swedish and english adolescents' attitudes toward the community presence of people with...

Swedish and English adolescents' attitudes toward the

community presence of people with disabilities

R. P. Hastings, K. E. SjoÈ stroÈ m & S. V. Stevenage

Department of Psychology, University of Southampton, Southampton, England

Abstract

Predictions derived from North American formulations of

normalization suggest that contemporary care policies for

people with intellectual disabilities will have a positive

impact on societal perceptions of this group. To test this,

adolescents' attitudes towards the community presence of

people with disabilities in a normalization-advanced

country (Sweden) and a relatively less normalization-

advanced country (England) were compared. It was

expected that Swedish and English participants would hold

equally positive views of people with a non-intellectual

disability, whereas English participants would hold less

positive views than Swedish participants of people with an

intellectual disability. The results gave limited support to

this expectation when dimensions of participants' attitudes

derived from a factor analysis were analysed. These results

are discussed with reference to other factors that may

influence attitudes in the two countries. In addition,

implications for future research and practice are outlined.

Keywords disability, community presence, attitudes,adolescents

Introduction

The philosophy of normalization has had asignificant impact on the process of care for people

with intellectual disabilities in both Europe and theUSA (Flynn & Nitsch 1980). One of the centraltenets of Wolfensberger's formulation ofnormalization is that members of devalued groups(such as people with intellectual disabilities) shouldbe integrated into valued facets of life, i.e. living innormative housing with valued people, beingeducated with non-devalued peers, working in thesame places as ordinary people and engaging in theleisure activities that are normative for society(Wolfensberger & Thomas 1983). By adhering tosuch ordinary roles, people with intellectualdisabilities are thought to be more likely to live up tothe societal expectations associated with these roles,and thus, become valued members of society(Wolfensberger 1972; Wolfensberger & Thomas1983). The theoretical background to this conclusionincluded labelling theories of deviance (for adiscussion focusing on intellectual disabilities, seeHastings & Remington 1993) and the notion of theself-fulfilling prophecy (Rosenthal & Jacobson 1966),both of which were influential at the time ofWolfensberger's early writing.

The major social policies resulting from the workof Wolfensberger and other supporters ofnormalization, as applied to the care of people withintellectual disabilities, were educational integration(mainstreaming) and community integration(deinstitutionalization). There has been a substantialamount of research effort invested in the evaluationof both of these policies. Two basic research designs

Correspondence: Dr Richard Hastings, Department of Psychology,

University of Southampton, Highfield, Southampton, Hampshire

SO17 1BJ, England.

# 1998 Blackwell Science Ltd

Journal of Intellectual Disability Research

VOLUME 42 PART 3 pp 246±253 JUNE 1998246

have been employed in the evaluation ofdeinstitutionalization schemes and the location ofresidences for people with intellectual disabilities incommunity settings. Firstly, repeated measuresdesigns have been used to compare pre- and post-integration performance on various criteria.Secondly, between-subjects designs have been usedto compare community-based services andinstitutional provision. Dependent measures haveincluded the quantity and quality of staff±clientinteraction, changes in adaptive and challengingbehaviours and the use of ordinary communityfacilities (Emerson & Hatton 1994). In addition,some studies have measured the attitudes of peopleliving in the locality of community homes towardstheir neighbours (real or fictitious) with intellectualdisabilities (for a review, see Okolo & Guskin 1984).

The majority of research in this area has indicatedthat some positive outcomes can be obtained. Forexample, a recent review (Allen 1989) concludedthat positive outcomes of the move from institutionsto the community include improvements in adaptivebehaviour, increased activity levels, more frequentsocial interaction with care staff, and more use ofcommunity facilities such as shops and restaurants.Conclusions such as these are often presented withat least two qualifications. Firstly, it is not clearwhether the effects are maintained in the longerterm. Secondly, psychological and social segregationmay persist despite physical integration (Palmblad1992).

Evaluations of deinstitutionalization and ofmainstreaming have concentrated on individualschemes, and in particular, on their effects on thepeople with intellectual disabilities involved.However, Wolfensberger's theory suggests that thesesocial policies will have an impact at a wider level onsocietal perceptions of people with intellectualdisabilities. In particular, one would expect thatpeople would become more positive about thepresence of individuals with intellectual disabilitiesin the community.

Of course, North American formulations were notthe only manifestations of normalization. Inparticular, Scandinavian writers formulated theirown principles based on earlier philosophies.Through the work of Bank-Mikkelsen and Nirje, theScandinavian concept of normalization in the care ofpeople with intellectual disabilities has emphasized

that such people have the same rights in life as otherpeople and that this should lead to as close to anordinary life as is possible (Emerson 1992). Incontrast, Wolfensberger's position has beenrepresented as an interest in normalizing services,i.e. locating them in the community and avoidingthe use of separate services for people withintellectual disabilities (Emerson 1992).

Attitude change (i.e. coming to value people withintellectual disabilities) is central to Wolfensberger'saccount of normalization. However, Scandinavianformulations have nothing specific to say about sucheffects. Working from Wolfensberger's perspective,one would still expect the Scandinavian approach tolead to attitude change within society. Even thoughthe Scandinavian emphasis is on the rights of peoplewith intellectual disabilities, this often translates atthe practical level into community living, educationalintegration and social integration. Thus, the effectsof normalization philosophies, and the social policiesbased upon them, is likely to be a change inperceptions of people with intellectual disabilities ata societal level.

Research at this societal level is extremely rare.Two strategies are available: (1) longitudinalresearch within a particular culture; and (2) cross-cultural comparisons of attitudes. Longitudinaldesigns would employ measures of attitudes fromseveral decades ago in comparison withcontemporary attitudes towards the communitypresence of people with intellectual disabilities.However, such designs have a number of inherentdifficulties; for example, new research projects wouldbe difficult to instigate given the significant changesin care policies over the past few decades, any effectscould be caused by a large number of other socialchanges (e.g. rising unemployment and declines inwelfare support) and the time involved is extensive.

An alternative approach would be to compareattitudes in cultures where normalization-basedsocial policies have been established for many years(e.g. Scandinavian countries) with cultures wherethese policies have been developed relatively morerecently (e.g. the countries of the UK). Of course,factors other than policies of care for people withintellectual disabilities may influence attitudestowards this population in the community. In thiscase, a control comparison of some kind would helpto separate the effects of social care policies; for

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R. P. Hastings et al. . Disability and community presence

# 1998 Blackwell Science Ltd, Journal of Intellectual Disability Research 42, 246±253

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example, one might expect attitudes towards peoplewith intellectual disabilities to vary between Englandand Sweden to a greater extent than attitudestowards people with non-intellectual disabilities thathave social effects but are not the subject of specificcare policies in either culture.

Wolfensberger's formulation of the principle ofnormalization suggests that full integration of peoplewith intellectual disabilities is the key factor infostering positive attitudes and eventual acceptance ofthis group. However, it is not clear how long a generalacceptance would take to emerge in a society. Thisproblem has not been addressed in previous research.In the present study, the authors expected that themaximum effect on attitudes would be seen inSwedish adolescents rather than in adults. The presentauthors based this conclusion on the observation thatadolescents living in Sweden in the 1990s are the firstcohort whose parents were schooled during a periodwhen integration policies were being actively pursued.In addition, this group would be old enough to havedeveloped their attitudes towards people withdisabilities. These attitudes would be more likely thanthose of younger children to reflect prevailing societalviews of people with disabilities. Therefore,adolescents would be appropriate comparison groupsin Sweden and England.

The present study involved a comparison ofattitudes towards the presence in the community ofpeople with disabilities (people with intellectualdisabilities and people with speech impediments)amongst Swedish and English adolescents. The mainhypothesis was that the difference between Englishand Swedish adolescents' attitudes towards thecommunity presence of people with a minor non-intellectual disability would be smaller than thedifference in their attitudes towards people withintellectual disabilities. It was expected that Englishadolescents would be much more negative thanSwedish adolescents about people with intellectualdisabilities.

Subjects and methods

Participants

One hundred and thirty English and 96 Swedishadolescents, aged between 14 and 16 years, took partin the study. Out of the total sample, 122

participants were male (82 English males and 40

Swedish) and 104 female (48 English and 56

Swedish). The skewed distribution of males in theEnglish sample occurred despite random selection ofparticipating class groups. This imbalance was notcaused by differing completion rates of thequestionnaires (only one or two questionnaires wereincomplete in each of the samples). Gender has beenshown to have a reliable effect on attitudes towardsdisability with females almost invariably expressingmore positive attitudes than males (Yuker & Block1986). Therefore, the present authors controlled forthe impact of respondents' gender in the statisticalanalyses.

The participants lived in the suburbs of smalluniversity towns (populations �100 000 inhabitants)and attended schools with 500±1000 students. Theparticipating schools all had a separate class forchildren with intellectual disabilities on site. Thesechildren were integrated with their peers for leisureand meal breaks, but attended only a small numberof regular classroom sessions. Such schools werechosen in order to present a stringent test of thehypotheses, i.e. proximity of children withintellectual disabilities and regular school-basedcontact were as similar in each country as waspractically possible to arrange. However, aMannWhitney U-test comparing the students' self-rated frequency of contact with people withdisabilities was significant, indicating that Swedishadolescents reported more contact with people withdisabilities than their English peers (z = 2.12;P < 0.05). Given this difference, the present authorsalso controlled for the effects of previous contact instatistical analyses.

Attitude questionnaire

No existing scale was available that measuredattitudes towards the community presence of peoplewith disabilities. Therefore, an attitude scale wasdeveloped specifically for use in the present study.

Twenty-four items were generated that reflectedthe range of situations and activities that variousauthors have argued should be characteristic of themore normative lives of people with intellectualdisabilities (e.g. Nirje 1980; O'Brien & Tyne 1981;Wolfensberger & Thomas 1983; see items listed inTable 1). The questionnaire items were constructed




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in the form `People like Stephen should/should not',with 12 items positively constructed and 12 wordedin a negative fashion. Stephen was the name of thetarget individual in the present study.

A preliminary reliability and validity study wasconducted using a sample of university studentsregistered on social science degree programmes.Fifty-five students (22 male and 33 female) wereasked to complete the scale in which the phrase`People like Stephen' was replaced with `People withlearning disabilities' in each of the items.Participants were asked to indicate their agreementwith each item using a five-point scale ranging from`strongly agree' to `strongly disagree'. Total attitudescores were calculated in the standard manner withscoring reversed on negatively worded items andscores on all items summed together.

Scores on each individual item were correlatedwith the total attitude score in a simple item analysis.Items that failed to correlate at least 0.3 with totalscores were rejected. Two items failed to meet thiscriterion (`People with learning disabilities should goto special schools' and `People with learningdisabilities should be taught how to interact withothers'). The reliability of the remaining 22-itemscale was assessed in two ways. Firstly, the internalconsistency of the scale was established and wasfound to be high (Cronbach's alpha = 0.87).Secondly, the same sample of students were asked tocomplete the scale again after a 2-week interval.Test±retest reliability for the total sample wasacceptable [r (41) = 0.71; P < 0.001]. Theconcurrent validity of the scale was explored bycorrelating the total attitude score with the amountof previous contact or experience with people withdisabilities (often shown to be positive in previousattitude research). The correlation between thesevariables almost reached statistical significance inthis sample [r (54) = 0.26; P = 0.058].

The revised 22-item attitude questionnaire wasthen administered to the participating adolescents.Respondents were asked to read one of two shortvignettes and then complete the attitude scale. Thevignettes were identical apart from the two differentlabels used in the description. In one version,Stephen was described as having a speechimpediment, and in the other, as having intellectualdisabilities. The full form of the vignette is givenbelow:

`Stephen is an 18-year-old who has a speechimpediment (a stutter)/learning disability. He enjoysplaying the piano and going for walks by the sea-sidewith his girlfriend and other friends of his. Stephenhas finished school and now works in a newspaperoffice.'

After completing the attitude scale, respondentswere asked to indicate their gender and theirprevious experience of people like the targetindividual using one of five frequencies ranging fromno contact to daily contact. The questionnaire wasoriginally constructed in English and translated toSwedish by two independent translators who werefluent in both languages.

Procedure

Questionnaires were distributed and completed inclassroom time in the schools involved in the study.Four class groups in the Swedish school participatedin the study. Questionnaires were also distributed tofour class groups in the English school. Class sizes inEngland were larger than in Sweden, resulting in adifference in the size of the samples in the twocountries. At the time of data collection, participantsin both countries were attending mixed abilityteaching sessions (but not with their peers withintellectual disabilities present).

The two versions of the vignette were randomlydistributed amongst the participating populations.Students were asked to complete the questionnaireson their own, without talking to their peers, so thattheir individual views could be obtained.

Results

Before statistical analyses were carried out, thereliability and validity of the scale were investigated forthe present samples. Internal consistency was high forthe research sample as a whole (Cronbach's alpha= 0.83), for English adolescents (a = 0.86) and forparticipants rating the intellectual disability (ID)vignette (a = 0.89). However, this value was lower forthe Swedish adolescents (a = 0.74) and for those ratingthe speech impediment (SpI) vignette (a = 0.69).

The validity of the scale was confirmed byexamining gender differences in the sample. Suchdifferences are a reliable feature of research on




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attitudes towards people with disabilities. Femaleshad significantly more positive attitudes(mean = 94.15, SD = 8.73) than males(mean = 86.63, SD = 10.34) in the sample as awhole [t(224) = 5.85; P < 0.001]. This differencewas also highly significant in the English sample[t(128) = 3.61; P < 0.001], the Swedish sample[t(94) = 3.45; P < 0.01], the ID group[t(112) = 5.27; P < 0.001] and in the SpI group[t(110) = 4.18; P < 0.001]. However, becausegender differences in attitudes were not the focus ofthe present study, these interactions were notformally investigated. Rather, gender was introducedas a covariate in the following analyses.

Total attitude scores

Total scores on the attitude questionnaire wereentered into a 2 (country: Sweden versusEngland)� 2 (disability: intellectual disability versusspeech impediment) between-subjects analysis ofcovariance (ancova). Respondents' self-categorizedlevel of previous contact and their gender wereentered as covariates in this analysis.

After adjustment for covariates, there was asignificant main effect for country and for disability.These main effects showed that those in the SpIgroups expressed more positive attitudes towards thetarget's community presence than did those in theID groups [F(1, 220) = 19.54; P < 0.001]. Inaddition, Swedish respondents expressed morepositive attitudes than English respondents [F(1,220) = 24.84; P < 0.001]. The predicted interactioneffect was not significant [F(1, 220) = 1.49;P = 0.22].

Data reduction

In addition to differences in total attitude scores,respondents may have expressed differing views onparticular aspects of the community presence ofpeople with disabilities (e.g. leisure and workintegration). Several authors have argued thatattitudes towards people with disabilities are likely tohave a number of components (e.g. Hastings &Graham 1995). To explore this possibility in thepresent case, scores on the individual items of theattitude scale were subjected to a data reductionexercise. The responses of all 226 participants were

entered into a Principal Axis Factor Analysisprocedure.

The decision about the number of factors toextract was facilitated by using initial statistics togenerate a scree plot, as recommended by Kline(1994). The resulting graph showed a definitechange in slope after two factors. Therefore, twofactors were extracted and subjected to an obliquerotation using Direct Oblimin. The results of thefactor analysis are displayed in Table 1. Only itemswith factor loadings of at least �0.5 were consideredrepresentative of each factor.

Table 1 Factor structure and loadings of adolescents' attitudes to-

wards the community presence of people with disabilities

FactorFactor and questionnaire items loading

Factor 1 (22.8% of variance): Ordinary LifeShould not be told at what time to go to bed 0.65

Should go to night-clubs 0.65

Should work in the same places as everyone else 0.62Should be encouraged to cook their own meals 0.60

Should not live away from other people 0.59

Should be encouraged to make spontaneous

decisions about their lives 0.58Should be able to attend the local swimming pool 0.56

Should determine their own daily routines 0.56

Should not always have someone with them

to look after them 0.55Should be able to choose where they work 0.54

Should choose where they go on holiday 0.54

Factor 2 (7.9% of variance): Leisure IntegrationShould visit their local shops regularly 0.66

Should spend time with their families 0.58

Should be involved in local clubs andorganizations with other people of their age 0.56

Should go on dates with people of the

opposite sex 0.51

Should spend their leisure time with otherpeople of the same age 0.50

Items with loadings < 0.5 on both factors

Should make friends with their neighboursShould be encouraged to use speech rather

than sign language

Should learn housework skillsShould live in ordinary homes

Should be able to attend training courses

at their place of work

Should be helped to make a success of their lives




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The first factor was associated with a wide rangeof items. As such, it was given the general label of`Ordinary Life'. The second factor was characterizedby items about leisure activities, and thus, waslabelled `Leisure Integration'.

Analysis of dimensions of attitudes towardscommunity presence

In order to investigate the effects of disability andcountry on the components of respondents' attitudesidentified in the factor analysis, a 2 � 2 mancovawas conducted. Participants' gender and contactratings were incorporated as covariates, and theirfactor scores on the two factors in Table 1 wereentered as dependent variables.

After adjustment for covariates and using Wilks'criterion, the mancova demonstrated a significantmain effect for disability [F(2, 219) = 42.10;P < 0.001], and for country [F(2, 219) = 24.66;P < 0.001]. There was also a significant interactioneffect [F(2, 219) = 8.82; P < 0.001]. The source ofthese effects was investigated using univariate ancovaprocedures. The disability effect was significant onlyfor the Ordinary Life variable, with SpI rated morepositively than ID [F(1, 220) = 65.65; P < 0.001].The country effect was significant for both theOrdinary Life factor [F(1, 220) = 10.61; P < 0.01]and the Leisure Integration factor [F(1,220) = 48.05; P < 0.001]. In both cases, Swedishadolescents held more positive attitudes than theirEnglish peers.

The interaction effect was significant only for theLeisure Integration factor [F(1, 220) = 10.63;P < 0.01]. Planned comparisons revealed that theEnglish ID group had less positive attitudes in thisdomain than the Swedish ID group [t(112) = 7.68;P < 0.001]. Although the difference was muchsmaller, there was also a significant differencebetween the Swedish and English SpI groups[t(61)1 = 2.64; P < 0.05]. The Swedish adolescentsexpressed more positive attitudes than the Englishgroup.

Discussion

The central hypothesis of the present study receivedpartial support from analyses of one of the threedependent variables' (Leisure Integration) factorscores. English adolescents held less positiveattitudes towards the integration in leisure situationsof people with intellectual disabilities than Swedishadolescents. Their attitudes towards people withspeech impediments in such situations were also lesspositive, but to a lesser extent.

Rather than a wholesale acceptance of people withintellectual disabilities, Swedish adolescentsexpressed more positive attitudes towards theintegration of such individuals into ordinary leisureactivities. This finding is encouraging. However, itmay represent a view that people with disabilities cando little `damage' in leisure situations, but have amore significant impact on the community shouldthey be encouraged to make their own life decisionsand become integrated into ordinary workenvironments. Thus, it may be relatively easy towork on attitude change on this dimension.Underlying perceptions of this kind warrantattention in future research.

The lack of positive findings using total attitudescores may reflect a frequent failure of such genericmeasures to detect differences in attitudes towardspeople with disabilities (Hastings et al. 1996).Research concerned with measuring attitudestowards people with disabilities should continue toexplore the latent dimensions of these attitudes.

The control comparison used in the present studyof attitudes toward a second group likely to elicit lessaccepting attitudes adds significant weight to theresults, i.e. the pattern of results reported is unlikelyto be caused by a general difference in attitudestoward disadvantaged individuals amongst Swedishand English adolescents. However, there may be anumber of other variables that could differentiallyimpact on attitudes toward intellectual disability andother impairments. Firstly, the level of self-reportedcontact with people with disabilities was lower in theEnglish than in the Swedish sample. However, theeffects of contact were statistically controlled for inall of the analyses as were the effects of respondentgender. The difference between the countries wasover and above that caused by either contact orgender effects. This assumes that the measure of

1Levene's Test for the Equality of Variances revealed that the

variances in the English SpI and Swedish SpI groups were not

equivalent. Hence, separate variances (`unpooled' procedure) were

used to calculate t. This procedure leads to an adjustment of the

degrees of freedom for the test.




251

contact used here was reliable and valid. No data areavailable relating to this issue, but aspects ofexperience other than a straightforward rating offrequency of contact could be important (e.g. levelof disability of contacts, intensity of contact andpersonal relationships with contacts).

Secondly, the samples may have differed in otherways not addressed in this study. For example,although schools in similar towns in Sweden andEngland were chosen, the present authors did notmeasure the socio-economic status (SES) of theadolescents' families. It is possible that SES affectsattitudes towards intellectual disability differentlythan it affects attitudes toward other groups. Inaddition, although adolescents in the same age rangewere selected from appropriate school classes, nodata were collected to establish the mean and spreadof age in each population. Thus, the effects observedmay be related to developmental changes in attitudestowards people with disabilities in the age range 14±16 years. This seems unlikely, but the possibilitycannot be ruled out.

A further limitation of the present study is that theattitudes measured may well be closely related to thechosen content of the questionnaire vignettes. Thedesign was such that a comparison of minor non-intellectual to relatively more severe intellectualdisabilities was required to answer the researchquestion. However, this meant that the intellectualdisability vignette described somebody who wasmost likely to be viewed as only having a mildcognitive impairment. A stronger test of the impactof normalization-based care policies at the societallevel would involve the measurement of attitudestowards those with severe intellectual disabilities.Even so, any differences between Swedish andEnglish adolescents' attitudes toward people withintellectual disabilities may be explained by factorsother than the relatively more temporally advancednature of care policies in Sweden. A multivariateapproach to measurement may provide furthersupporting data. For example, a measure ofadolescents' knowledge of disability policy andlegislation may differentiate between the twocountries and show a strong relationship withattitudes. Further research is needed to addressthese questions.

Given the neglect of the topic of the present studyby researchers in the field of intellectual disabilities,

a great deal more research needs to be carried out inorder to complete the picture about the effects ofnormalization. In addition to the issues raised above,research should address at least two other importantquestions. Firstly, theoretical and practical work isneeded to identify the expected speed of change insocietal attitudes towards people with disabilities.Secondly, even if people express positive attitudestowards those with disabilities, it does notnecessarily follow that they interact any differentlywith them (Heinemann 1990). The quantity andquality of interactions have formed the basis ofevaluations of individual integration ordeinstitutionalization projects, and their applicationat a less specific level to compare different culturesshould be explored.

In conclusion, the present study focused on theuntested assumption that care policies for people withintellectual disabilities, based on the principles ofnormalization, would lead to more positive attitudestowards the presence of such people in the generalcommunity. With qualification because ofmethodological limitations, some support forhypotheses derived from this expectation has beenshown through the measurement of Swedish andEnglish adolescents' attitudes towards the communitypresence of people with disabilities. However, a majorquestion remains about the direction of influencebetween integration practices and societal attitudestowards people with disabilities. It is not clear howthese concepts are causally related.

One could argue that changes in attitudes towardspeople with disabilities resulted in more progressiveapproaches to care in Sweden than in England.Alternatively, the results of the present study can beinterpreted in the light of Wolfensberger's theory thatdeviant roles for people with disabilities foster negativeattitudes. Each position has rather differentimplications for intervention approaches designed toincrease the acceptance of people with disabilities. Thelatter theory suggests that actively involving peoplewith disabilities in everyday life will result in acceptingattitudes on the part of members of their communities.On the other hand, it may be necessary to changepeople's attitudes through educational approaches andother means before people with disabilities can beintegrated into the community.

The reality of the situation is probably thatintegration of people with disabilities and societal




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attitudes towards them interact to influence eachother. Therefore, integration may enhance furthersocietal attitudes that are already positive enough toinstigate integration programs. If this is the case,then logically a negative change in attitudes towardspeople with disabilities could result in the reversal ofinclusive care policies. This could occur under awide range of conditions. For example, at the timeof writing, and as a result of economic pressures,Sweden is engaged in a debate about the level ofstate support given to people with intellectualdisabilities. Thus, societal perceptions of people withintellectual disabilities and other disabilities requirecareful monitoring to prevent any return tosegregation as the norm.

Acknowledgements

The authors would like to thank Bob Remington,and all the teachers and students who participated inthis study.

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Received 10 February 1997; revised 28 January 1998




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