Each of these types of cognitive responses has its own set of emotional reactions.

We
encourage adolescents to identify both their feelings and the phsycologic reactions that
accompany them. For example, the adolescent who states she is satisfied with her appearance
may report feeling high levels of anxiety and a phsycologic response of a stomach ache, when
faced with the prospect of surgery. Further exploration of the issue may help the adolescents
identify personal conflicts about future surgery. This model opens the door and stimulates the
adolescents to talk openly.
A similiar approach can be used with parents when they find themselves in conflict with their
adolescents child. For some families the struggle over additional surgeries is part of greater
parent versus adolescents power struggles. The disagreement about surgery may represent
just one more conflict area. For others, however, the struggle relates to the parents own need
to fulfill their perceived obilgation to their child. For these parents, their automatic thoughts
are : We need to make sure that everything is done that the doctors recommend. When he
was born this plan was outlined for us and we cant stop now or we will have failed our
child. Feeling associated with these thoughts include anxiety, guilt, and sometimes anger
that their child is making them appear at fault. Phsycologic reactions vary, but may include
tightness in the chest, headaches, or even weepiness.
In treatmnet, once these differing perspectives have been identified, the parents and child can
be guided throught a joint sharing of feelings during which they are encouraged to examine
the other persons perspective and to arrive at a mutually agreeable plan of action (see
Fishman, 1988 and Foster and Robin, 1988 for additional treatment strategies). As them
members, we have no set rule about what that action should be. Our role is to facilitate a plan
that meets the familys needs at the present time.
SOCIAL COMPETENCE
The interpersonal demands of adolescents can also be difficult for some children to master.
This difficulty is ilustrated in some of the early studies on adolescents with clefts, which
suggested that pshycological difficulties, when they occured, were evident in the social
domain. Tobiasen reported that 57% of children between 12 and 16 years of age were rated as
less socially competent than their peers and 20% were in the maladjusted range (Tobiasen et
al., 1992). Richman (1983) found that about half the adolescents he studied demonstrated
significant adjusments problems, most in the area of social adjusments problems. KappSimon and colleagues (Kapp-Simon et al., 1992) found that parents associated better social
skills with better adjusment and less behavioral inhibition in the teen years.
Most of the literature on children with cleft lip and palate is based on parent, teacher, or selfreport. However, McGuire and colleagues (1992) obtained observation data on young
adolescents with visible facial differences in the school setting. They found that adolescents
with facial differences made fewer approaches to theirs peers and, it turn, were approached
less frequently by peers than children without facial differences. Additionally, they were more
likely to engage in ineffective approach behaviors than were their peers. They tended to
watch rather than participate in peer interactions behavior described by others as
hovering (Coie and Kupersmidt, 1983: Dodge. 1983). Their physical stance when they did
venture forth included infrequent eye contact, slouched posture, and a monotonous tone of
voice. Even when they did attempt to interact with a peer, the effort was so tentative and
distant that they were often ignored.
The inability to make or keep friends when one is teenager is significant and should not be
glossed over lightly. Adolescents is the time when peer relationships should take on a primary

focus in each childs life. As stated earlier, it is appropriate for the adolescents to move away
from family and establish important relationships of their own. Failure to do this hinders the
process of individuation which is necessary for the adolescents to mature into a productive
adult (Bloom, 1980).
The question then arises regarding what kinds of intervention might be appropriate for these
adolescents. Clinical experience suggets that many adolescents who are having social
difficulties take the stand that the cause of their problem is their facial demorfity, and if
surgery could be done sooner or were more successful, the they wouldnt have these
problems. Certainly, it is recognized that appearance that differs from the norm can be
stigmatizing and that there is a societal (and particulary adolescents) bias toward fitting in
(MacGregor, 1990). In addition, for some teens, improving facial appearance through surgery
can have a beneficial psycological effect. However, the social behavior of the adolescents
can also play a pivotal role in how people respond to him or her. Thus, treatment efforts
recommended for the adolescents include a multi intervention approach of improving
appearance through surgery and, when appropriate, use of make-up, and teaching the
adolescents specific social skills that help them feel more comfortable with their peer group.
The remainder of this article will detail an approach to social skills training which would be
appropriate for adolescents with cleft lip and palate.
SOCIAL SKILLS TRAINING
Kapp-Simon and Simon (1991) have developed a program for teenage children with special
needs that focuses on five basic categories of skills : (1) social initiation, (2) conversational
skills, (3) assertion or direct communication, (4) empathy or active listening, and (5) conflict
resolution and solving. The initial focus of the program is on the development of selfawareness, the program promotes the age-appropriate development of identity formation.
Self-awareness in turn serves as a precondition for self-control, self-expression, selfdirection, and the ability to relate to other with empathy.
The Self-Understanding Model attempts to integrate the significant aspects of personal
experience onto an interlocking whole. In the context of social skills training, the adolescents
are encouraged to develop an awareness of their physical sensations, emotional arousal,
cognitions, and behavior patterns both as individuals and as they relate to one another. For
example, an adolescents who is not invited to a party may attribute the exclusion to having a
cleft lip and palate rather than to acknowledging a personal tendency to stay on the side-lines
in conversations at school. When encouraged to identify the components of the SelfUnderstanding Model associated with the exclusion, the adolescents might report thoughts,
such as, I look terrible or If I didnt have this scar I would have been invited. Identified
feelings might include anger or resentment which continues to build as the individual
considers the unfairness of the situation. Body reaction might include a stomach ache or
headache. The action might be to avoid talking to any of the kids going to the party or even
staying home from school around the time of the party to avoid hearing the kids talk about it.
After those maladaptive, but very common reactions are discussed, more adaptive coping
techniques are presented and discussed. Adaptive thoughts to replace If I didnt have this
scar, I would have been invited might be Im not the only one who wasnt invited, Chris
and Jaime werent either and they dont have anything wrong with them; or Maybe I need
to be friendlier. Initial feeling might still include dissappoinment and anger, but with more
adaptive thoughts could slowly be replace with determination and hope. Body reaction like
the aches in stomach or head may also dissipate as the adolescents becomes more involved
with adaptive behavior, such as reaching out to others. In contrast to the withdrawal, actions

may include attempts to be friendlier in school, or effort to talk more with classmate.
Repeated use of this type of paradigm develops the adolescents awareness of how their own
thoughts, feelings and behaviors are interrelated. It also gives them a sense of control as they
recognize that they can positively affect their behavior by monitoring their thoughts and
recognizing their feelings and body reactions.
Sel-awareness forms the backdrop for teaching other skills. The first of these is Social
Initiation. As disscused above, social inhibition is a very common characteristic of
adolescents whose appearance differs from the average. The adolescents with residual
scarring from a cleft lip does face an extra challenge at the beginning of relationship when
they want to be recognized for themselves and not looked on as someone who is different. In
teaching social initiation, we first draw open the self-understanding model in an effort to help
the adolescents recognize how they are currently reacting to a situation which calls for social
initiation. Typically we might ask the teen to imagine herself entering the school yard where a
group of classmates are talking. We prompt, You know these students but are not close
friends. How would you go about getting involved in the conversation with them? An
amazing number of the adolescents we have worked with respond by saying they would not
try. They finish the scenario by sneaking into the school by a side door or walking to the far
side of the schoool yard until the bell rings for them to go in.
We counter this response by teaching specific group entry techniques through didactics, role
play, and video modelling. These include : (1) listening for the topic being discussed by the
group and preparing a comment on it rather than changing the topic, (2) asking questions
about the topic at hand, which is more effective than raising a question that is not pertinent to
the discussion, (3) reacting to someone elses statement, or (4) sharing an opinion. Also
discussed in this context are the pheripheral skills required to make oneself acceptable to a
group (e.g., teaching the adolescents to look directly at the person he or she is speaking to,
using a pleasant tone of voice which is loud enough to be heard, or smiling and using non
verbal cues such as head nods when listening to anothers response are samples of the kinds
of skills which are covered).
The next group of skills, conversationals skills, are geared to keep up the contact with peers.
In addition to initiation skills, some of the basic ones include: (1) staying on topic, a skill that
demonstrates continued interest in the other group members concerns, while providing a
focus which keeps the discussion moving, (2) taking turns, a skill which enables the
adolescents to learn how not to monopolize the conversation by balancing talk about self
(self-dislosure) and by either asking questions of the other, or listening to self-disclosure of
others, and (3) giving compliments, a skill which descreases the adolescents focus on self by
forcing him or her to identify competencies in another person.
In the contaxt of teaching initiation and conversation skills, we also focus on axiety
management. The adolescents is initially taught to recognize to onset of anxiety. For many
people this is best done via awareness of a physical cue (e.g., sweaty hands, fluttering heart,
dry mouth). This recogition again draws on the self-awareness taught throught the SelfUnderstanding Model. Once the adolescents recognize the symptoms of anxiety, they are then
directed to take a relaxing breath as means of focusing themselves. Next they are taught to
remind themselves of the specific coping techniques, which they have already identified. An
example of positive coping for a boy about to go on an initial date with a high school soccer
player might include a self-statement such as, Shell be nervous too. If I direct teh
conversation to soccer, I know shell have a lot to say and it will help us both feel more at

ease. The next step is to actually perform the coping strategy. Finally, the adolescents gives
hemself positive feedback for using the coping schema.
The coping skills which are taught to handle social anxiety are also applicable to presurgical
or dental anxiety. The adolescents can be taught to anticipate the aspects of a surgical or
dental procedure he or she will find stressful and plan a coping response. When faced with
the situation, they implement the steps outlined above to help themsleves cope more
effectively. In most cases, this can be done without any embrassment to the adolescents,
because no one else need know what they are doing.
Another social skill which is taught is called direct communication or assertion. This skills
provides the adolescents with techniques which are a direct counter to the inhibition and with
drawal, which is a common tendency for adolescents with cleft lip and palate. Direct
communication requires the adolescents to express feelings and needs in a clear statement.
Components of the skill which we teach include : (1) use of an I message (i.e., starting a
sentence with I rather than you). Thus a statement such as Youve been very insensitive to
me becomes I felt bad when I didnt get a call from you as I expected. (2) concreteness
(i.e., speaking clearly and specifically about the topic of concern). This requires a specific
statement of feelings, a description of what the event was, which brought about those
feelings, and, if appropriate, a description of ones behavioral response to the situation. (3)
eye contact. (4) straight-forward posture and (5) honest tone of voice, which means the
adolescents tone of voice must be congruent with the intended message (e.g., not quiet and
timid when trying to be assertive).
One of the topic areas often used as a takeoff point for teaching assertion is the handling of
teasing or negative reactions to an individuals differences. Specific techniques discussed
might include: (1) direct eye contact and a smile in response to a curious stare (as opposed to
turning away or attempting to hide ones face), (2) matter of fact responses which provide
information without expression of negative affect, (e.g., Yes, I do have a scar; its from a
surgery I had when I was younger), (3) use of I messages to comunication how they feel
about talking about differences (e.g., I get upset when you talk about my lip every time you
see me. Ive given you an explanation now Id just like to drop it), (4) defocusing from
coment about differences by ignoring the comment and at the same time actively switching
the topic or initiating a positive conversation with a different peer, (5) self-assertion using a
positive reframe (e.g., when teased about needing another surgery, respond by saying, Im
proud of my ability to cope with surgery and Ive learned a lot about medicine and hospitals
in the process).
The next skill, empathy or active listening, teaches the adolescents to focus on the other
persons feelings and actions. Focusing on the other is an important deterrent to selfconsciusness. If the adolescents is attempting to understand the other person, he cannot be
thinking about himself. Additionally when an adolescents expresess understanding of other
peoples esperience, she, herself, will be more appealing. People like to be with individuals
who are good listeners.
Finally, conflicts resolution or problem solving requires an integration of the skills which
have been taught. Steps involved in effective problem solving include (1) definition of the
problem, (2) development of alternative plans of action, (3) obtaining feedback from others
about potential effectiveness of plans developed, (4) decision of specific plans, (5)
implementation of plan, (6) evaluation of plan effectiveness and (7) repeat applicable part of
6 step as needed. To complete these steps effectively, adolescents must first draw on the Self-

Understanding Model to identify the thoughts, feeling, body reactions and behaviors, which
arise in response to the situation. They must than be able to initiate and maintain a
conversation with the peer or adult with whom they have the disagreement. They must be
able to use direct communication to convey their perspective on the disagreement to the other
person and they must use empathy to communicate to the other so that they understand his or
her perspective. Persistence trought each of these steps should allow the adolescents to
reslove problem situations more effectively.
In summary, the interventions we choose to use with adolescents need to be congruent with
the developmental stage of this age group. Additionally, the skills outlined in this article are
life-skills, which are valuable not only in adolescents, but throughout life in employment,
marriage, friendship, and parenting. Development of social competence will enable the
individuals we treat to present themselves to society with confidence and assurance.
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