Journal of Intellectual Disability Research, 1992, 36, 143-155
Teachers' attitudes towards plastic surgery in children with Down's syndrome N. SAVIOLO-NEGRIN & F . CRISTANTE Dipartmento di Psicologia Generate, Universita di Padova, Padova, Italy ABSTRACT. The problem of whether to improve on the physical appearance of children with Down's syndrome by means of plastic surgery is a much debated question which involves bio-ethical and ideological concepts. In this research, the opinions of a group (M=132) of Italian elementary and junior school teachers are investigated on the basis of a questionnaire. Data are analysed through the application of log-linear models, and parameter estimates are calculated for each response category and interactions between response categories and types of teachers. Results show a greater acceptance of children with Down's syndrome as they are by people who have daily experience of them and who can get to know them better from all points of view. On the other hand, plastic surgery for children with Down's syndrome is considered with more favour by people who are less psychologically involved with them.
INTRODUCTION Like other types of 'manipulations' on man (e.g. artificial fertilization and organ transplants), the controversy surrounding the opportunity to improve the physicial appearance of children with Down's syndrome (DS) by means of plastic surgery involves bio-ethical and ideological concepts. In the particular case of DS, the problem is further complicated by psychological, cultural, social and medical factors Society gives more credibility to people who are physically attractive and attribute positive personality characteristics to them, believing them to be kinder, more sensitive and more sociable and extroverted (Dion, 1972). The facial malformations of children with DS, although not especially ugly, are characteristic, and are a stigma, like a 'mark' of recognition (Goffman, 1963). Children with DS characteristically have epicanthic folds, oblique lid axis, saddknose, fiat jaw bones, and, in early age, may also have macroglossia, hypotonic lower lip, and a weak or double chin, all often associated with strabismus (Lemperle, 1985). Congenital malformations of the palate and teeth and acquired oral pathology accompany these facial abnormalities, which may be often extremely varied (Righi & Belladonna, 1986). Cosmetic surgery—correction of saddle-nose, epicanthic fold, palpebral fissure or flat cheeks—carried out in these mentally retarded children causes serious perplexity. Contrary or favourable attitudes towards such surgery may be similar to thoSe generally found towards all types of cosmetic surgery which are unusual and often the object of prejudice in some social and cultural classes. However, in the particular i
Correspondence: Dr Nila Saviolo-Negrin, Dipartimento di Psicologia Generale, Pz. Capitaniato 3, 35100 Padova, Italy. :
144 A^. Saviolo and F. Cristante case of children with DS, cosmetic surgery has no effect on mental retardation and may be seen only as a mystification or falsification of physical appearance. Thus, the problem is complex and very controversial, even in countries where such plastic surgery is more common than in Italy, and opinions on whether to subject children with DS to plastic surgery or not are divided. An investigation by Strauss et al. (1988) of the social perception of the effects of facial cosmetic surgery on children with DS, carried out on a sample of normal adolescents who were asked for their judgments on photographs of children with DS before and after cosmetic operations, revealed that young people judge aspect and intelligence as correlated and that they estimate the intelligence of DS children who have been operated on as higher. As Meang (1989) points out, this type of research, carried out with photographs or videotapes, is questionable from the methodological viewpoint, since such before-and-after judgments depend too heavily on photographic technique, facial expression, hairstyle and pose. Katz & Kravetz (1989) have recently discussed the methodological and psychological problems emerging from various studies on the effects of plastic surgery in children with DS. The authors observe that many researchers based on the impressions of adults who are directly involved, such as parents and doctors, may lead to opinions in favour of surgical intervention, since the people 'believe' that language and physical appearance improve, but their opinions are not supported by measurable, objective phenomena; for example, improved phonetics and word articulation. Studies using various methodologies (Parsons et aL, 1987), in which the capacity to produce sounds and language in children with DS before and after tongue reduction surgery was evaluated by experts, indicate that there are no statistically significant differences between the operated-on group of children and those who had not received surgery. Moreover, the essential role of the tongue in language articulation is still not clear (Mackain, 1984): phonological disabilities are basically a developmental problem and not necessarily due to macroglossia (Dodd, 1976). It should be noted that no comparison is made in these investigations between the cost and effectiveness of the operation and other therapeutic, psychosocial and educational methods which would allow the same goals to be reached. For example, Dodd & Leahy (1984) believe that the problems deriving from hypotonia of the muscles of the vocal apparatus may be improved by non-surgical techniques (e.g. planned exercises and constant checking of nasal and oral hygiene). Radrud et al. (1984) report that tongue protrusion may be reduced with self-monitoring techniques. The production of linguistic sounds is also controlled by different feedback between articulatory movements of the tongue and sensorial systems of auditory, tactile and proprioceptive type (Borden & Harris, 1984), and may be greatly improved by suitable biofeedback. As regards social acceptance, Katz & Kravetz (1989) note that it is often the inappropriate behaviour of the mentally handicapped, rather than their physical appearance, which promotes negative attitudes towards them, and that inappropriate behaviour is not changed by plastic surgery. Careful training may be more effective in improving social behaviour and thus the attitudes of others towards children with DS.
Attitudes towards plastic surgery 145 The research of Katz & Kravetz (1989) has been commented on by various authors, who add their observations to the critical points of the problem. Dodd & Leahy (1989) repeat that there is no evidence of any particular advantage in tongue reduction and facial cosmetic surgery, and even warn against possible surgical complications which may reduce tongue sensitivity and mobility. Mearig (1989) observes that other anomalies—such as deafness or orthodontic malformations, which are often neglected in DS—should be faced as regards their influence on language disabilities. Specific and periodic dental treatment and dental hygiene will correct and prevent malformations and pathologies which are especially serious in children with DS in that they increase the complications of the syndrome. Lastly, Sherman (1989) wonders whether parents' interest in cosmetic surgery is really due to their interest in their children or whether it may not in fact be a problem of their own. This means that it becomes difficult to acritically accept parents' satisfaction, as Lemperle reports (1985), as an appropriate measure of the success 0f facial plastic surgery in children with DS. Bearing in mind these critical observations, the present authors believed that research into the social perception and attitudes of teachers—less directly involved than parents in the education of and assistance to children with DS—would be interesting. Also, during both lessons and playtime, teachers spend much time witjh these retarded children who, in Italy, attend ordinary schools, and are thus in a good position to observe how children with DS are accepted by school peers and how they interact socially. The authors believed that such research, albeit indirectly, could show how 'different' children are rejected or accepted and reveal the cultural, social and psychological factors intervening in the approach to the mentally retarded. Therefore, the opinion of 'others' on the opportunity of subjecting DS children to plastic surgery may be a test of acceptance and attitudes towards the mentally retarded, above all if this problem is posed not so much with respect to parents, whose dynamic relationship with their retarded children is complex (Mannoni, 1964), but to doctors, teachers, peers and employers—that is, 'others'. It should not be forgotten that the survival of people with DS has increased considerably in the last 30 years, the percentage of adults with DS over 55 being about 40% (Richards & Siddiqui, 1980). In addition, in Italy, handicapped children attend ordinary schools until the age of 14 and are then trained for manual work in specially protected professional environments. The possibility of entering the world of wofk depends on many factors: level of mental retardation, acquired abilities, degree p{ autonomy, and general state of health. However, it is also influenced by the favourable attitude and degree of acceptance of the social and working environments, which may in turn be positively or negatively influenced by the physical grooming and pleasant appearance of young DS people. In their investigation on the pros and cons of facial plastic surgery on children with DS at the Child Development Center, Providence, Rhode Island, USA, Pueschel et dl. (1986) prepared a double-version, multiple-choice questionnaire given to both parents of DS children and to doctors. The questionnaire examined various functional arid aesthetic problems which could be iihproved with plastic surgery and rated opinions on social acceptance. It revealed that, whereas parents did not believe that surgery
146 A^. Saviolo and F. Cristante
could make their children more acceptable socially, doctors were more confident and more favourable towards it. In the present investigation, the authors gave a questionnaire to a sample of elementary and junior school teachers in Padova in north-east Italy, aiming to obtain their opinions regarding plastic surgery on DS children. Their responses indicated the attitude ofthe school and of society towards mentally retarded—'different'—children. The aim of this research may be divided briefly into two main points: (1) overall analysis of teachers' opinions on the acceptance of children with DS and on the advantages of functional and aesthetic plastic surgery; and (2) analysis of opinion differences among subsamples of teachers, considered according to 'type of school' (elementary or junior) and the 'experience' of having had children with DS in their classes. METHOD A three-page questionnaire, modified from that of Pueschel et al. (1986) was given to a sample of 132 teachers of the city of Padova, 61 elementary-school (ES) and 71 junior-school (JS) teachers. It was preceded by a letter which set out the reasons for the investigation and described which studies and plastic surgery operations were most frequently carried out on children with DS, with their possible functional and aesthetic advantages. The first four questions provided information on subject taught, years of teaching experience and whether teachers had ever had DS children in their classes. Therefore, the sample could be subdivided into two comparison groups of 56 experienced teachers who currently had children with DS in their classes (T-I-DS) and other teachers who had never had them (T-DS), although they were informed about them. Three other multiple-choice questions revealed teachers' opinions on their degree of acceptance of such children. Another group of questions posed the problem of acceptance after plastic surgery, and asked teachers whether they were in favour of functional or aesthetic surgery or not. From this modified questionnaire, the authors considered responses to questions which may represent an especially significant 'opinion'. These 'opinions' dealt with: (1) the infiuence of facial characteristics of DS children on various aspects of development; (2) teachers' lower expectations due to facial characteristics; (3) social acceptance before and after surgery; (4) possible psychosocial consequences after surgery; (5) development after surgery; (6) suitability of surgery; (7) possible risk and reactions of others; (8) criteria for recommending surgery; and (9) opportunity of functional or aesthetic plastic surgery. Results were analysed by means of two-dimensional contingency tables, to compare the opinions of ES and JS teachers and then those of T+DS and T - D S .
Attitudes towards plastic surgery 14/ Analysis of the association between types of teacher and response categories w; carried out using log-linear models (Andersen, 1980). Estimates of the parameter^ corresponding to each response category effect and to the single interactions between types of teachers and response categories were calculated and interpreted. In the tables showing results, asterisks indicate the significance of the estimatec} parameter corresponding to a particular response category (margins of tables), and to the interactions between types of teachers and response categories. Frequency percentages are reported.
RESULTS
:
As mentioned before, results are described on the base of contingency tables. The decision of presenting the full tables is motivated by the interest of illustrating not only the significant results but also the frequency distributions and the general trends of opinions in different groupsofteachers. The data indicate the percentage responses in the various subsamples (ESi elementary school teachers; JS, junior school teachers; T+DS and T - D S , teachers respectively with and without experience of teaching DS children/having DS children in their classes) and on the whole sample. A significant negative response is observed in teachers on the influence of facial
Table 1. Opinion regarding influence of facial features on various aspects of development (%)' Question: Do you feel that the facial features of children with Down's syndrome may exert some influence on the following categories? : ES JS T+DS T-DS Total Mental development Yes No
Don't know
8 84* 8
12 63 25
6 80 14
13 67 19
10 73 17
48 39 13
63 25 12
43 46* 11
65 21 13
56 32 12
28 44 28
51* 18 31
37 37 25
42 25 32
40 30 30
8 79* 13
28 48 34
12 68 20
14 57 27
14 62* 24
Social development Yes No
Don't know Language development Yes No
Don't know Acquisition of autonomy Yes No Don't know
*P
Teachers' attitudes towards plastic surgery in children with Down's syndrome N. SAVIOLO-NEGRIN & F . CRISTANTE Dipartmento di Psicologia Generate, Universita di Padova, Padova, Italy ABSTRACT. The problem of whether to improve on the physical appearance of children with Down's syndrome by means of plastic surgery is a much debated question which involves bio-ethical and ideological concepts. In this research, the opinions of a group (M=132) of Italian elementary and junior school teachers are investigated on the basis of a questionnaire. Data are analysed through the application of log-linear models, and parameter estimates are calculated for each response category and interactions between response categories and types of teachers. Results show a greater acceptance of children with Down's syndrome as they are by people who have daily experience of them and who can get to know them better from all points of view. On the other hand, plastic surgery for children with Down's syndrome is considered with more favour by people who are less psychologically involved with them.
INTRODUCTION Like other types of 'manipulations' on man (e.g. artificial fertilization and organ transplants), the controversy surrounding the opportunity to improve the physicial appearance of children with Down's syndrome (DS) by means of plastic surgery involves bio-ethical and ideological concepts. In the particular case of DS, the problem is further complicated by psychological, cultural, social and medical factors Society gives more credibility to people who are physically attractive and attribute positive personality characteristics to them, believing them to be kinder, more sensitive and more sociable and extroverted (Dion, 1972). The facial malformations of children with DS, although not especially ugly, are characteristic, and are a stigma, like a 'mark' of recognition (Goffman, 1963). Children with DS characteristically have epicanthic folds, oblique lid axis, saddknose, fiat jaw bones, and, in early age, may also have macroglossia, hypotonic lower lip, and a weak or double chin, all often associated with strabismus (Lemperle, 1985). Congenital malformations of the palate and teeth and acquired oral pathology accompany these facial abnormalities, which may be often extremely varied (Righi & Belladonna, 1986). Cosmetic surgery—correction of saddle-nose, epicanthic fold, palpebral fissure or flat cheeks—carried out in these mentally retarded children causes serious perplexity. Contrary or favourable attitudes towards such surgery may be similar to thoSe generally found towards all types of cosmetic surgery which are unusual and often the object of prejudice in some social and cultural classes. However, in the particular i
Correspondence: Dr Nila Saviolo-Negrin, Dipartimento di Psicologia Generale, Pz. Capitaniato 3, 35100 Padova, Italy. :
144 A^. Saviolo and F. Cristante case of children with DS, cosmetic surgery has no effect on mental retardation and may be seen only as a mystification or falsification of physical appearance. Thus, the problem is complex and very controversial, even in countries where such plastic surgery is more common than in Italy, and opinions on whether to subject children with DS to plastic surgery or not are divided. An investigation by Strauss et al. (1988) of the social perception of the effects of facial cosmetic surgery on children with DS, carried out on a sample of normal adolescents who were asked for their judgments on photographs of children with DS before and after cosmetic operations, revealed that young people judge aspect and intelligence as correlated and that they estimate the intelligence of DS children who have been operated on as higher. As Meang (1989) points out, this type of research, carried out with photographs or videotapes, is questionable from the methodological viewpoint, since such before-and-after judgments depend too heavily on photographic technique, facial expression, hairstyle and pose. Katz & Kravetz (1989) have recently discussed the methodological and psychological problems emerging from various studies on the effects of plastic surgery in children with DS. The authors observe that many researchers based on the impressions of adults who are directly involved, such as parents and doctors, may lead to opinions in favour of surgical intervention, since the people 'believe' that language and physical appearance improve, but their opinions are not supported by measurable, objective phenomena; for example, improved phonetics and word articulation. Studies using various methodologies (Parsons et aL, 1987), in which the capacity to produce sounds and language in children with DS before and after tongue reduction surgery was evaluated by experts, indicate that there are no statistically significant differences between the operated-on group of children and those who had not received surgery. Moreover, the essential role of the tongue in language articulation is still not clear (Mackain, 1984): phonological disabilities are basically a developmental problem and not necessarily due to macroglossia (Dodd, 1976). It should be noted that no comparison is made in these investigations between the cost and effectiveness of the operation and other therapeutic, psychosocial and educational methods which would allow the same goals to be reached. For example, Dodd & Leahy (1984) believe that the problems deriving from hypotonia of the muscles of the vocal apparatus may be improved by non-surgical techniques (e.g. planned exercises and constant checking of nasal and oral hygiene). Radrud et al. (1984) report that tongue protrusion may be reduced with self-monitoring techniques. The production of linguistic sounds is also controlled by different feedback between articulatory movements of the tongue and sensorial systems of auditory, tactile and proprioceptive type (Borden & Harris, 1984), and may be greatly improved by suitable biofeedback. As regards social acceptance, Katz & Kravetz (1989) note that it is often the inappropriate behaviour of the mentally handicapped, rather than their physical appearance, which promotes negative attitudes towards them, and that inappropriate behaviour is not changed by plastic surgery. Careful training may be more effective in improving social behaviour and thus the attitudes of others towards children with DS.
Attitudes towards plastic surgery 145 The research of Katz & Kravetz (1989) has been commented on by various authors, who add their observations to the critical points of the problem. Dodd & Leahy (1989) repeat that there is no evidence of any particular advantage in tongue reduction and facial cosmetic surgery, and even warn against possible surgical complications which may reduce tongue sensitivity and mobility. Mearig (1989) observes that other anomalies—such as deafness or orthodontic malformations, which are often neglected in DS—should be faced as regards their influence on language disabilities. Specific and periodic dental treatment and dental hygiene will correct and prevent malformations and pathologies which are especially serious in children with DS in that they increase the complications of the syndrome. Lastly, Sherman (1989) wonders whether parents' interest in cosmetic surgery is really due to their interest in their children or whether it may not in fact be a problem of their own. This means that it becomes difficult to acritically accept parents' satisfaction, as Lemperle reports (1985), as an appropriate measure of the success 0f facial plastic surgery in children with DS. Bearing in mind these critical observations, the present authors believed that research into the social perception and attitudes of teachers—less directly involved than parents in the education of and assistance to children with DS—would be interesting. Also, during both lessons and playtime, teachers spend much time witjh these retarded children who, in Italy, attend ordinary schools, and are thus in a good position to observe how children with DS are accepted by school peers and how they interact socially. The authors believed that such research, albeit indirectly, could show how 'different' children are rejected or accepted and reveal the cultural, social and psychological factors intervening in the approach to the mentally retarded. Therefore, the opinion of 'others' on the opportunity of subjecting DS children to plastic surgery may be a test of acceptance and attitudes towards the mentally retarded, above all if this problem is posed not so much with respect to parents, whose dynamic relationship with their retarded children is complex (Mannoni, 1964), but to doctors, teachers, peers and employers—that is, 'others'. It should not be forgotten that the survival of people with DS has increased considerably in the last 30 years, the percentage of adults with DS over 55 being about 40% (Richards & Siddiqui, 1980). In addition, in Italy, handicapped children attend ordinary schools until the age of 14 and are then trained for manual work in specially protected professional environments. The possibility of entering the world of wofk depends on many factors: level of mental retardation, acquired abilities, degree p{ autonomy, and general state of health. However, it is also influenced by the favourable attitude and degree of acceptance of the social and working environments, which may in turn be positively or negatively influenced by the physical grooming and pleasant appearance of young DS people. In their investigation on the pros and cons of facial plastic surgery on children with DS at the Child Development Center, Providence, Rhode Island, USA, Pueschel et dl. (1986) prepared a double-version, multiple-choice questionnaire given to both parents of DS children and to doctors. The questionnaire examined various functional arid aesthetic problems which could be iihproved with plastic surgery and rated opinions on social acceptance. It revealed that, whereas parents did not believe that surgery
146 A^. Saviolo and F. Cristante
could make their children more acceptable socially, doctors were more confident and more favourable towards it. In the present investigation, the authors gave a questionnaire to a sample of elementary and junior school teachers in Padova in north-east Italy, aiming to obtain their opinions regarding plastic surgery on DS children. Their responses indicated the attitude ofthe school and of society towards mentally retarded—'different'—children. The aim of this research may be divided briefly into two main points: (1) overall analysis of teachers' opinions on the acceptance of children with DS and on the advantages of functional and aesthetic plastic surgery; and (2) analysis of opinion differences among subsamples of teachers, considered according to 'type of school' (elementary or junior) and the 'experience' of having had children with DS in their classes. METHOD A three-page questionnaire, modified from that of Pueschel et al. (1986) was given to a sample of 132 teachers of the city of Padova, 61 elementary-school (ES) and 71 junior-school (JS) teachers. It was preceded by a letter which set out the reasons for the investigation and described which studies and plastic surgery operations were most frequently carried out on children with DS, with their possible functional and aesthetic advantages. The first four questions provided information on subject taught, years of teaching experience and whether teachers had ever had DS children in their classes. Therefore, the sample could be subdivided into two comparison groups of 56 experienced teachers who currently had children with DS in their classes (T-I-DS) and other teachers who had never had them (T-DS), although they were informed about them. Three other multiple-choice questions revealed teachers' opinions on their degree of acceptance of such children. Another group of questions posed the problem of acceptance after plastic surgery, and asked teachers whether they were in favour of functional or aesthetic surgery or not. From this modified questionnaire, the authors considered responses to questions which may represent an especially significant 'opinion'. These 'opinions' dealt with: (1) the infiuence of facial characteristics of DS children on various aspects of development; (2) teachers' lower expectations due to facial characteristics; (3) social acceptance before and after surgery; (4) possible psychosocial consequences after surgery; (5) development after surgery; (6) suitability of surgery; (7) possible risk and reactions of others; (8) criteria for recommending surgery; and (9) opportunity of functional or aesthetic plastic surgery. Results were analysed by means of two-dimensional contingency tables, to compare the opinions of ES and JS teachers and then those of T+DS and T - D S .
Attitudes towards plastic surgery 14/ Analysis of the association between types of teacher and response categories w; carried out using log-linear models (Andersen, 1980). Estimates of the parameter^ corresponding to each response category effect and to the single interactions between types of teachers and response categories were calculated and interpreted. In the tables showing results, asterisks indicate the significance of the estimatec} parameter corresponding to a particular response category (margins of tables), and to the interactions between types of teachers and response categories. Frequency percentages are reported.
RESULTS
:
As mentioned before, results are described on the base of contingency tables. The decision of presenting the full tables is motivated by the interest of illustrating not only the significant results but also the frequency distributions and the general trends of opinions in different groupsofteachers. The data indicate the percentage responses in the various subsamples (ESi elementary school teachers; JS, junior school teachers; T+DS and T - D S , teachers respectively with and without experience of teaching DS children/having DS children in their classes) and on the whole sample. A significant negative response is observed in teachers on the influence of facial
Table 1. Opinion regarding influence of facial features on various aspects of development (%)' Question: Do you feel that the facial features of children with Down's syndrome may exert some influence on the following categories? : ES JS T+DS T-DS Total Mental development Yes No
Don't know
8 84* 8
12 63 25
6 80 14
13 67 19
10 73 17
48 39 13
63 25 12
43 46* 11
65 21 13
56 32 12
28 44 28
51* 18 31
37 37 25
42 25 32
40 30 30
8 79* 13
28 48 34
12 68 20
14 57 27
14 62* 24
Social development Yes No
Don't know Language development Yes No
Don't know Acquisition of autonomy Yes No Don't know
*P
