DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY
REVIEW
The association between children’s contact with people with disabilities and their attitudes towards disability: a systematic review MEGAN MACMILLAN 1,2
| MARK TARRANT 2 | CHARLES ABRAHAM 2 | CHRISTOPHER MORRIS 1,2
1 Peninsula Cerebra Research Unit (PenCRU), University of Exeter Medical School, University of Exeter, Exeter; 2 NIHR PenCLAHRC, University of Exeter Medical School, University of Exeter, Exeter, UK. Correspondence to Megan MacMillan, University of Exeter Medical School, University of Exeter, 31 Haighton Building, St Luke’s Campus, Heavitree Road, Exeter EX1 2LU, UK. E-mail: [email protected]
PUBLICATION DATA
Accepted for publication 8th September 2013. Published online 13th November 2013. ABBREVIATIONS
CATCH
STROBE
Chedoke–McMaster Attitudes Towards Children with Handicaps Strengthening the Reporting of Observational Studies in Epidemiology
AIM The aim of this review was to systematically review and synthesize observational evidence of associations between children’s naturally varying contact with people with disabilities and their attitudes towards disability. METHOD A comprehensive search was conducted across multiple databases. Studies were included if they measured children’s contact with people with disabilities and their attitudes towards disability. Qualitative research and studies that experimentally varied the amount of contact children had were excluded. Data were synthesized in a narrative review. RESULTS There were 35 studies that met the inclusion criteria: 22 of these reported a statistically significant association between contact with people with disabilities and more positive attitudes towards disability; two studies reported a negative association between contact and attitudes; and 11 studies reported no association. Incomplete reporting of the methods and results across studies limited the conclusions that could be drawn. INTERPRETATION Studies identified in this review generally indicate that children’s contact with people with disabilities is associated with more positive attitudes towards disability. There is a need for more rigorous research to examine the effect of children’s contact with people with disabilities on their attitudes towards disability.
Children with disabilities are often the targets of negative attitudes. Parents of children with disabilities have described how negative attitudes are more disabling than their child’s impairments.1 A meta-analysis of studies published between 1990 and 2000 found that, generally, children have better attitudes towards children without disabilities than they do towards those with physical or intellectual impairments.2 Furthermore, in a cohort study conducted over 3 years, between 21% and 30% of children with disabilities experienced peer victimization, as reported by their parents.3 Experiencing negative attitudes and being victimized by peers is associated with self-blame, loneliness, anxiety, and low self-worth.4 Therefore, it is important to understand negative attitudes towards disability and the factors associated with those attitudes. A series of psychological interventions derived from the ‘contact hypothesis’5 have been designed to promote positive attitudes towards a range of social groups. By creating positive interactions (contact) between members of different social groups, negative attitudes may be reduced.6 Positive contact can break down psychological group boundaries, reduce anxiety, and elicit emotions such © 2013 Mac Keith Press
as empathy directed towards outgroup members who are otherwise often inhibited in intergroup contexts.7 A systematic review and meta-analysis of studies involving a range of intergroup contexts suggested that contact is nearly always successful in improving attitudes and reducing prejudice.6 However, the review did not focus on children’s attitudes and it did not specifically examine attitudes towards disability. UK government policies generally promote inclusive education,8 which is reflected in the large number of children with disabilities who attend mainstream schools. Although inclusive education enables contact between children with and without disabilities, research examining the association between naturally occurring contact and children’s attitudes has not been synthesized. Given that negative attitudes have adverse implications for children with disabilities,4 the impact of encouraging contact in schools on children’s attitudes towards disability needs to be better understood. The aim of the current systematic review was to synthesize the evidence regarding the association between children’s natural contact with people with disabilities and their attitudes towards disability. DOI: 10.1111/dmcn.12326
529
METHOD Inclusion and exclusion criteria Studies were included in the review if they (1) focused on children (under 18y) and (2) measured children’s attitudes towards disability. Studies were excluded if they (1) focused only on the experiences of discrimination of children with disabilities; (2) manipulated contact (e.g. experiments, intervention studies); (3) were qualitative or case studies; or (4) were not reported in English. Once studies had been screened for the above criteria, full-text copies of the articles were retrieved if they measured the contact children had with people with disabilities and quantified the associations between these variables. Identification of studies A systematic search was conducted using the following databases: MEDLINE (using the Ovid interface), Applied Social Science Index and Abstracts (ASSIA; using the Proquest interface), PsycINFO (using the Ovid interface), and Educational Resources Information Centre (ERIC; using the Proquest interface). Databases were searched in August 2012 using variations of the terms ‘child’, ‘attitudes’, and ‘disability’ (search terms are provided as supporting information, Appendix S1). We did not limit the search by the publication date. Retrieved references were stored in reference management software (Endnote X4) and duplicates were removed. Additional studies were sought through backward and forward citation chasing. Study selection The first reviewer (MM) screened the titles and abstracts of the search results to identify relevant articles. Additionally, as a quality assurance check, a second reviewer (KW) screened 10% of the search results. After screening, the first reviewer retrieved full-text copies of the articles. The two reviewers (MM and KW) then independently reviewed these for inclusion and any discrepancies that arose were resolved through discussion. Data extraction and synthesis A data extraction form was piloted and refined; this included details of the authors, date, setting, participants, measures of attitudes, measures of contact, and results. The results extracted included a comparison of means of children’s attitudes towards disability with differing amounts of contact with people with disabilities, as well as the correlational results between attitudes and contact. The first reviewer (MM) extracted all data and the second reviewer (KW) checked all data extraction. Discrepancies were resolved by discussion. Studies were described in detail and aggregated using narrative synthesis.9 Quality appraisal The ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE)10 checklist was used to assess the completeness and transparency of reporting in the 530 Developmental Medicine & Child Neurology 2014, 56: 529–546
• • •
What this paper adds Children who have more contact with people with disabilities generally report more positive attitudes towards disability. Published research into contact with and attitudes towards disability lacks complete reporting of methods and results. Measures of children’s contact with people with disabilities and their attitudes towards disability vary considerably, precluding synthesis of results across studies.
included studies. The STROBE checklist identifies potential sources of bias and strengths of individual studies using 22 items. The first reviewer (MM) used the checklist to record whether each item was apparent and adequately reported. The second reviewer (KW) checked all of the quality appraisal checklists.
RESULTS Study selection Figure 1 summarizes the identification and selection of studies. MEDLINE located 1484 studies, ASSIA located 450 studies, PsycINFO located 3244 studies, and ERIC located 1786 studies. A total of 1540 studies were duplicates and were removed from the search. We screened the titles and abstracts of the 5424 studies which had been retrieved and read 54 full-text studies. After excluding 25 studies, 29 studies were included in the review. Six additional studies were sought through backward and forward citation chasing, creating a total of 35 studies included in this review. Study characteristics The studies included in this review explored children’s attitudes towards a range of disabilities. Some studies explored attitudes towards specific disabilities (i.e. Down syndrome,11,12 hearing impairments,13 and communication disabilities).14 The majority of studies (n=15) explored attitudes towards disability more generally. The majority of studies included were conducted in the USA (n=14) and in Canada (n=6). The other studies were carried out in the UK (n=3), Greece (n=2), Australia (n=2), Israel (n=1), Italy (n=1), Ireland (n=1), France (n=1), and New Zealand (n=1). In addition, one study was carried out in both Israel and Canada (n=1), one study was carried out in both the USA and Greece (n=1), and one study did not report a location.15 Studies were published between 1966 and 2011, with 13 studies out of the total 35 conducted in the 1980s, and 10 studies published since 2000. All studies recruited participants from schools and included both male and female participants. Sample sizes ranged from 6016 to 583717 with a total of 22 477 participants across the 35 studies. The number of schools sampled was not reported in four studies, but ranged from 118 to 6817 in the other studies. The age of participants ranged from 4 to 18 years old; 13 studies reported the school year but not the participants’ actual ages. Two studies failed to provide any details about the participants’ ages or school year.19,20 The largest
Identification
Records identified through
Additional records identified
database searching
through other sources
(n=6964)
(n=6)
Records after duplicates were removed
Included
Eligibility
Screening
(n=5430)
Records screened
Records excluded
(n=5430)
(n=5370)
Full-text articles assessed for eligibility (n=60)
Studies included in a
Full-text articles excluded, with reasons (n=25) - Intervention based studies (n=7) - Not in English (n=5) - Does not examine the association between contact and attitudes (n=8) - Qualitative studies (n=2) - Participants aged over 18 years (n=3)
narrative synthesis (n=35)
Figure 1: Study selection; PRISMA flow diagram.
age range in any study was 6 years, which was found in two studies; one of these sampled children aged 7 to 12 years21 and the other sampled children aged 8 to 13 years.22 Seven studies described a theoretical framework that was to be tested by their findings. The most frequently reported theory was Allport’s contact hypothesis5 (n=4).23–26 Other theories include social development theory,27,28 the theory of planned behaviour,29,30 and social identity theory.31,32
Outcomes Across studies, attitudes were assessed using 26 different measures, with the Chedoke–McMaster Attitudes Towards Children with Handicaps (CATCH)33 measure being the one used most frequently. The CATCH was used in full in four studies,14,34–36 and a subscale was used in one
additional study.37 The ‘Attitudes Towards Disabled Persons’38 scale, or adapted versions of it, was used in four studies.24,39–41 In addition to self-reported attitude measures, other techniques included asking children questions about how they would respond to a disabled child described in a written vignette.12,32,42 One study used a ‘post-box’ technique,25 which involved participants posting pictures of children with and without disabilities into boxes labelled in stages from ‘always’ to ‘never’ to represent how much they would like to play or work with them. Finally, two studies used peer nomination methods, which involved participants ranking or nominating children in their class or school with whom they would most like to interact.18,43 Children’s previous contact with people with disabilities was measured either through self-reports or through contact at the school level. Self-reported contact was used Review
531
in 13 studies. There is no standard measure of selfreported contact across the literature. The majority of studies that used self-reported contact asked about disabled friends, family members, and classmates. Some studies asked for more detailed information about the contact, such as whether they had played or talked to a disabled child in the past week11,14,35 or how many hours in a week they typically spent with people with disabilities.44 Schoollevel contact, used in 22 studies, is a measure of contact that is based on the level of disability inclusion within the school. The majority of studies using this measure of contact (n=15) categorized schools or classrooms as having either ‘no children with disabilities’ (i.e. no contact) or ‘some children with disabilities’ (i.e. contact). However, seven studies used a range of methods to categorize schools into ‘contact’ or ‘no contact’ settings. These included teachers’ ratings of the perceived contact between children with and without disabilities,22,30,45 the amount of time children with and without disabilities had spent together in a school or classroom,21,43 and the change in attitudes after a semester or year in an inclusive classroom.18 Two studies examined the correspondence between selfreported contact and school-level contact.12,40 Both studies reported significant (positive) associations between the two measures of contact and, therefore, only used the schoollevel measure of contact in the analysis of the results (although effect sizes for the relationship between the two measures of contact were not reported).
Quality appraisal The completeness of reporting of the included studies was generally poor. No studies reported determining sample size a priori. However, because only three studies had a sample size below 100, there was likely to be enough power to detect a significant association. Twelve studies failed to discuss the location of the study or dates regarding recruitment and nine studies did not adequately describe their participants (e.g. the numbers of males and females or their age). Furthermore, none of the studies reported confidence intervals. Effect sizes were reported in only four studies;16,17,46,47 we have, therefore, calculated effect sizes when possible. Additionally, different effect sizes were used for correlational data and for comparing means; therefore, all available effect sizes were transformed into effect size (Cohen’s d) to allow comparisons to be made between individual studies. Over half of the studies (n=18) failed to report attempts to reduce potential bias in their methodological techniques. Those studies that did attempt to limit biases used random sampling within schools, purposive sampling to create representative samples, and attempts to reduce social desirability bias (e.g. through making the surveys anonymous, which has shown to be successful at reducing social desirability response bias).48 Furthermore, 22 studies failed to report participant consent levels or whether there were any missing data. Only one study provided a detailed description of the handling of missing data at each stage.36 532 Developmental Medicine & Child Neurology 2014, 56: 529–546
Although the majority of studies (n=23) used previously validated instruments measuring attitudes towards disability, Vignes et al.36 were the only authors to explain their choice of attitude measure, discussing evidence of reliability and validity in this domain. Additionally, at least 30 studies recruited participants from multiple schools; however, Vignes et al.36 were the only authors to employ a multilevel analysis to adjust for clustering effects within schools.
Main results of individual studies Of the 35 studies included in this review, 16 reported a significant positive association between the amount of contact children had with people with disabilities and their attitudes towards disability.14,16,17,21,22,30,32,34–37,40,45–47,49 These studies all showed that the more contact children had with people with disabilities, the more positive their attitudes were towards disability. From the nine articles in which effect sizes were available or calculated, effect size d ranged from 0.17 to 2.45 (Table I). Six further studies failed to identify a significant association between contact and attitudes when the attitude measure as a whole was included in the analysis. Five of these studies reported subscales within the attitude measure to be significant.13,15,19,44,50 Of these five studies, three studies13,15,19 had effect sizes ranging from low to moderate. Finally, one study reported significant associations between individual attitude questions and contact.51 None of the authors of these studies justified the decision to explore subscales or individual items. Eleven studies found no association between contact and attitudes to disability.11,12,18,20,23,24,26,39,41–43 Only two studies found a negative association between contact and attitudes: one of these28 reported a small effect size and the other52 failed to report an effect size or the descriptive statistics to calculate an effect size. The positive association between contact and attitudes towards disability is also observed when studies are separated according to the measure of contact (school level vs self-report). Of the 22 articles that used school-level contact, a significant positive association between contact and attitudes towards disability was reported in 12, a negative association was reported in two, and no association was reported in eight of the articles. Of the 13 studies which measured contact through self-reports, 11 studies reported a significant positive association between contact and attitudes and 2 studies found no association. DISCUSSION Overall, contact with people with disabilities was associated with more positive attitudes towards people with disabilities among participating children. Of the 35 studies included in the review, 22 showed a positive association on all or some of the attitude measures, 11 showed no association, and just two showed a negative association. From the first study28 that found a negative association between contact and attitudes, the authors stated that the
Review
533
Physical disabilities (using pictures)
Inclusive disability
Inclusive disability
Child with no communication
Archie and Sherrill, 1989 (USA)23
Barrett and Kitchenham, 1992 (Canada)24
Blockberger et al., 1993 (Canada)14
Type of disability being assessed
Arampatzi et al., 2011 (Greece)28
Author(s), year (country)
Table I: Study characteristics
249 from nine schools
89 (48 in ‘contact’ setting and 41 in ‘non-contact’ setting); unknown number of schools
229 (143 in ‘contact’ setting and 86 in ‘non-contact’ setting) from two schools
658 (353 in ‘contact’ setting and 305 in ‘non-contact’ setting) from 15 schools
Number of individual participants and schools
Whether the classroom included a disabled child (n=1 or 2) or not (n=0) Self-reported by the child: included whether they had a disabled child at their school, had a disabled friend or family member, or talked or played with a disabled person in the last week
8th and 10th grades
9–10y
School level: comparing inclusive and segregated schools
School level: comparing inclusive and segregated schools
Measure of contact
5th and 6th grades
Mean=11y
Age
CATCH scale (Rosenbaum et al.)33
Children’s attitude toward integrated PE revised (CAIPER; Block56) Children’s attitude toward handicapped scale (Rapier et al.57) ATDP scale (Yuker and Block)58
Measure of attitudes
Significant difference for those who reported having a disabled friend (p
REVIEW
The association between children’s contact with people with disabilities and their attitudes towards disability: a systematic review MEGAN MACMILLAN 1,2
| MARK TARRANT 2 | CHARLES ABRAHAM 2 | CHRISTOPHER MORRIS 1,2
1 Peninsula Cerebra Research Unit (PenCRU), University of Exeter Medical School, University of Exeter, Exeter; 2 NIHR PenCLAHRC, University of Exeter Medical School, University of Exeter, Exeter, UK. Correspondence to Megan MacMillan, University of Exeter Medical School, University of Exeter, 31 Haighton Building, St Luke’s Campus, Heavitree Road, Exeter EX1 2LU, UK. E-mail: [email protected]
PUBLICATION DATA
Accepted for publication 8th September 2013. Published online 13th November 2013. ABBREVIATIONS
CATCH
STROBE
Chedoke–McMaster Attitudes Towards Children with Handicaps Strengthening the Reporting of Observational Studies in Epidemiology
AIM The aim of this review was to systematically review and synthesize observational evidence of associations between children’s naturally varying contact with people with disabilities and their attitudes towards disability. METHOD A comprehensive search was conducted across multiple databases. Studies were included if they measured children’s contact with people with disabilities and their attitudes towards disability. Qualitative research and studies that experimentally varied the amount of contact children had were excluded. Data were synthesized in a narrative review. RESULTS There were 35 studies that met the inclusion criteria: 22 of these reported a statistically significant association between contact with people with disabilities and more positive attitudes towards disability; two studies reported a negative association between contact and attitudes; and 11 studies reported no association. Incomplete reporting of the methods and results across studies limited the conclusions that could be drawn. INTERPRETATION Studies identified in this review generally indicate that children’s contact with people with disabilities is associated with more positive attitudes towards disability. There is a need for more rigorous research to examine the effect of children’s contact with people with disabilities on their attitudes towards disability.
Children with disabilities are often the targets of negative attitudes. Parents of children with disabilities have described how negative attitudes are more disabling than their child’s impairments.1 A meta-analysis of studies published between 1990 and 2000 found that, generally, children have better attitudes towards children without disabilities than they do towards those with physical or intellectual impairments.2 Furthermore, in a cohort study conducted over 3 years, between 21% and 30% of children with disabilities experienced peer victimization, as reported by their parents.3 Experiencing negative attitudes and being victimized by peers is associated with self-blame, loneliness, anxiety, and low self-worth.4 Therefore, it is important to understand negative attitudes towards disability and the factors associated with those attitudes. A series of psychological interventions derived from the ‘contact hypothesis’5 have been designed to promote positive attitudes towards a range of social groups. By creating positive interactions (contact) between members of different social groups, negative attitudes may be reduced.6 Positive contact can break down psychological group boundaries, reduce anxiety, and elicit emotions such © 2013 Mac Keith Press
as empathy directed towards outgroup members who are otherwise often inhibited in intergroup contexts.7 A systematic review and meta-analysis of studies involving a range of intergroup contexts suggested that contact is nearly always successful in improving attitudes and reducing prejudice.6 However, the review did not focus on children’s attitudes and it did not specifically examine attitudes towards disability. UK government policies generally promote inclusive education,8 which is reflected in the large number of children with disabilities who attend mainstream schools. Although inclusive education enables contact between children with and without disabilities, research examining the association between naturally occurring contact and children’s attitudes has not been synthesized. Given that negative attitudes have adverse implications for children with disabilities,4 the impact of encouraging contact in schools on children’s attitudes towards disability needs to be better understood. The aim of the current systematic review was to synthesize the evidence regarding the association between children’s natural contact with people with disabilities and their attitudes towards disability. DOI: 10.1111/dmcn.12326
529
METHOD Inclusion and exclusion criteria Studies were included in the review if they (1) focused on children (under 18y) and (2) measured children’s attitudes towards disability. Studies were excluded if they (1) focused only on the experiences of discrimination of children with disabilities; (2) manipulated contact (e.g. experiments, intervention studies); (3) were qualitative or case studies; or (4) were not reported in English. Once studies had been screened for the above criteria, full-text copies of the articles were retrieved if they measured the contact children had with people with disabilities and quantified the associations between these variables. Identification of studies A systematic search was conducted using the following databases: MEDLINE (using the Ovid interface), Applied Social Science Index and Abstracts (ASSIA; using the Proquest interface), PsycINFO (using the Ovid interface), and Educational Resources Information Centre (ERIC; using the Proquest interface). Databases were searched in August 2012 using variations of the terms ‘child’, ‘attitudes’, and ‘disability’ (search terms are provided as supporting information, Appendix S1). We did not limit the search by the publication date. Retrieved references were stored in reference management software (Endnote X4) and duplicates were removed. Additional studies were sought through backward and forward citation chasing. Study selection The first reviewer (MM) screened the titles and abstracts of the search results to identify relevant articles. Additionally, as a quality assurance check, a second reviewer (KW) screened 10% of the search results. After screening, the first reviewer retrieved full-text copies of the articles. The two reviewers (MM and KW) then independently reviewed these for inclusion and any discrepancies that arose were resolved through discussion. Data extraction and synthesis A data extraction form was piloted and refined; this included details of the authors, date, setting, participants, measures of attitudes, measures of contact, and results. The results extracted included a comparison of means of children’s attitudes towards disability with differing amounts of contact with people with disabilities, as well as the correlational results between attitudes and contact. The first reviewer (MM) extracted all data and the second reviewer (KW) checked all data extraction. Discrepancies were resolved by discussion. Studies were described in detail and aggregated using narrative synthesis.9 Quality appraisal The ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE)10 checklist was used to assess the completeness and transparency of reporting in the 530 Developmental Medicine & Child Neurology 2014, 56: 529–546
• • •
What this paper adds Children who have more contact with people with disabilities generally report more positive attitudes towards disability. Published research into contact with and attitudes towards disability lacks complete reporting of methods and results. Measures of children’s contact with people with disabilities and their attitudes towards disability vary considerably, precluding synthesis of results across studies.
included studies. The STROBE checklist identifies potential sources of bias and strengths of individual studies using 22 items. The first reviewer (MM) used the checklist to record whether each item was apparent and adequately reported. The second reviewer (KW) checked all of the quality appraisal checklists.
RESULTS Study selection Figure 1 summarizes the identification and selection of studies. MEDLINE located 1484 studies, ASSIA located 450 studies, PsycINFO located 3244 studies, and ERIC located 1786 studies. A total of 1540 studies were duplicates and were removed from the search. We screened the titles and abstracts of the 5424 studies which had been retrieved and read 54 full-text studies. After excluding 25 studies, 29 studies were included in the review. Six additional studies were sought through backward and forward citation chasing, creating a total of 35 studies included in this review. Study characteristics The studies included in this review explored children’s attitudes towards a range of disabilities. Some studies explored attitudes towards specific disabilities (i.e. Down syndrome,11,12 hearing impairments,13 and communication disabilities).14 The majority of studies (n=15) explored attitudes towards disability more generally. The majority of studies included were conducted in the USA (n=14) and in Canada (n=6). The other studies were carried out in the UK (n=3), Greece (n=2), Australia (n=2), Israel (n=1), Italy (n=1), Ireland (n=1), France (n=1), and New Zealand (n=1). In addition, one study was carried out in both Israel and Canada (n=1), one study was carried out in both the USA and Greece (n=1), and one study did not report a location.15 Studies were published between 1966 and 2011, with 13 studies out of the total 35 conducted in the 1980s, and 10 studies published since 2000. All studies recruited participants from schools and included both male and female participants. Sample sizes ranged from 6016 to 583717 with a total of 22 477 participants across the 35 studies. The number of schools sampled was not reported in four studies, but ranged from 118 to 6817 in the other studies. The age of participants ranged from 4 to 18 years old; 13 studies reported the school year but not the participants’ actual ages. Two studies failed to provide any details about the participants’ ages or school year.19,20 The largest
Identification
Records identified through
Additional records identified
database searching
through other sources
(n=6964)
(n=6)
Records after duplicates were removed
Included
Eligibility
Screening
(n=5430)
Records screened
Records excluded
(n=5430)
(n=5370)
Full-text articles assessed for eligibility (n=60)
Studies included in a
Full-text articles excluded, with reasons (n=25) - Intervention based studies (n=7) - Not in English (n=5) - Does not examine the association between contact and attitudes (n=8) - Qualitative studies (n=2) - Participants aged over 18 years (n=3)
narrative synthesis (n=35)
Figure 1: Study selection; PRISMA flow diagram.
age range in any study was 6 years, which was found in two studies; one of these sampled children aged 7 to 12 years21 and the other sampled children aged 8 to 13 years.22 Seven studies described a theoretical framework that was to be tested by their findings. The most frequently reported theory was Allport’s contact hypothesis5 (n=4).23–26 Other theories include social development theory,27,28 the theory of planned behaviour,29,30 and social identity theory.31,32
Outcomes Across studies, attitudes were assessed using 26 different measures, with the Chedoke–McMaster Attitudes Towards Children with Handicaps (CATCH)33 measure being the one used most frequently. The CATCH was used in full in four studies,14,34–36 and a subscale was used in one
additional study.37 The ‘Attitudes Towards Disabled Persons’38 scale, or adapted versions of it, was used in four studies.24,39–41 In addition to self-reported attitude measures, other techniques included asking children questions about how they would respond to a disabled child described in a written vignette.12,32,42 One study used a ‘post-box’ technique,25 which involved participants posting pictures of children with and without disabilities into boxes labelled in stages from ‘always’ to ‘never’ to represent how much they would like to play or work with them. Finally, two studies used peer nomination methods, which involved participants ranking or nominating children in their class or school with whom they would most like to interact.18,43 Children’s previous contact with people with disabilities was measured either through self-reports or through contact at the school level. Self-reported contact was used Review
531
in 13 studies. There is no standard measure of selfreported contact across the literature. The majority of studies that used self-reported contact asked about disabled friends, family members, and classmates. Some studies asked for more detailed information about the contact, such as whether they had played or talked to a disabled child in the past week11,14,35 or how many hours in a week they typically spent with people with disabilities.44 Schoollevel contact, used in 22 studies, is a measure of contact that is based on the level of disability inclusion within the school. The majority of studies using this measure of contact (n=15) categorized schools or classrooms as having either ‘no children with disabilities’ (i.e. no contact) or ‘some children with disabilities’ (i.e. contact). However, seven studies used a range of methods to categorize schools into ‘contact’ or ‘no contact’ settings. These included teachers’ ratings of the perceived contact between children with and without disabilities,22,30,45 the amount of time children with and without disabilities had spent together in a school or classroom,21,43 and the change in attitudes after a semester or year in an inclusive classroom.18 Two studies examined the correspondence between selfreported contact and school-level contact.12,40 Both studies reported significant (positive) associations between the two measures of contact and, therefore, only used the schoollevel measure of contact in the analysis of the results (although effect sizes for the relationship between the two measures of contact were not reported).
Quality appraisal The completeness of reporting of the included studies was generally poor. No studies reported determining sample size a priori. However, because only three studies had a sample size below 100, there was likely to be enough power to detect a significant association. Twelve studies failed to discuss the location of the study or dates regarding recruitment and nine studies did not adequately describe their participants (e.g. the numbers of males and females or their age). Furthermore, none of the studies reported confidence intervals. Effect sizes were reported in only four studies;16,17,46,47 we have, therefore, calculated effect sizes when possible. Additionally, different effect sizes were used for correlational data and for comparing means; therefore, all available effect sizes were transformed into effect size (Cohen’s d) to allow comparisons to be made between individual studies. Over half of the studies (n=18) failed to report attempts to reduce potential bias in their methodological techniques. Those studies that did attempt to limit biases used random sampling within schools, purposive sampling to create representative samples, and attempts to reduce social desirability bias (e.g. through making the surveys anonymous, which has shown to be successful at reducing social desirability response bias).48 Furthermore, 22 studies failed to report participant consent levels or whether there were any missing data. Only one study provided a detailed description of the handling of missing data at each stage.36 532 Developmental Medicine & Child Neurology 2014, 56: 529–546
Although the majority of studies (n=23) used previously validated instruments measuring attitudes towards disability, Vignes et al.36 were the only authors to explain their choice of attitude measure, discussing evidence of reliability and validity in this domain. Additionally, at least 30 studies recruited participants from multiple schools; however, Vignes et al.36 were the only authors to employ a multilevel analysis to adjust for clustering effects within schools.
Main results of individual studies Of the 35 studies included in this review, 16 reported a significant positive association between the amount of contact children had with people with disabilities and their attitudes towards disability.14,16,17,21,22,30,32,34–37,40,45–47,49 These studies all showed that the more contact children had with people with disabilities, the more positive their attitudes were towards disability. From the nine articles in which effect sizes were available or calculated, effect size d ranged from 0.17 to 2.45 (Table I). Six further studies failed to identify a significant association between contact and attitudes when the attitude measure as a whole was included in the analysis. Five of these studies reported subscales within the attitude measure to be significant.13,15,19,44,50 Of these five studies, three studies13,15,19 had effect sizes ranging from low to moderate. Finally, one study reported significant associations between individual attitude questions and contact.51 None of the authors of these studies justified the decision to explore subscales or individual items. Eleven studies found no association between contact and attitudes to disability.11,12,18,20,23,24,26,39,41–43 Only two studies found a negative association between contact and attitudes: one of these28 reported a small effect size and the other52 failed to report an effect size or the descriptive statistics to calculate an effect size. The positive association between contact and attitudes towards disability is also observed when studies are separated according to the measure of contact (school level vs self-report). Of the 22 articles that used school-level contact, a significant positive association between contact and attitudes towards disability was reported in 12, a negative association was reported in two, and no association was reported in eight of the articles. Of the 13 studies which measured contact through self-reports, 11 studies reported a significant positive association between contact and attitudes and 2 studies found no association. DISCUSSION Overall, contact with people with disabilities was associated with more positive attitudes towards people with disabilities among participating children. Of the 35 studies included in the review, 22 showed a positive association on all or some of the attitude measures, 11 showed no association, and just two showed a negative association. From the first study28 that found a negative association between contact and attitudes, the authors stated that the
Review
533
Physical disabilities (using pictures)
Inclusive disability
Inclusive disability
Child with no communication
Archie and Sherrill, 1989 (USA)23
Barrett and Kitchenham, 1992 (Canada)24
Blockberger et al., 1993 (Canada)14
Type of disability being assessed
Arampatzi et al., 2011 (Greece)28
Author(s), year (country)
Table I: Study characteristics
249 from nine schools
89 (48 in ‘contact’ setting and 41 in ‘non-contact’ setting); unknown number of schools
229 (143 in ‘contact’ setting and 86 in ‘non-contact’ setting) from two schools
658 (353 in ‘contact’ setting and 305 in ‘non-contact’ setting) from 15 schools
Number of individual participants and schools
Whether the classroom included a disabled child (n=1 or 2) or not (n=0) Self-reported by the child: included whether they had a disabled child at their school, had a disabled friend or family member, or talked or played with a disabled person in the last week
8th and 10th grades
9–10y
School level: comparing inclusive and segregated schools
School level: comparing inclusive and segregated schools
Measure of contact
5th and 6th grades
Mean=11y
Age
CATCH scale (Rosenbaum et al.)33
Children’s attitude toward integrated PE revised (CAIPER; Block56) Children’s attitude toward handicapped scale (Rapier et al.57) ATDP scale (Yuker and Block)58
Measure of attitudes
Significant difference for those who reported having a disabled friend (p
