Emotional and behavioral adjustment problems during the childhood years are commonly conceptualized in terms of internalizing and externalizing behavior. Internalizing factors include anxiety, depression, social withdrawal, and somatic complaints, while externalizing factors include aggression, oppositional behaviors, conduct disorders, and attention/hyperactivity disorders (2, 3).

Social inhibition is a behavioral characteristic of particular concern for the child with CFC (4, 5, 6). In turn, social introversion, withdrawal, loneliness, and problems with social interaction have been associated with dissatisfaction with appearance (7, 8). Parents of a child with CFC report peer teasing, exclusion from the peer group, and acting younger or choosing to play with younger peers two to three times more frequently than parents of unaffected children (9, 10, 11). Parents frequently attribute those difficulties to facial differences or accommodations of their child to those facial differences. Objective ratings of facial difference have been associated with increased behavioral inhibition (12), which may also be related to quality of social interaction (13). Focus group interviews with adolescents with CFCs provide further information that these teens attribute their perceived lack of welcome by peers to their facial appearance (14). The child who perceives himself to be less welcome by peers may choose to limit their social groups to one or two children with whom they feel safe. Others may choose solitary activities. Either situation serves to decrease anxiety (15, 16). A small observational study (13) demonstrated that individuals with CFCs engaged in fewer social interactions than their peers and that those attempts at interaction were more often ineffectual.

Both Spriestersbach (17) and Richman (5) originally focused research attention on behavioral inhibition as a core characteristic of the child with CFC. More recent research has demonstrated that the child who experiences behavior problems frequently experience both externalizing and internalizing problems (9, 10,12,18, 19). Rogers and Kapp-Simon (18) found that self-reported problems with social interactions and peer popularity were highly associated with parent-reported problems in both internalizing and externalizing psychological adjustment. The behavior problems demonstrated by the child may represent an ineffective attempt to handle the frustration associated with social rejection (20). Robinson et al. (21) have posited that individuals with CFCs who are having social difficulties develop a “negative social interaction style” that results in social shunning. They suggest that initial social rejection may lead individuals with CFCs to act in a manner that is aggressive, defensive, or shy.

Adjustment problems for the child with CFC occur more frequently when he or she must also cope with learning disorders (22). The child with CFC experiences learning disorders at two to three times the rate of nonaffected children (23, 24, 25). This combination of findings makes it difficult to disentangle the effects of appearance from those of cognitive functioning. The child with learning problems who does not have a CFC experiences more social and behavioral difficulties than peers without learning problems (26, 27). He or she is also more likely to experience specific social skills deficits than a child without such challenges (26, 27).

There has been little empirical focus on the adjustment of adults with CFCs. Studies have identified adjustment problems in adults that include less frequent participation in social activities, reports of interpersonal difficulties, and less frequent, and later marriage (28, 29, 30, 31, 32, 33, 34, 35). Higher rates of anxiety, depression, and heart palpitations have also been reported in comparison to unaffected individuals (36). Women with CFCs report greater depression than men with similar conditions (35). In addition, greater dissatisfaction with appearance was associated with higher rates of anxiety and depression, fewer friendships, and a belief that appearance affected job choice (35,36). Similarly, Sarwer et al. (37) related negative self-ratings of attractiveness and dissatisfaction with appearance to lower self-esteem, poorer quality of life, and more frequent reports of discrimination.

Barden asserts that “facial attractiveness is perhaps one of the most salient and unique characteristic that others may use as a basis for impression formation in any given social context” (38). As reviewed in Chapter 3, there is ample evidence to
support the contention that facial configuration and attractiveness influence the reactions and judgments that observers make about an individual, with more attractive individuals receiving positive attributions while less attractive individuals are judged more harshly (39, 40, 41, 42, 43, 44, 45, 46). A meta-analysis completed by Langlois et al. (47) concluded that: “Beauty is more than just in the eye of the beholder; people do judge and treat others with whom they interact based on attractiveness; and perhaps most surprisingly, beauty is more than skin deep” (p. 404).

In an effort to relate the broader literature on facial appearance to facial differences in individuals with CFCs, researchers have looked for associations between CFC-related impairment and aspects of psychological adjustment. These empirical investigations have not provided a consistent picture. In part, the inconsistencies are related to differences in research questions and methodologies. However, the complexities of the relationships among the variables in question also thwart simple answers (35).

Ratings of attractiveness have been obtained from treating surgeons, professionals who treat children with CFCs who are not surgeons, parents, naïve observers including other children, and the affected individuals themselves. Using a variety of measurement techniques, this research has found remarkable congruence in judgments of severity or impairment caused by CFCs between parents and other observers (48, 49, 50, 51, 52). Studies have also shown that judgments of attractiveness are affected by both severity and type of CFC condition (53, 54).

While there may be congruence in ratings of appearance, the relationships between physical appearance and psychological adjustment are more complex. For example, in one study, preschoolers with CFCs reported higher self-concept than a comparison group despite the fact that they were rated as less attractive (55). However, in another study, elementary school children with CFCs demonstrate lower self-concept than comparison children (15,56).

The relationships between appearance ratings and psychological adjustment are even less clear in adolescence, when studies begin to consider self-ratings of appearance and the perceived need for additional surgical treatment. Many of the studies that found congruence between parent and outside raters have found little agreement with self-ratings of appearance (14,48, 49, 50, 51,57, 58), although a few have found agreement (37,59). When there are discrepancies among raters, adolescents and adults tend to judge their appearance more negatively than others (48, 49, 50, 51,57).