriptive statistical summaries were applied to the qualitative data (frequency of contact) and the childrens attributions (reasons for choices or ranking) for their first and last
preference rankings. Students t tests for independent samples
evaluated mean ranking changes within the group with cleft
lip and palate. Nonparametric statistics were not used in this
analysis; although the data (rankings) are noncontinuous, they
are replete with ties (same ranks across multiple subjects).
Therefore the use of the Mann-Whitney U test is not recommended (Conover, 1999) because the data violate key assumptions that are not correctable and the power of the Mann-Whitney U test is substantially reduced. Subsequently, the Students
t test for independent samples remains the most robust and
valid test for these ranked data despite potential violations of
both type I and II error that does not effect the outcome (Hsu
and Feldt, 1969). Facial ratings were summarized, and a reliability correlation (Ebel, 1951) was computed for the raters of
facial status. Confidence intervals are presented for each total
groups means (facial and control) to assist in interpretation.
Power calculations and effect size are not available for the
nonparametrics but are calculated on the Students t test analyses. Data analyses were completed using SPSS for Windows
(1999).
RESULTS
Facial ratings of all children were completed independently
by two speech and language pathologists and a clinical psychologist with extensive experience with facial disfigurement.

Ratings were completed using 3-by-5-inch color high-quality

full frontal facial photos of all children. All pictures were completed at the time of a clinic examination and child interview.
The rating index consisted of a six-category scale ranging from
category 1 (signifying normal facial figurement) to category 6
(indicating severe facial disfigurement). The intraclass reliability for the mean rating scores of the ratings obtained according to the intraclass correlation formula for average scores
is presented by Ebel (1951). This reliability procedure resulted
in an intraclass correlation coefficient of .96. Similar intraclass
correlation coefficients of .84 had been reported by Richman
(1976) and Millard (unpublished data) in children with facial
clefts.
Preference Rankings
Facial group (FG). Table 1 displays the results of the child
interviews for the FG group in response to the question, Who
would you like to play with the most? The Kendall W was
significant (p # .01) for each sex, boys W 5 .09 (p # .001),
girls W 5 .26 (p # .001), and the entire group, total W 5 .10
(p # .001). The ranking, no disability (1) through crutch/
brace (6) was not random. The child with no disability is
selected as their first playmate as in all prior studies. There
were some sex differences within the FG group, with girls
showing lower preference for obesity and higher preference
for the arm-hand deformity. Boys, however, were more positive toward those in wheelchairs and less positive toward armhand deformity. Both sexes in the FG group reported a higher
preference in contrast to the American normative standard (Table 1; Richardson, 1983) for facial differences, children depicted with obesity, and those in wheelchairs.
Control group (CG). Table 2 displays the results of the child
interview for the CG group in response to the question, Who
would you like to play with the most? The Kendall W was
significant (p # .001) for each sex, boys W 5 .14 (p # .001),
girls W 5 .16 (p # .001), and the entire group total W 5 .15
(p # .001). The ranking no disability (1) through crutch/
brace (6) was not random. Those in the CG group selected

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Cleft PalateCraniofacial Journal, November 2001, Vol. 38 No. 6

TABLE 2 Preference Ranking of Control Children

Boys
Mean
11.16
Age

Rank
1
2
3
4
5
6

(n 5 30)

Mean
2.20
3.40
3.50
3.73
3.90
4.26

N
H
O
W
F
C

Girls
SD
1.44

Mean
10.34

SD
1.86
1.52
1.65
1.83
1.32
1.36

N
H
O
F
W
C

SD
1.17
(n 5 38)

Kendall W .14*

Mean
2.31
3.00
3.60
3.73
3.86
4.47

American
Normative

Total
(n 5 68)

SD
1.86
1.48
1.28
1.36
1.97
1.40

N
H
O
F
W
C

Kendall W .16*

Mean
2.26
3.17
3.55
3.80
3.81
4.38

SD
1.84
1.50
1.44
1.34
1.90
1.38

Confidence
1.812.71
2.813.54
3.203.90
3.484.13
3.344.27
4.044.71

N
C
W
H
F
O

Kendall W .15*

Data from Richardson and colleagues (1983).

95% upper and lower confidence intervals for each total mean.
N 5 no disability; W 5 wheelchair; O 5 obese; F 5 face; H 5 hand; C 5 crutch/brace.
* p # .001.

the child without a disability as their first choice, similar to all

earlier results. There are few sex differences in this control
group in contrast to the FG group and earlier studies (Harper
et al., 1986; Harper, 1995, 1997, 1999). Children in this group
(CG) are more positive (lower ranking) in their preferences for
children depicted with an arm-hand deformity, those with obesity, and those with facial differences when contrasted to the
American normative standard (Table 2; Richardson, 1983) and
data reported by Brantley and Clifford (1979) for children with
a facial cleft.
Surgical Repair and Preference Rankings
It was suspected that a fundamental reason for a low-preference (higher rank) ranking toward the child with the cleft
from those with facial differences may very likely reflect a
personal awareness of reacting to their own appearance because of the frequent explicit and implicit social rejection of
others combined with the common problem of major dysfluencies in verbal communication with peers. Presumably if such
visible and communicative differences were repaired, modified, or habilitated, the preference ranking for a child depicted
with a cleft in these actual interviews by those with a facial
cleft (lip or palate) might improve (e.g., become more positive
with a higher preference, a lower rank suggesting more comfort with their own differences). It is acknowledged that there
are a multitude of reasons underlying this assumption. Nevertheless, a more positive play preference ranking might reflect
a more positive self-esteem of those with such differences.

TABLE 3 Cleft Group Lip and Palate Status at Assessment

Girls
(n 5 17)

Lip only repaired: 3

Lip only unrepaired: 2
Palate only unrepaired: 4
Lip repaired/palate unrepaired: 6
Lip/palate unrepaired: 2

Boys
(n 5 37)

Lip only repaired: 3

Lip only unrepaired: 7
Palate only unrepaired: 3
Lip repaired/palate unrepaired: 14
Lip/palate unrepaired: 10

This aforementioned factor possibly reflects the next comparison in this study.
Children in the facial group in this study represent several
different subgroups (Table 3): (a) those who have had a previous surgical repair and those who have not had any surgical
repair, and (b) those in each of these groups exhibiting different types of facial impairment (i.e., cleft lip and palate, cleft
lip only, and palate only). Children in the palate-only group
were included because of their communicative difficulties.
Children with existing prosthetic obturators were not included
in this study.
Those children with a prior surgical repair (lip only repaired
or lip repaired but palate open) and those without surgical
repair (lip only, lip and palate, or palate only) were compared
in their mean-average ranking of the child depicted with facial
differences among the six pictures. Students t tests were used
to evaluate differences in mean rankings of the child depicted
with a facial difference for each sex and the total group in the
FG, contrasting the repaired versus unrepaired groupings (Table 4). Those who had (total group) surgery (repaired, n 5
26) reported a mean rank of 3.31 for the child with a facial
cleft versus those who had not yet completed surgery (unrepaired, n 5 28) reported a mean rank of 4.11; t 5 1.75, df 5
52, p # .08). The boys who had surgery (repaired, n 5 17)
reported a mean rank of 3.29 for the child with a facial cleft
versus those who had not yet completed surgery (unrepaired,
n 5 20) reported a mean rank of 4.30; t 5 1.84, df 5 35, p
# .07). Finally, the girls who had surgery (repaired, n 5 9)
reported a mean rank of 3.33 for the child with a facial cleft
versus those who had not yet completed surgery (unrepaired,
TABLE 4 Cleft Group Lip and Palate Status at Assessment:
Facial Ratings
Boys
(n 5 37)

Girls
(n 5 17)

Repaired
Unrepaired

n59
n58

Mean/SD
2.88/.83
3.58/2.41

n 5 17
n 5 20

Mean/SD
2.79/.86
4.78/1.65

Harper and Peterson, ATTITUDES TOWARD IMPAIRMENT

TABLE 5 Control Children: Selected Attributions

Least Preferred*
Normal
She looks aloof.
She could find others to play.
He has no disability and does not need care.
He already has friends.
Normals are proud.
Obese
She is fat.
He is fat and strong.
He is fat and helps me eat healthy food.
He is fat.
I do not like him.
Crutch/Brace
Hard to walk. He has the biggest disability.
He is sick and cannot walk.
Cannot walk . . . cannot play well.
He is crippled.
Hand
She cannot use arm. He is not friendly.
He cannot play my games.
He cannot play by himself.
Crippled and cannot play.
Face
I would not be able to understand her. Cannot talk well.
He/she has a defect. Cannot understand . . . leads to a fight.
He looks old, ugly.
I have a classmate like him.
Wheelchair
Hard to play in a wheelchair.
Not able to play well.
He will play slow.
He has the biggest disability.
* Children asked, Why did you leave this one last?
Most frequent response within category.

n 5 8) reported a mean rank of 3.62; t 5 .33; df 5 15; p #

.72.
Although none of the differences are significant, the children
who had completed surgical procedures reported more positive
(lower) rankings of the picture of the child with a facial cleft.
Using a power analysis of Students t tests for the acrossgroups comparison, the effect size (d) was calculated using the
pooled standard deviation (SD 5 1.709), resulting in d 5 .47.
Entering the power table for a two-tailed Students t test, alpha
5 .05, n 5 27 (harmonic mean for unequal ns [n 5 27]), and
d 5 .50 results in a power estimate of 43. There is a 57%
chance that one would miss a significant result given these
circumstances. Given a moderate effect size (Cohen, 1988) and
the probability (57%) of a type II error, a larger sample would
improve power and may yield a significant result.
Reasons for Choices of Children With Facial Cleft
Children in both FG and CG groups reported reasons for
their initial play choices and the last choice. Of the 54 children
in the craniofacial group, 52 reported reasons for the first and
last choice. The two who did not said, I dont know. All 68
children in CG offered reasons for these first and last choices.
Most frequent responses associated with each picture for each
group are noted in Tables 5, 6, 7, and 8. Briefly, those with a
facial cleft (lip or palate) who ranked the child with cleft last,

571

least preferred, indicated the following explanations for their

choice: problems in verbal communication, ugly, teasing,
looks like me, and cannot play ball. Children in the CG
selecting the child with a cleft as last, least preferred, reported
their reasons as follows: communication difficulties, defect appearance, teasing, and fears that play activities would make
the cleft worsen and they would be rebuked by the parents of
the child with a cleft as a result. The most frequent reasons
for low play preference identified by children with clefts and
those without such differences relate to communication and
appearance. Interestingly, both study groups, those with clefts
and controls, acknowledge that facial appearance seems to
negatively spread to the functional skills of the person (i.e.,
cannot play). Childrens reasons for their preferences may also
be related to their understanding or awareness of causation, a
finding recently noted by Reed et al. (1999) as well. The explanation and attributions of those in the CG (Tables 5 and 6)
present a mix of attitudes, seemingly inconsistent combinations
of positive and negative attitudes that appear ambivalent. Similar interpretations have been offered by Ries and Hodgins
(1995) in reviewing the literature on responses to those with
physical handicaps. The reasons for these responses are complex and will be noted in the Discussion section.
Frequency of Awareness and Contact and Preference
Ranking
Following each childs completion of the preference rankings, they were interviewed regarding their reported contact
and general awareness of those with the physical disabilities
depicted. These data represent a structured interview designed
to report percentage of contact with the disabilities depicted.
Results of contact are summarized across each group (FG/CG)
for each physical disability and are presented in Table 9. The
data were analyzed by testing for differences between proportions (Conover, 1999) of the respective groups (cleft, control)
for each of the six picture categories. There were no significant
differences (facial z 5 .03; obese z 5 .28; wheelchair 2 5
.01; hand z 5 .01; crutch/brace z 5 .02) between the groups
in each category. No differences are apparent between the
groups in the frequency of reported contact with disabilities
depicted.
DISCUSSION
Children in the Philippines without disability share some
important similarities to their peers preferences toward physical disability from other countries throughout the world. It
seems likely that disability preference is affected by the perceived impact of the disability on play interactions. In this
respect, the higher a disability is ranked, the lower its preference by children. This ranking may reflect both frequency of
contact (e.g., familiarity) and severity of physical impairment.
Disabilities with low frequency and high functional impact
(crutches/brace) are least preferred, again a finding noted

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Cleft PalateCraniofacial Journal, November 2001, Vol. 38 No. 6

TABLE 6 Control Children: Selected Attributions

TABLE 7 Children With Facial Differences: Selected

Attributions

Most Preferred*
Normal
She is thin; she can play.
She/he is normal.
She looks neat, nice.
He/she can play with me.
No defects.
He is healthy.
Obese
He is fat and can play.
He is nice because he is fat.
She has no defects; she okay.
Because he is kind of normal.
Crutch/Brace
He is sick and cannot walk.
I feel sorry for her/him.
Hand
He does not have much of a disability.
He is missing only fingers.
I feel sorry for her.
Face
She can still play with me.
His cleft will get worse if he plays.
A lot of people tease him.
Children with cleft are kind and understanding.
Even if she has a defect . . . she is nice to play with.
Wheelchair
I feel sorry for her. He has no one to play with, cannot play well.
He has fewer friends, so I picked him first.
I will play with him, and he will be happy.
Looks sad, and cannot walk. I pity him/her.
Has the worst disability.
* Children asked, Why did you pick this one first?
Most frequent response within category.

Least Preferred*
Normal
I do not like him.
I do not know, no answer.
I do not know him.
She is pretty.
Obese
I do not like him.
She does have a good attitude toward me.
He/she is fat.
She is so fat, she will quarrel with me.
Crutch/Brace
He is crippled.
Bad to look at crutches.
He has crutches.
She is not nice.
Hand
He has no arm, he is disabled.
He is crippled.
Do not want to play . . . he is crippled.
She has no hand.
Face
He has a cleft and cannot play ball.
Because he cannot speak well.
We will tease each other . . . we cannot understand each other.
Cannot understand him.
She is ugly.
Wheelchair
He does not play well, cannot walk.
He is crippled.
I might get hurt by the wheelchair.
He looks quarrelsome.
She is nice and will still play with her.
* Children asked, Why did you leave this one last?
Most frequent response within category.

across other studies from the United States and other countries
(Harper, 1999).
The results of the preference ranking interviews with the
children from the Philippines with facial clefts (FG) of the lip
or palate reveal both similarities and differences as contrasted
to Harpers (1995) earlier Western and non-Western studies
(Harper, 1997). The FG group uniformly selected the child
without a disability as their first and preferred playmate. Similarly, those in the CG endorsed the child without a disability
as their initial most frequent choice. A universal preference
exists with participants selecting those without a disability as
a preferred playmate (Richardson, 1983; Harper et al., 1986;
Harper, 1995, 1997, 1999). Children in the CG reported preferences for playmates with physical disabilities that have less
impact on play and social communication skills. Both groups
(FG and CG) reported similar low play preference (last choice)
for children depicted with crutches and a brace. These latter
disabilities reflect the least common disability present in childrens contacts in Negros and also those physical disabilities
with high functional impact (legs). Neither group reports significant rejection or high preference for obesity in contrast to
earlier findings (high rejection in the United States, high preference in Nepal) by Harper (1995, 1997). The FG reported a
higher preference for children in wheelchairs (second choice
after normal), compared with their nondisabled peers in Bacolod City, and in contrast to children in the majority of studies
by Harper (1995). The only other physically disabled group

who reported such a high preference for those using wheelchairs was adolescents with orthopedic-mobility disability
(wheelchair users) from the United States (Harper et al., 1986).
This latter preference for playmates using wheelchairs from
the facial cleft group in the Philippines may reflect a more
sympathetic response to those peers with obvious physical disability. This is supported by their comments (i.e., Tables 7 and
8).
The FG overall group ranking depicted children with facial
differences in the middle (fourth for boys, third for girls), and
those in the CG are somewhat lower comparatively (fifth for
boys, fourth for girls). Facial differences are quite common in
the Philippines among the depicted disabilities, at least compared with the other areas studied by Harper and colleagues.
This higher frequency might impact attitudes in a more positive fashion in general. It is likely that there are multiple as
well as different reasons maintained by children in these two
groups (FG and CG) for their play preference rankings toward
those depicted with a facial cleft. Childrens preference rankings in the CG (Tables 5 and 6) in regard to those with a facial
cleft likely reflect some combination of the following: unfamiliarity, rejection, lower priority of play choice in relation to
other visible differences depicted, avoidance related to uncomfortableness in social or verbal communication, and fears
based on existing cultural mores and myths (Cheng, 1990;

Harper and Peterson, ATTITUDES TOWARD IMPAIRMENT

TABLE 8 Children With Facial Differences: Selected

Attributions
Most Preferred*
Normal
He can play ball. He looks complete.
He is nice. Not disabled.
He is handsome. I like him.
She/he has no disability.
She is pretty.
Obese
He is who I want.
I like him . . . he/she is okay.
Crutch/Brace
No selections.
Hand
So they can play well and run.
We are friends.
He has no one to play with.
Face
We are the same and equal.
He is like me . . . we do not speak clearly.
He is just right. She can walk.
We are the same.
I like him. She is nice.
Wheelchair
I would like to try his wheelchair.
I like his wheelchair.
Wheelchair looks nice.
His speech is okay, not like a cleft boy.
I pity her because she is crippled.
* Children asked, Why did you pick this one first?
Most frequent response within category.

Shaw, 1981b). Children in the FG who reported a low play

preference for playmates with a facial cleft may have many
similar reasons as their peers without such physical differences
of the lip or palate (Tables 7 and 8).
Although infrequent, some children in both groups (i.e.,
those with clefts and those without any physical disability) did
select a child with a cleft as their preferred playmate. Children
with facial differences who selected the child with cleft first
(i.e., most preferred) as a playmate seem to be making a positive self-affirmation and explained this choice by noting that
they selected this as their first choice because he/she is like
me, we are the same. Other positive reasons from these children include a personal liking (shes nice, just right) or an
acknowledged compatibility and that the cleft does not inhibit
play activities in comparison with the other disabilities depicted. Control children who responded by selecting a child
with a cleft as a preferred playmate reported largely sympathetic responses as their explanation for their selection.
Data from earlier studies (Harper et al., 1985, 1994; Harper,
1997) have suggested a general relationship between frequency
of contact or familiarity and severity of impairment or prevalence of these disabilities depicted and their impact on childhood preference ranking. Generally, in earlier studies (Harper,
1997), there appeared to be an association between amount of
contact and general frequency of disabilities and subsequent
ranking. Also the lower the contact, the more severe the disability and the less common the disability. The data presented
here in this study do not conform very well to these notions

573

TABLE 9 Frequency of Contact

Face

Obese

Wheelchair

Hand

Crutch/
Brace

Facial group,
n 5 54

27
50%

9
17%

8
15%

7
13%

3
5%

Control group,
n 5 68

41
60%

12
18%

7
10%

6
9%

2
3%

Subject Group

(Table 9). On the basis of what we know about physical disabilities in the Philippines, children with facial disfigurement
would likely be more common than those with visible physical
disabilities and therefore have relatively frequent contact for
either the FG or the CG. Children in wheelchairs and those
using a crutch or brace are of very low prevalence in this
culture.
Children with a facial cleft received lower preferences for
play interaction from their nondisabled peers in the Philippines
in comparison with other physical disabilities. The child depicted with a facial cleft is often avoided more (not preferred
as a playmate) than others with more physically interfering
disabilities (e.g., wheelchair, arm-hand). This finding is similar
to all other countries studied in the Western and non-Western
world. This visible and physical difference is not the only aspect that affects this play interaction. Clearly many children
with such facial differences also have associated and significant communication difficulties because of other oral-facial
and palatal problems. Communication can be difficult to understand for others and subsequently avoided for a variety of
reasons on behalf of peers. Such communication difficulties
are also common in some neuromuscular disorders (e.g., cerebral palsy), also resulting in avoidance (Harper, 1991). These
problems in communication often become among the more
significant factors in the interpersonal interactions and subsequent interpretations leading to social avoidance (Jones et al.,
1984; Richman, 1991) and negative social value of the person
with such communication problems. Children clearly avoid
and tease others that may make them feel uncomfortable
during social interaction (Gething, 1991; Gerrard, 1991).
Children with facial differences reported some similar preferences as their nondisabled peers for playing with peers with
physical disabilities. Those without physical disabilities are
uniformly favored over all depicted disabilities from those
children with facial differences. The data in this study do not
suggest that children with a facial cleft who have had a surgical lip repair reported significant differences in their ranking
of the cleft picture. However, these children tended to respond with a more positive preference ranking (lower average
rank) toward children depicted with facial differences when
compared with those children with facial or palate differences
who have not had any surgical repair. Such children in this
study who have undergone some surgical repair offered more
positive self-statements for their choice of child with cleft as
a preferred playmate and rated the child with a facial cleft
more positively. These repairs would suggest a trend toward
more positive self-esteem for those who receive such treat-

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Cleft PalateCraniofacial Journal, November 2001, Vol. 38 No. 6

ment. This is true for those who have completed lip repairs
but with existing palatal surgical or prosthetic closure to be
done in the future. Clearly, more empirical data are needed in
this area.
Interestingly, those children who receive a complete repair
of the lip and palate logically might respond in an even more
positive fashion to this interview-play procedure. Such children who experience the benefit of facial changes (lip repair)
and improvements in communication (palatal repair) might experience additional gains in self-esteem. However, communication improvement (broadly defined) may not be axiomatic
following palatal closure without the assistance of speech or
language therapy. Children who have major speech dysfluencies and are highly inhibited for several years do easily recover
communication and social skills on their own or show significant improvement (Heller, et al., 1981; Bardach et al., 1984;
Richman, 1983, 1991). It might be useful to focus on these
social behaviors as suggested by Rumsey (unpublished data)
and Tobiasen (1995) and provide specific social skills training
for the child in combination with assistance for the family
dealing with negative social reactions (Tobiasen, 1995). Harper
and Peterson (2000) have suggested that training in self-disclosure about the disability by children with disabilities and
their families can be very helpful in promoting positive social
interactions, reducing stigmatizing attributions, and promoting
positive self-affirmation. Children, when trained, can offer relevant information about their disability combined with other
positive disclosure (Rotenberg, 1995). Acknowledgment of
such information has revealed benefits on both sides of the
interpersonal dyad (Hustorf et al., 1979; Gresham, 1982; Sigelman and McGrail, 1985; Royse and Edwards, 1989; TingTomey, 1991; Burmeister and Prager, 1995). Such public and
more open clarification of disability has been noted by Goffman (1963) who offers specific coping strategies.
These interview data based on childrens responses to a selfreported picture ranking task provide suggestive and preliminary empirical data validating what some children with facial
clefts (lip or palate) experience following surgical treatment,
an increase in reported positive self-esteem (Lefebvre and Barclay, 1982; Pertschuk and Whitaker, 1982, 1985; Arndt et al.,
1986; Palkes et al., 1986). There are numerous benefits from
craniofacial surgery but less evidence documenting reliable
and valid interpersonal changes, especially in large groups of
treated children. These data and outcomes await further replication and refinement.
Childs Personal Response
Many children with existing clefts (lip or palate) were reported to experience significant teasing and physical aggression from peers and in some cases adults. It was not uncommon for children to become increasingly inhibited to the point
of complete school avoidance and virtual silence outside their
home and immediate family. Children were routinely described
as very shy and preferring to stay at home and play alone
or with siblings. Parents reported quite accurately that their

worries for their children reflected much child sadness and, in

several instances, depression or withdrawal-like symptoms.
Again, numerous stories reflected the increasing withdrawal of
children with unrepaired clefts as they became adolescents, a
difficult time also noted by Richman (1983), Richman, et al.
(1985) and Richman and Millard (1997). The personal pain
and anguish were overwhelmingly evident in the parents comments, emotions, and their childrens faces.
Twenty-six children and families were interviewed following their initial surgical repair (6 lip only and 20 lip repaired
with open palate) returning for palatal closure or obturator, etc.
These initial repairs were completed on the children in most
instances in the previous year in Bacolod City by Operation
Smile personnel and local professionals. These children were
between 10 and 14 years of age and were of both sexes. Parents reported that following surgery, children experienced a
reduction in teasing from peers when they returned to school,
were less shy, and seemed to have more positive self-esteem.
Parents continuing concerns were related to anticipated improvement in the childs communication ability (will speak
clearly) following palatal closure. Expectations focused on further education and a hope for the child to act normal. The
future became more optimistic for these children in their parents opinion following surgical treatment in the parents reports.
CONCLUSIONS
Children in the Philippines share similarities to their peers
in many countries throughout the world in their expressed play
preferences and attitudes toward visible physical disabilities.
All children recognize that physical disabilities may interfere
with play and social interactions. Children in the Philippines
respond to their playmates with physical disability on the basis
of their familiarity and amount of contact with a particular
disability and a specific child and to the extent that the disability is perceived as interfering with play opportunities
(physically or interpersonally). Children of the Philippines
without disabilities in this study did not express any unique
(either for or against) preference toward children depicted as
obese. This outcome toward obesity (actually higher preference) is in contrast to prior Western (low preference) and nonWestern (higher preference) studies (Harper, 1995).
Childrens attitudes toward their peers with facial differences in this study reflected low play preference and avoidance
as shown in all earlier studies (Harper et al., 1986; Harper,
1995, 1997, 1999). Children with facial differences are frequently selected next to last by their peers without physical
disabilities in this analog study. Peers without physical disabilities also report some illogical reasons for avoidance of
those depicted with a cleft (e.g., cannot play). Again, when
the face is the center of differences, such perceived difference often generalizes or negatively spreads (Wright, 1983;
Bull and Rumsey, 1988; Harper, 1999) to other features of the
person. It is also likely that these peers without physical disability may have experienced difficulty in communicating with

Harper and Peterson, ATTITUDES TOWARD IMPAIRMENT

those with facial differences (palate, etc.) and may be indicating that the person did not want play with them or also that
they (peers) experienced some unspecified discomfort in this
former interaction. Several authors reported confusion and
misinterpretation on both sides of this dyad (Tobiasen, 1995).
Such reactions are not unusual given the noted shyness and
inhibition of those children with clefts (lip or palate; Richman
and Harper, 1978; Bull and Rumsey, 1988).
General social inhibition of those with clefts of the lip or
palate is well documented (Richman et al., 1985; Kapp-Simon
et al., 1992) Regardless of the reasons underlying the low play
preference for children with facial differences, avoidance is
common, and social uncomfortableness is likely high on each
side of this interpersonal dyad. It also must be emphasized that
a small minority of peers without physical disability do respond more positively in their play selections toward the child
with a cleft and to children with other visible physical differences (Table 6). Often such positive responses are based on
early and close contact (e.g., playmate, friend, relative, etc.)
with someone with facial differences or other visible physical
differences. Some children also express genuine sorrow and
concern and kindness as a basis for this play preference
as well. Similar conclusions are noted by Katz (1981). Less
favorable reasons include pity and those wanting to look
good for the interviewer. Quite frankly, these latter acquiescent response (saying good things) styles are less common in
children on the basis of interviewing more than 1400 children
in a variety of Western and non-Western cultures.
Children with facial difference (cleft lip or palate) in this
study offered a more positive preference for the child depicted
with a facial cleft after they had some degree (usually lip repair) of facial reconstruction. This change, although nonsignificant in this study, reflects an encouraging trend and would
seem to signal that more positive self-esteem follows an improvement in ones physical and communicative features. It is
acknowledged that data presented here are preliminary and
require both replication and refinement. However, the data outcome is robust given the randomness of the sample and the
low fidelity of the interview procedure tasks generally with
children. Children with a facial repair noted here do verbalize
more positive self-statements following such surgical assistance in this Philippine culture. These statements need to be
linked to identified behavioral changes in future studies. The
attributions offered by the children for their play choices (Tables 5, 6, 7, and 8) represent a valuable repository of explanations that may assist health care researchers and professionals and parents in understanding and reducing the stereotypes
associated with visible physical differences in children.
Several methodological issues are worth noting in this study.
The data in this study (picture rankings) were not normally
distributed, which may present some underlying threats to any
form of statistical analysis and subsequent generalizability. It
is also evident that the unequal sex distribution across samples
may have influenced the findings and limited some generalizability. Equal sex distribution of children may have given
somewhat different results, although the results across groups

575

are rather similar and consistent with many earlier studies by

the senior author. Finally, the literature on picture-ranking
studies (Yuker, 1983) and attitude study has been plagued by
the relatively low relationship between what respondents say
and what they do, the important attitude-behavior link. Clearly,
there are more data identifying differential responding to this
picture-ranking task, compared with available behavioral data
linking these expressed verbal preferences to specific real-life
actions of their respondents. In this respect, this study remains
an important analog paradigm for potential social interactions
among children with and without particular visible disabilities.
These data highlight the need for more studies in naturalistic
settings attempting to link the childs preference rankings to
specific behavioral outcomes among their peers. Studies that
incorporate behavioral observations linked to attitude report of
children are needed.
Acknowledgments. This pilot study was completed with the permission of Operation Smile International. Specific recognition is also directed to Project Hope
and Edith Y. Villanueva for invaluable assistance. Special thanks go to the
children and families of Negros, Philippines, who freely gave of their time and
provided us with valuable insights to their courage and hopes. Finally, thanks
to J. Murray who facilitated all aspects of this study with encouragement and
enthusiasm. Special thanks to D. Clay, H. Morriss, and L. Richman for comments on early drafts of this manuscript, and R. Forsyth and H. D. Hoover for
statistical consultation.

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