“Children’s Attitudes Toward Peers With Unintelligible Speech Associated With Cleft Lip and/or Palate” (2017), by Alice Lee, Fiona E. Gibbon, and Kimberley Spivey

In May 2017, Alice Lee, Fiona E. Gibbon, and Kimberley Spivey published “Children’s Attitudes Toward Peers With Unintelligible Speech Associated With Cleft Lip and/or Palate,” hereafter “Children’s Attitudes,” in The Cleft Palate Craniofacial Journal. About one in every 1600 babies in the US is born with both cleft lip and cleft palate, which are birth defects that can also occur independently. Those birth defects occur when the lip or roof of the mouth, also called the palate, do not fully develop during pregnancy. The condition often results in speech difficulties, even after children undergo surgery to repair their cleft palate. “Children’s Attitudes” was one of the first articles investigating how different age groups of children judged their peers with speech difficulties who had undergone a cleft palate repair surgery. The authors found that peers’ attitudes towards speech problems tended to be negative. “Children’s Attitudes” concludes that judgment from peers can negatively affect children with speech difficulties and argues that increased public awareness of speech difficulties may reduce barriers that children with those difficulties face.

Cleft lip and cleft palate are birth defects that can be present individually as a cleft lip or a cleft palate, or together as a cleft lip and palate. A cleft can be unilateral, which is when a cleft occurs on one side of the mouth, or bilateral, which is when clefts occur on both sides of the mouth. Children born with clefts can have problems related to eating, speaking, hearing, and breathing. People with cleft lip and palate may receive dental care, speech therapy, or surgery. Physicians call the surgical procedure to repair cleft lip cheiloplasty and the procedure to repair cleft palate palatoplasty. The goal of the cheiloplasty is to close up the cleft present on the lip or upper lip, while a palatoplasty aims to close up the cleft present on the palate. Those procedures can help the patient develop normal speech, but speech difficulties may continue after the surgery.

The authors of “Children’s Attitudes” all had experience working in speech and language therapy at some point in their lives. Lee worked as the editor of the Journal of Clinical Speech and Language Studies from 2010 to 2019. As of 2023, Lee is a lecturer in Speech and Hearing Sciences at University College Cork, or UCC, in Cork, Ireland, and works as the Section Editor for The Cleft Palate-Craniofacial Journal. She also works as a speech and language therapist and is a member of various speech disorder groups such as The Child Speech Disorder Research Network. Lee has conducted research and published studies on speech disorders in individuals who are lacking typical facial structure and who have disabilities in their nervous system. Gibbon’s research focuses on new developments to improve diagnosis and treatments for children with speech disorders or impairments. Gibbon served as the Head of Department at UCC from 2009 until she retired in 2016. As of 2023, the Department of Speech and Hearing Sciences recognizes her as Emeritus Professor. At the time when “Children’s Attitudes” was published, Spivey worked as a speech and language therapist in Auckland, New Zealand.

“Children’s Attitudes” references many previous studies on listeners’ attitudes toward individuals with communication disorders, with most previous research focusing on adult listeners’ judgments. Lee and colleagues reference one study published in 2007 by Megan Overby, Thomas Carrell, and John Bernthal that analyzed the perceptions of teachers on the competence of students with intelligible speech in comparison to students with unintelligible speech. The study found that the teachers associated children who have intelligible speech with more positive perceptions of academic, social, and behavioral competence, while it was more likely for teachers to expect children with unintelligible speech to struggle academically, socially, and behaviorally. Another study they reference from 2008 found that adult participants had more favorable social perceptions of normal speech compared to disordered speech. The authors of “Children’s Attitudes” use those and other similar studies as evidence that listeners tend to form negative attitudes and judgements towards others based purely on their different speech characteristics. However, those studies primarily investigated attitude formation in adults. Lee and colleagues recognize a knowledge gap about peer attitudes towards children with reduced speech intelligibility from cleft palate, which led them to further study that topic.

“Children’s Attitudes” is divided into five main sections. The authors begin with an untitled introduction referencing some previous studies that investigated how individuals with speech disorders, specifically due to abnormalities of the bones in the head or face, experience negative judgments and attitudes from society and through interactions with peers during their everyday lives. The second section, “Method,” describes the study’s participants, which included ninety typically developed children of three different age groups and twenty adults who made judgements on recorded speech samples the authors provided. The authors acquired speech samples from two typically developing children, and eight children with repaired cleft palate. In the third section, “Measures,” the researchers convey that they calculated intelligibility of the ten speech samples based on the twenty adults’ ability to understand them, and used a three-point scale with positive and negative adjectives to calculate how children judged the speaker in each sample. In the fourth section, “Results,” the authors describe that the child participants are more likely to associate certain negative traits to children with what they called unintelligible speech. The authors also describe that there were differences between how the three age groups rated some of the social and personal attributes of the children in the speech samples. In the final section called “Discussion,” the authors discuss that lower speech intelligibility is related to certain negative stereotypes and call for future research and increasing awareness of communication difficulties.

In the untitled introduction, the authors discuss the context surrounding their research on children’s attitudes toward unintelligible speech and the previous studies on judgments and stereotypes toward people with communication disorders. The authors emphasize how many previous research articles have found that people negatively associate certain traits or beliefs towards those with speech difficulties. The authors of “Children’s Attitudes” argue that it is important to the study peer attitudes of children with repaired cleft palate since they and their typically developing peers have frequent interactions. To emphasize that, the authors cite the World Health Organization and the International Classification of Functioning, Disability, and Health, which explain that one of the most important environmental factors that influences the social functioning of a person with speech difficulties are peer attitudes. Due to the demonstrated importance of peer attitudes toward those with speech issues, the authors investigated the relationship between speech intelligibility and peer judgement, and if the judgements differ by age.

The “Method” section of the article provides details on how the researchers found the participants for the study. In the beginning of the “Method” section, the researchers describe the participants in their study. In total, they gathered ninety typically developing students who were from three different primary schools in Cork City, Ireland. They divided those children into three age groups, each with thirty children. The age groups ranged from seven to eight years old, nine to ten years old, and eleven to twelve years old. The researchers also recruited twenty adult participants, ten men and ten women, who ranged from nineteen to forty years of age with various occupations. The researchers picked adults and children who did not have any prior or current hearing, speech, or language difficulties. They also made sure the subjects had no learning disabilities and were native English speakers.

The “Method” section goes on to describe that the researchers acquired speech samples from a previous project that involved typically developing children and children that had cleft palate repair. The researchers got the speech samples from a research project that Lee worked on in 2007, where Lee collected speech samples from ten children by instructing them to read sentences aloud. Of those ten speech samples, two were of typically developed children and the other eight were of children with repaired cleft palates. The eight children with repaired cleft palates received care from Glasgow Dental Hospital in Glasgow, Scotland, and continued having speech difficulties. Each child involved previously recorded ten sentences, and from those ten the researchers selected three for each, to use in “Children’s Attitudes.”

In third section, “Measures,” the researcher explain how they measured the intelligibility of each speech sample based on the adult’s ability to understand the speaker. The twenty adult participants in “Children’s Attitudes” listened to the samples and wrote down the words they understood each speaker say. Based on the percentage of words the adult listeners correctly transcribed, the authors determined a speech intelligibility score, which they indicated with a percentage. Using the adults’ transcriptions, the researchers calculated the speech intelligibility score of the two children with typical development as ninety-nine percent, while the eight children with cleft palate repair had a score that ranged from thirty-three to eighty-five percent of the time. 

After calculating the intelligibility score of each speech sample, the authors describe that they gave the ninety participating children the speech samples to listen to, which the participants then rated according to a scale the authors designed. The authors came up with eight different sets of child-friendly adjectives that were opposite each other, known as bipolar adjective pairs, to make into a rating scale. For each bipolar adjective pair, the researchers made them into a three-point scale where the child participants rated whether they thought the speaker in the speech sample was positive, neutral, or negative in relation to each adjective pair. For example, if a child participant was given the naughty-good adjective pair, the participant would rate whether they thought the speaker in the speech sample was naughty, the negative attribute, good, the positive attribute, or say they were unsure, which the authors rated as neutral. To measure the participant’s attitude towards the speaker, the authors assigned an attitude score of one to negative, two to neutral, and three to positive. The ninety child participants individually listened to three sentences from the ten speakers in a quiet room at their school. They then made judgements on the scale using the adjective pairs on what they thought the speakers from the speech samples looked and acted like. The researchers then collected the numerical scores and calculated the mean for each adjective pair for each of the speakers. They also performed statistical analysis to find how strongly correlated the mean speech intelligibility score was to the peer ratings made by the different age groups.

In “Results,” the authors describe that they found different age groups of children strongly associated the sick-healthy, no friends-friends, and ugly-good looking attributes with speech intelligibility. The authors found that different age groups only associated some of the traits in the bipolar adjective pairs with speech intelligibility to a statically significant degree. The authors found that children aged seven to eight years strongly associated the voices of children with speech difficulties with being sicker, while they associated the voices of typically developing children as being healthier. In children aged nine to ten years, the authors found that they most significantly associated low speech intelligibility with having no friends, and intelligible speech with having friends. The authors found that the eleven-to-twelve-year age group associated speech difficulties with the traits of being ugly and having no friends, while they were more likely to associate a typically developed voice as being better looking and having more friends. Across the three age groups, the authors found the most significant difference in attribute ratings for the traits measuring whether the voice was mean-kind, and shy-outgoing. However, there was no significant difference in ratings for the two groups of older children, those beings the nine-to-ten and eleven-to-twelve-year groups.

In the “Discussion” section, the authors reiterated their intent to investigate the attitudes of typically developing children toward their peers with a speech impairment after cleft palate repair, how their work aligns with previous research, and how age played a factor in judgment ratings. They found that those with speech difficulties were associated with being less healthy, not as good looking, and having little to no friends. Lee and colleagues found results in line with previous research articles that reported that children and individuals with speech disorders or difficulties had lowered social acceptance and others perceived them negatively. Furthermore, “Children’s Attitudes” demonstrated mixed results regarding the age effect on social acceptance ratings, which was similar to previous research. The authors explain that there may be other factors playing into that, such as how they measured peer judgements. They further justify the mixed results since research has previously shown that after a child reaches eight years, they view the social world differently than younger children, clarifying why there might be a difference in social acceptance ratings between the younger and older age groups.   

Continuing in the “Discussion” section, the authors relay the importance of raising awareness against negatively stereotyping those with communication disorders. According to the authors, when listeners negatively stereotype individuals with communicative difficulties, it places the individuals at a disadvantage that can impact their social functioning within society and among peers. They argue that their results emphasize the need for increased public awareness. The authors discussed a classroom-based program that Marilyn Langevin, who researched speech disorders in Edmonton, Canada, developed in 2000 to promote positive attitudes towards peers with speech disorders. The program aimed to help children develop positive attitudes toward their peers with speech difficulties using videos, lessons, and activities. Langevin reported that the children who took part in the program had improved attitudes towards their peers with speech disorders. Lee and colleagues argue that programs like those could be developed for children with unintelligible speech associated with cleft palate and other craniofacial anomalies to reduce the barriers they face.

Finally, in the “Discussion” section, the authors relay that their study had strengths and limits regarding its design and measurement methods. The strengths that the researchers noted included having a large sample size of children and the attribute rating method they implemented had already been tested. The authors further discuss that measuring speech intelligibility accurately was difficult because when speech intelligibility is poor, there are inconsistent ratings of intelligibility between listeners. Lee and colleagues also explain that including more social and personal attributes, and a larger point scale would be more useful for analysis. Finally, a limitation the researchers highlighted was that they measured intelligibility only through adults instead of children. They express that finding a reliable way to measure intelligibility through children would be an important addition to future research.

As of 2023, “Children’s Attitudes” has primarily been cited in further research investigations on the relationship between individuals with speech difficulties and their quality of life. In 2019, Jill Nyberg, a researcher from Stockholm, Sweden, and colleagues, published “‘She Sounds Like a Small Child or Perhaps She has Problems’ – Peers’ Descriptions of Speech in 7-Year-Olds Born With Cleft Palate,” hereafter “Peers’ Descriptions of Speech,” to examine how seven-year-old children describe cleft palate speech. “Peers’ Descriptions of Speech” cited Lee and colleagues when recognizing the societal importance of negatively stereotyping communication disorders because of the possible disadvantages that can cause. Those disadvantages include psychological, educational, and employment disadvantages they cause. “Children’s Attitudes” was also cited in “Peer Attitude Toward Children with Cleft (Lip and) Palate Related to Speech Intelligibility, Hypernasality and Articulation,” which Kim Bettens and colleagues published in 2020 to provide additional evidence that children with speech disorders due to cleft lip and palate experience negative attitudes.

“Children’s Attitudes” shows how children with cleft palate and communicative difficulties are negatively stereotyped, highlighting the need for public awareness, but there are many other areas of support that children with clefts and their families need. There are various organizations such as Smile Train and Operation Smile that work towards improving the quality of life for children with cleft lip and palate. Smile Train, a non-profit organization dedicated to helping children with clefts around the world, developed a free app for children with clefts to practice speaking in an interactive way to improve their speech and allow them to become more comfortable speaking. Operation Smile is another organization that is committed to providing treatment and improving care for children with cleft conditions. “HablemOS” is a speech therapy program developed by Operation Smile to increase the number of qualified speech therapists across Latin America. As Lee and colleagues found, children face negative stereotypes from their peers even after cleft palate repair surgery, which is why speech therapy programs such as HablemOS are important for children both before and after surgery.

“Children’s Attitudes” studied the attitudes toward children with unintelligible speech due to cleft palate, how those attitudes differ among age groups, and the effects those attitudes can have on social-cognitive skills. The authors demonstrated the importance of encouraging positive attitudes towards children with speech impairments and raising public awareness for individuals with communicative difficulties.