Research in Developmental Disabilities 35 (2014) 34823495

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Review article

Interventions aimed at increasing knowledge and improving

attitudes towards people with intellectual disabilities among
lay people
Leila Seewooruttun *, Katrina Scior
Clinical, Educational and Health Psychology, University College London, United Kingdom

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 14 April 2014
Received in revised form 10 July 2014
Accepted 14 July 2014
Available online 14 September 2014

Despite policies aimed at ensuring equal rights and maximising respect and social
inclusion for people with intellectual disabilities, in their daily lives many continue to face
negative attitudes and discrimination within society. Misconceptions about what it means
to have an intellectual disability and about the capabilities of people with intellectual
disabilities appear widespread, and may contribute to prejudice and discrimination. This
review provides a summary and evaluation of empirical interventions aimed at increasing
knowledge and targeting negative attitudes towards this population among lay people of
working age. An electronic search using PsycINFO, Web of Science and PubMed identied
22 English language studies published between 1990 and early 2014 that reported a
specic intervention with a lay population sample. The majority of studies reported
promising outcomes, particularly those aimed at increasing knowledge of intellectual
disability through education. Support for the positive inuence of contact with people
with intellectual disabilities was demonstrated across several interventions. Interventions
delivered at least partly by individuals with intellectual disabilities, and educational
interventions appear to hold the most promise. The evidence is limited though by the
weaknesses of measurement tools employed.
Crown Copyright 2014 Published by Elsevier Ltd. All rights reserved.

Keywords:
Intellectual disabilities
Intervention
Knowledge
Attitudes
Stigma
Contact

Contents
1.
2.

3.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Aims of the current review . . . . . . . . . . .
1.1.
Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Search strategy . . . . . . . . . . . . . . . . . . . . .
2.1.
Inclusion criteria . . . . . . . . . . . . . . . . . . .
2.2.
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Overview of studies included . . . . . . . . .
3.1.
Overview of methodology and reporting
3.2.
Overview of ndings . . . . . . . . . . . . . . . .
3.3.

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* Corresponding author at: Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, United
Kingdom. Tel.: +44 0207 6791897.
E-mail address: leila.seewooruttun.10@ucl.ac.uk (L. Seewooruttun).
http://dx.doi.org/10.1016/j.ridd.2014.07.028
0891-4222/Crown Copyright 2014 Published by Elsevier Ltd. All rights reserved.

L. Seewooruttun, K. Scior / Research in Developmental Disabilities 35 (2014) 34823495

4.

3.3.1.
Interventions that aimed to increase knowledge and improve attitudes . . . . . . . .
Interventions that incorporated contact with people with intellectual disabilities
3.3.2.
3.4.
Measures used to evaluate intervention effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.
Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3483

..................
to improve attitudes .
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1. Introduction
Intellectual disabilities are characterised by intellectual impairment and signicant decits in two or more areas of
adaptive functioning that begin during the developmental period (American Psychiatric Association, 2013; WHO, 1992).
Around two per cent of the population meet diagnostic criteria for intellectual disability (WHO, 1992) thus this population
is not an insignicant minority, even if often rather invisible. The 2006 UN Convention on the Rights of Persons with
Disabilities formally recognised the equal rights of people with disabilities and makes it incumbent on governments to
tackle societal barriers that stop people with disabilities from being valued and equal members of society (United Nations,
2006). However, in order to target such efforts effectively we need a good understanding of such barriers and what works in
tackling them.
The limited evidence suggests misconceptions among lay people are not uncommon, including about the causation of
intellectual disabilities (Madhavan, Menon, Kumari, & Kalyan, 1990), and associated conditions such as Downs
Syndrome (Gilmore, Campbell, & Cuskelly, 2003). Evidence on public attitudes and knowledge regarding intellectual
disability is more voluminous, yet paints a varied picture. Recent large scale attitude surveys in the UK and Canada
suggest that lay people are generally in favour of inclusion, which may show promising evidence for the efforts of
disability activists and policy makers (Ouellette-Kuntz, Burge, Brown, & Arsenault, 2010; Scior, Kan, McLoughlin, &
Sheridan, 2010). However, evidence abounds that pejorative attitudes and discrimination towards people with
intellectual disabilities are still widespread. They consistently emerge as one of the least desirable groups to socially
interact with (Gordon, Feldman, Tantillo, & Perrone, 2004) and are at increased risk of targeted violence, physical assault
and anti-social behaviours, compared to those affected by other forms of disability (Quarmby, 2008; Sheikh, Pralat, Reed,
& Sin, 2010). Discrimination in the form of reduced employment opportunities, poorer access to education, housing and
good quality healthcare are common experiences among people with intellectual disabilities (Cummins & Lau, 2003;
Emerson, Baines, Allerton, & Welch, 2013; Emerson, Hatton, et al., 2013). Much of the research has provided descriptive
accounts of attitudes and has relied heavily on the use of self-report attitudinal measures (Scior, 2011; Werner, Corrigan,
Ditchman, & Sokol, 2012). Despite the limitations of such measures, reviewed by Werner et al. (2012), there appears a
clear need for initiatives aimed at tackling negative and prejudicial attitudes towards people with intellectual disabilities
if they are to live safe, inclusive and empowered lives.
1.1. Aims of the current review
The current review set out to summarise the ndings of studies conducted between 1990 and 2014, which have evaluated
interventions aimed at increasing knowledge and targeting negative attitudes towards this population. In particular, we
aimed to answer the following questions: (1) what interventions have been developed to tackle low knowledge of and
negative attitudes towards people with intellectual disabilities?; (2) what were their effects?; and (3) how were these effects
measured?
2. Method
2.1. Search strategy
A computerised search was undertaken in March 2014 across the following databases: PsycINFO, Web of Science and
PubMed. The search string keywords used were (learning disabil*, intellectual disabil*, mental retardation OR
developmental disabil*), AND (knowledge, belief*, attitude*, stigma OR public), in conjunction with terms used to denote
change interventions (tackle, intervention*, education*, reduction). The results for all searches were collated and duplicates
removed. All studies were selected for review by assessing eligibility through reading the abstracts or the full paper in cases
where the abstract was not sufcient to establish its relevance to this review.
Hand searches of the following key journals were also conducted dating from the year 1990: Research in
Developmental Disabilities, Journal of Intellectual Disability Research, Journal of Applied Research in Intellectual
Disabilities, Journal of Intellectual and Developmental Disability and American Journal of Intellectual and Developmental
Disabilities. Finally, the reference list of each article included in the review was reviewed this did not yield any articles
not already identied.

L. Seewooruttun, K. Scior / Research in Developmental Disabilities 35 (2014) 34823495

3484

2.2. Inclusion criteria

The inclusion criteria for this review were: (1) published in English; (2) published in peer reviewed journals; (3) in the
period 1990 to March 2014; (4) the sample population was aged 16 years and above; (5) articles reported a specic
intervention that aimed to impact attitudes towards people with intellectual disabilities and/or increase knowledge or
understanding of intellectual disability. Studies that related to learning difculties such as dyslexia, other developmental
disorders such as Autistic Spectrum Disorders or physical disability were excluded from the review. Similarly, studies that
did not specically focus on intellectual disability and encompassed a spectrum of disabilities including physical and sensory
impairments were excluded (Sharma, Forlin, & Loreman, 2008; Smedema, Ebener, & Grist-Gordon, 2012; Timms, McHugh,
OCarroll, & James, 1997). Articles relating to mental illness stigma were also omitted to ensure a specic focus on intellectual
disability. After reviewing the full papers, studies that reported attitudinal shifts or increased knowledge as an outcome of
research conducted for alternative means, such as challenging behaviour training, were excluded (Lowe et al., 2007; McGill,
Bradshaw, & Hughes, 2007; Williams, Dagnan, Rodgers, & McDowell, 2012). Studies that assessed attitudes without testing
an intervention (Beh-Poojah, 1991; Boyle et al., 2010; Schwartz & Rabinovitz, 2001) or which focused on increasing social
inclusion within an educational setting (Barr & Bracchitta, 2008; Carter & Hughes, 2005) were excluded.
3. Results
The search yielded a total of 7909 initial references, of which 22 met all inclusion criteria and were included in the review.
Fig. 1 details the process of identifying articles for inclusion in the review.
3.1. Overview of studies included
Of the 22 articles included in the review, the earliest was published in 1990 whilst the majority of studies (n = 15) were
published from 2000 onwards. Nineteen studies were conducted in the UK, USA, Australia or Canada with the remaining
three studies conducted in Israel, China and Hong Kong. Twelve studies used a student sample, which varied from
psychology undergraduates, teachers in training to medical students. Five studies drew samples from the general
population. All the articles relied on convenience sampling methods. Only one study utilised a qualitative research design

Search of PsycINFO, Web of

Science and PubMed n=7889

References identified through hand searches

of key journals n=20

All identified articles screened for

duplicates and study relevance n=7909
Duplicates n=8 and
irrelevant articles
n=7817 removed
Screened against inclusion criteria n=84
Failed to meet inclusion
criteria n=47

Full text assessed against inclusion

criteria n=37
Did not empirically test an
intervention on attitude
change/ increasing
awareness n=15
Included in review n=22
Fig. 1. Flow diagram of search process.

L. Seewooruttun, K. Scior / Research in Developmental Disabilities 35 (2014) 34823495

3485

(Sharma, Lalinde, & Brosco, 2006); several others employed mixed methods which allowed for qualitative reections from
participants to be obtained (Freudenthal, Boyd, & Tivis, 2010; Iacono et al., 2011; Tracy & Iacono, 2008). An overview of all
studies included in the review is provided in Table 1.
3.2. Overview of methodology and reporting
All studies but one (Hall & Hollins, 1996) provided sufcient detail about the nature of the intervention that was
evaluated. Fifteen studies used standardised and validated measures which are reviewed in Section 3.4. Six articles used a
measure developed for the respective study, four of which provided detailed descriptions of the measurement content
(Adler, Cregg, Duigan, Ilett, & Woodhouse, 2005; Roper, 1990a, 1990b; Wong & Wong, 2008). The remaining study was
qualitative in design (Sharma et al., 2006).
Sixteen of the 21 quantitative studies used a repeated measures design with measurements taken at baseline and post
intervention (Adler et al., 2005; Bailey, Barr, & Bunting, 2001; Campbell, Gilmore, & Cuskelly, 2003; Freudenthal et al., 2010;
Hall & Hollins, 1996; Iacono et al., 2011; Kobe & Mulick, 1995; Li & Wang, 2013; MacDonald & MacIntyre, 1999; Melville
et al., 2006; Nosse & Gavin, 1991; Rae, McKenzie, & Murray, 2011; Rimmerman, Hozmi, & Duvdevany, 2000; Tracy & Iacono,
2008; Walker & Scior, 2013; Wong & Wong, 2008). One study provided baseline data for both the experimental and
comparison group but did not report post-data for the comparison group (Nosse & Gavin, 1991). Two studies were limited in
design by their omission of repeated measures or a control group (Roper, 1990a, 1990b). Studies by Varughese and Luty
(2010) and Varughese, Mendex and Luty (2011) used comparison groups but did not collect baseline data. Consequently, the
conclusions that can be drawn from these studies are limited.
Given that all the studies obtained a specic population using convenience sampling methods, limitations regarding
generalisability of ndings should have been considered. Only two studies provided sufcient detail to ascertain whether
potential recruitment bias had been considered or addressed (Iacono et al., 2011; Sharma et al., 2006). All studies provided
sufcient detail about the data analysis, although two did not report statistical signicance with alpha values (Iacono et al.,
2011; Roper, 1990a).
Overall, the literature in this area is not without shortcomings, most prominently a lack of baseline data. Furthermore, the
diversity in the nature, content and duration of the interventions reviewed makes it difcult to evaluate their effectiveness
against one another. Overall, attempts to improve negative attitudes towards people with intellectual disabilities and
increase knowledge are few and far between. Therefore the ndings warrant further consideration, not least to identify areas
for further research.
3.3. Overview of ndings
Five studies aimed to increase knowledge about intellectual disability and evaluated whether their interventions created
a shift in attitudes. Seventeen studies evaluated interventions that tackled attitudes towards people with intellectual
disabilities and utilised some variant of contact as an integral part of the intervention. Of these 17, eleven evaluated direct
contact with people with intellectual disabilities, whilst six assessed the impact of indirect contact. The results are
summarised in turn below.
3.3.1. Interventions that aimed to increase knowledge and improve attitudes
Two studies intended to increase understanding and improve attitudes among students. Campbell et al. (2003) evaluated
whether a university educational programme modied attitudes towards disability and increased knowledge of Downs
syndrome. Students completed a 13-week course which provided formal lectures on human development, individual
differences, atypical development and disability. The training had a signicant impact on the students knowledge of Downs
syndrome with more accurate and positive estimations regarding development and academic achievement being held after
the intervention. More positive views of inclusion were endorsed in their attitudes. However, the study did not use a control
group nor a follow-up, making it difcult to conclude whether elements of the intervention itself had created a shift towards
more positive attitudes and whether these were sustained at follow-up. The impact of educational vignettes with varying
diagnostic labels on students attitudes was assessed by MacDonald and MacIntyre (1999). Four vignettes described daily life
activities, hobbies and interests of a person with severe intellectual disabilities. Whilst the study sought to test whether label
changes applied to other disorders as well as intellectual disabilities, results regarding intellectual disability are focused on
here. The vignettes were identical across groups apart from the label used to describe the disability which was altered:
mental retardation (group 1); ZahnWaxler Syndrome (group 2); attention decit disorder (group 3); and Thivierge
Syndrome (group 4). Females were generally more positive in their attitudes and a signicant main effect for participant
educational attainment and gender was found. No effect of label change on attitudes was indicated, suggesting that whilst
brief educational information can result in more positive attitudes, label changes in themselves do not. The study did not
assess the stability of attitudinal changes over time and its generalisability is limited by the use of a self-selected student
sample.
Other studies evaluated the impact of training programmes delivered to staff teams and agencies in light of the common
nding that the unmet training needs of professionals working with people with intellectual disabilities contribute to the
inequalities experienced by the latter (Melville et al., 2005). Support for training initiatives was found by a study conducted

3486

Table 1
Overview of studies included in the review.
Focus

Sample

Design and measures

Key results

Adler et al. (2005)

UK

Impact of participation
in a vision screening
programme on attitudes
and awareness of
ophthalmic complications
in ID patients

173 qualied/student
optometrists, no demographics
provided

Repeated measures, 2 groups

- 1 day lectures and supervised
clinical practice (experimental group)
- Half day lectures with no
practical training or contact
(control group)
- Self-constructed questionnaire
- Pre/post measures

- Self-rated knowledge of ophthalmic complications

in ID increased across groups
- Higher increase in condence for experimental group
- 52% attitude change in experimental group, 30% in
control group
- Condence levels related to number of clinical
contacts with ID patients

Bailey et al. (2001)

UK

Impact of training on
attitudes towards ID within
the police

57 trainee police ofcers

(87% response rate)

Quasi-experimental repeated measures,

2 groups
- Experimental (n = 27); control (n = 30)
- Training, role-play, discussion
- Attitudes to mental retardation and
eugenics (AMRE)
- Pre/post measures

- Signicant shift in AMRE scores for intervention group

- Training produced more favourable attitudes towards ID

Campbell et al. (2003)

Australia

Impact of formal teaching

and experiential learning
on attitudes, inclusion
and knowledge of Downs
syndrome

274 student teachers

Quasi-experimental repeated measures

- 13 week course plus eldwork
- Interaction with Disabled Persons
Scale (IDP)
- Questionnaire on knowledge and
attitudes re. Downs syndrome
(Wishart & Manning, 1996)
- Pre/post measures

- Increase in knowledge of Downs syndrome

- Reduction in positive and negative stereotypes endorsed
- Increase of positive views regarding inclusive education
for children with Downs syndrome

Freudenthal et al. (2010)

USA

Impact of volunteering at
Special Olympics on
attitudes and expectations
of athletes with ID

Healthcare students/faculty
volunteers
Pre (n = 80), post (n = 55)
(77% healthcare students,
42% previous experience
caring for people with ID)

Mixed methods
- Screening exercises with athletes
(approx. 12 h contact)
- Prognostic Belief Tool (PBS)
- Pre/post measures

- No signicant change overall in PBS scores

- Positive increase in expectations of people with
severe ID only
- Qualitative data indicated improved perceptions
and increased recognition of the athletes abilities

Hall and Hollins (1996)

UK

Effect of a workshop
taught by actors with
ID on attitudes

28 medical students, no
demographics provided

- Attitudes more positive post intervention

Within groups design
- Workshop delivered by people with ID
- Ratings of 10 statements concerning
people with Downs syndrome
- Pre/post measures

Hall and Minnes (1999)

Canada

Impact of media on
attitudes towards people
with Downs syndrome

92 psychology undergraduates
(55% female, mean age
19.6 years)

Experimental design, 3 groups

- Drama, documentary or control lm
- Attitudes Towards Disabled
Persons Scale
- Feelings of Comfort Scale
(Marcotte & Minnes, 1989)
- Jackson Social Desirability scale
(Jackson, 1974)

- Inclusive beliefs predicted by prior media exposure,

contact and social desirability rather than lm type
- Documentary associated with more positive affect
towards ID
- Behavioural intentions predicted by drama and
documentary
- Favourable attitudes associated with previous
positive contact rather than frequency

L. Seewooruttun, K. Scior / Research in Developmental Disabilities 35 (2014) 34823495

Authors (year)
Country

Impact on attitudes of
lms as part of a
teaching package

241 students
(71% female)

Mixed methods
- Interaction with Disabled Persons
Scale (IDP)
-Pre/post IDP

No attitude change
Qualitative data indicated more positive attitudes
Films rated as good educational awareness tool
Person-centred perception increased

Kobe and Mulick (1995)

USA

Impact on attitudes of
10 week course and
contact with people with ID

37 psychology undergraduates
(84% female, mean age 22 years;
69% previous contact with ID)

Repeated measures
- Educational sessions and clinical
contact with people with ID
- Attitudes towards Mental Retardation
and Eugenics (AMRE)
- Pre/post measures

- No attitude change
- Increase in self-rated knowledge
- Post-test attitude scores associated with
educational attainment only

Li and Wang (2013)

China

Impact of contact on
attitudes of volunteers
towards inclusion

100 college students (63% female,

mean age 21 years)

Repeated measures, 2 groups

- Experimental group delivered one
week service at Special Olympics
Games. No intervention control.
- Mental Retardation Attitude
Inventory-Revised (MRAI-R)
- Pre/post (after 1 week)/follow-up
(4 weeks) measures

- Volunteers attitudes enhanced by contact and

maintained at one month follow-up
- Females held more favourable attitudes across groups

MacDonald and
MacIntyre (1999)
Canada

Impact on attitudes
towards ID of (a)
vignettes using different
labels and (b) educational
information

168 students
(45% female, mean age 22 years)

Repeated measures
- 4 x educational vignettes with
different diagnostic labels
- Mental Retardation Attitude
Inventory-Revised (MRAI-R)
- Pre/post measures

- Main effect of education on attitudes across groups

- No attitude change associated with label change yet
brief educational information resulted in more
positive attitudes
- Females more positive overall

Melville et al. (2006)

UK

Effect of training on
knowledge, skills and
self-efcacy working with
people with ID

201 nurses (69% response

rate at baseline)

Experimental design, 3 groups

- (1) training pack + plus 3 h contact
with professionals and person with ID;
(2) training pack only;
(3) control
- Questionnaire on knowledge of
health developed by authors
(Melville et al., 2005)
- Pre/post measures

- Signicant differences in knowledge scores between

groups 1 and 2 compared to controls
- Change in self-efcacy scores between group
1 and 3 indicate favourable impact of intervention
- Positive impact on clinical practice reported by
participants following the intervention

Nosse and Gavin (1991)

USA

Impact of a two and

half day organised direct
contact experience on
attitudes

31 students
(78% female, mean age 21 years)
75% enrolled on health
related courses

Repeated measures, 2 groups

- (1) workshop providing direct
contact with people with ID; (2) control
- Adjective Generation Technique
(Allen & Potkay, 1983)
- Semantic differential scale
(Gottlieb & Corman, 1975)
- Pre/post measures experimental
group only

- More favourable and positive attitudes at baseline

held by experimental group
- Direct contact improved attitude scores and
reduction in anxiety related adjectives

Rae et al. (2011)

UK

Impact of a half day

training event on
knowledge of ID

40 teachers
(mean age 44 years; 68%
had child with ID in
their class)
Follow-up: n = 19

Within-group repeated measures

- Training package on ID
- Questionnaire on criteria for ID
(McKenzie et al., 2000)
- Pre/post and follow-up measures

- Increased knowledge of ID criteria after

intervention sustained at one month follow-up

L. Seewooruttun, K. Scior / Research in Developmental Disabilities 35 (2014) 34823495

Iacono et al. (2011)

Australia

3487

Focus

Sample

Design and measures

Key results

Rimmerman et al.
(2000)
Israel

Effect of controlled
contact with children with
disabilities on attitudes

139 students
(81% female, mean
age 22 years)

Quasi-experimental, 4 groups
- (1) prior contact and wish to
tutor child with ID (n = 34); (2) no
prior contact and wish to tutor child
with ID (n = 28); (3) prior contact with
wish to tutor other child (n = 39); (4)
no prior contact and wish to tutor
other child (n = 38)
- 4 month tutoring programme
- Disability Factor Scale-General (DFS-G)
- Pre/post measures

- Reduced rejection and anxiety associated with prior

contact or no contact but wish to tutor child
- Contact best predictor of reduction in rejection
- Association between contact and attitudes related
to time and length
- Longer duration required for realistic attitudes

Roper (1990a)
USA

Impact of contact on
volunteers perceptions
of athletes with ID

369 volunteers
(60% female; 50% <21 years)

Quasi-experimental
- Questionnaire at start of event
- Participants grouped by number of
games attended; experience,
prior contact
- Self-developed measure recording
demographics, experience, ID
perceptions, social distance

- Contact did not inuence perceptions

- Frequent sustained contact associated with reduced
positive perceptions
- Female participants more favourable

Roper (1990b)
USA

Impact of contact on
volunteers perceptions
of athletes with ID
Impact on awareness of
experiential learning and
contact with families
whose child has a disability

Same as Roper (1990a)

Same as Roper (1990a)

63 medical students

Qualitative
- Student interviewed assigned family
with child with disability, 2 h contact
- One-page narrative description of the
visit and observations provided

- Contact did not affect perceptions

- Sustained levels of contact associated with less
positive perceptions
- 4 major themes:
(1) Insight: 27% reported powerful educational experience
and change in understanding;
(2) Information: 44% described families wanting more
information from health teams;
(3) Obstacles: acknowledgement of hardship, nancial strain;
(4) Adjustment: increased understanding of coping and
adjustment

Tracy and Iacono

(2008)
Australia

Impact on attitudes of
training and contact with
people with ID

128 medical students

(mean age 22 years)

- Attitude scores and comfort interacting with people

Mixed methods
with ID increased
- Training on communication using
- 99% evaluated the intervention positively
didactic teaching, role-play, and
- 77% valued direct contact
workshop led by people with ID
- 45% reported greater understanding and insight
- Interaction with Disability Persons
- Direct contact associated with attitude change
Scale (IDP)
-Pre/post IDP measures
- Qualitative data from written evaluation

Varughese and Luty

(2010)
UK

Effect of viewing
pictures of people with
ID and dysmorphic
features on stigmatising
attitudes

360, general population

convenience sample
(74% female, mean age 48 years)

- Small positive attitude change in

Experimental design, 2 groups
experimental group
- (1) experimental group viewed
photo of man with ID, (2) control group - Attitudes not affected by order of exposure
to experimental conditions
did not
view a photo when completing measures
- Attitude to Mental Illness Questionnaire
(AMIQ)
- Post intervention, 6 month follow-up with
group crossover

Sharma et al. (2006)

USA

L. Seewooruttun, K. Scior / Research in Developmental Disabilities 35 (2014) 34823495

Authors (year)
Country

3488

Table 1 (Continued )

Effect of presenting
pictures of people
with ID and dysmorphic
features on stigmatising
attitudes

187, general population

convenience sample

- Positive attitude change associated with photo

Experimental design, 2 groups
of smartly dressed man with ID
- (1) viewed picture of man with ID
and dysmorphic features; (2) viewed
picture of smartly dressed man with ID
while completing measures
- Attitude to Mental Illness Questionnaire
(AMIQ)
- Post measure only

Walker and Scior (2013)

UK

Effect of two web

delivered indirect
contact interventions
on attitudes and social
distance

925, general population

convenience sample
403 at follow-up

Experimental repeated measures

design, - 2 groups watched lms
based on (1) intergroup contact
theory, or (2) protest message

- Both interventions produced positive shift in attitudes

and social distance in short term, some effects
maintained at 1 month follow-up
- Protest based intervention had greater effect on aspects
of inclusion attitudes and evoked stronger emotional
reactions

Wong and Wong (2008)

Hong Kong

Effect of training on
attitudes, knowledge
and skills

45 residential staff
(36 female)

Experimental design, 2 groups

- 6 session training vs no training
(control)
- Self-constructed questionnaire
with vignette on attitudes, knowledge
and skills
- Pre/post measures

- Increased knowledge and skills

- Attitudes more positive post intervention

L. Seewooruttun, K. Scior / Research in Developmental Disabilities 35 (2014) 34823495

Varughese et al. (2011)

UK

3489

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by Rae et al. (2011) who evaluated training on diagnostic criteria and general information about intellectual disability on
teaching staffs knowledge. The training increased knowledge scores and these improvements were sustained at one month
follow-up. However, the sample was small (n = 40) and only 19 follow-up questionnaires were received, which suggests that
the sustained improvement presented at follow-up should be viewed cautiously. Similar ndings were presented by Wong
and Wong (2008) who evaluated the effectiveness of staff training which included education, role-play, videotaped exercises
and homework. A questionnaire developed for the study was administered by trained interviewers to prevent the potential
bias inherent in a self-report format. The training was found to increase staff members knowledge and skills and shifted
attitudes towards facilitating self-determination. The authors acknowledged that a larger sample and a longitudinal focus
would be required to conclude that the type of training offered could lead to sustained effects on knowledge and attitudes.
Attitudes among trainee police ofcers were the focus of a study by Bailey et al. (2001). The ofcers in the intervention group
undertook training relating to people with intellectual disabilities which involved role-play, plenary and a session on
stereotypes run by one of the authors. The control group did not participate in these exercises. Controlling for baseline scores, a
signicant shift in attitudes in a favourable direction was observed in the intervention group. The ndings should be considered
with caution given the small sample and the lack of follow-up data to assess whether more positive attitudes were sustained.
3.3.2. Interventions that incorporated contact with people with intellectual disabilities to improve attitudes
As noted, of the 17 studies that integrated contact in their interventions six provided indirect and 11 direct contact. Of the
former, three provided indirect contact via lms, two through exposure to photographs of people with intellectual
disabilities, and one through experiential learning. The rst of these explored the impact of two television representations of
people with Downs syndrome on attitudes among psychology students (Hall & Minnes, 1999). Measures of social
desirability and television preferences were administered before participants were assigned to the experimental groups.
Two experimental lms were tested; a documentary and a drama portraying the life of a man with Downs syndrome. A
control group watched a lm-based drama featuring a young man who did not have a disability. The documentary lm was
associated with more positive affect and greater feelings of comfort. Prior media exposure, contact with people with
intellectual disabilities and social desirability were found to be signicant predictors of beliefs and attitudes. The study
benetted from utilising two testing procedures to explore possible order effects, but baseline data were not obtained.
Furthermore, the study used a student sample that may have held fairly positive and inclusive attitudes to begin with.
The potential value of indirect contact through lm presentations was further explored by Iacono et al. (2011). They
showed documentary lm footage that depicted the lives of people with intellectual disabilities as part of a training package
for students. In this instance, the lms did not affect attitudes measured using the Interaction with Disabled Persons Scale
(IDP, Gething, 1994) but focus group data indicated a shift towards more positive attitudes and a more person-centred
perception of people with disabilities amongst the students. As in other studies, the student sample was self-selected and
therefore may already have held inclusion friendly attitudes. Of interest though is the failure of the measurement tool to
discern any changes in attitudes, perhaps due to its limited sensitivity and construct validity (Iacono, Tracy, Keating, &
Brown, 2009). Another potential explanation is a tendency for more socially desirable responding in the focus groups
compared to the more anonymous questionnaire.
The effects of web delivered indirect contact interventions that showed a lm either presenting injustices and
discrimination perpetrated against people with intellectual disabilities or people with and without intellectual disabilities
engaged in the pursuit of a common goal were examined by Walker and Scior (2013). They concluded that even a brief
10 min Internet delivered intervention can have small, positive effects on attitudes and social distance, but that the effects of
such interventions on real life behaviour remain untested.
The effects of viewing photographs of people with intellectual disabilities on stigmatising attitudes amongst a general
population UK sample were examined in two studies. In Varughese and Lutys (2010) study, the experimental group viewed a
picture of a man with Downs syndrome who was dressed smartly while completing an attitude measure, while the control
group received a written vignette describing a man with Downs syndrome whilst completing the same attitude measure.
Accompanying the measure with a picture had a small yet signicant effect in reducing stigmatised attitudes. In a follow-up
study, Varughese et al. (2011) found that a picture of a smartly dressed man with intellectual disabilities working in an ofce
had a small yet signicant effect in reducing stigmatising attitudes when compared to a picture depicting a man with
intellectual disabilities and visible dysmorphic features. However, neither of these two studies collected data at baseline to
illustrate participants attitudes to begin with, and one should be tentative about drawing any rm conclusions from these
minimal interventions, as it is likely that participants responses were biased by social desirability rather than indicating any
enduring attitude change.
The impact of indirect contact through an experiential learning module where the families of children with disabilities
were interviewed by medical students was assessed by Sharma et al. (2006). The students subsequently wrote a narrative of
the visit which was analysed using grounded theory. A quarter of the students described the intervention as a powerful
educational experience and reported change in their understanding of families perspectives on disability. The authors
contended that a small experiential intervention can provide individuals with increased insight and awareness of issues
relating to disability which may otherwise be unobtainable through formal educational courses or training. Limitations
inherent in the uncontrolled nature of the design and issues of social desirability should be borne in mind when considering
these ndings. Furthermore, whilst it appears that students experiences of the interviews were largely positive, it would
have been valuable to hear more about the reections of participants who may have had less positive experiences.

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Although studies incorporating indirect contact are welcome contributions to the literature there are limitations in terms
of their scope and ecological validity. Eleven studies over the review period evaluated the effect of direct contact on attitudes
and awareness regarding intellectual disability. Five of these provided direct contact as part of more formal training
programmes for students or healthcare professionals. Tracy and Iacono (2008) explored whether a 3-h training session on
communication, which integrated didactic learning, discussion, disability awareness tasks and workshop exercises
facilitated by a tutor with intellectual disabilities had positive effects on attitudes. The training had a signicant impact on
attitude scores with students reporting feeling more comfortable about interacting with people with intellectual disabilities
following the intervention. In the absence of follow-up data, it should be noted that the contact was very brief and therefore
the sustainability of positive attitude change is questionable.
Additional support for direct contact as a key feature in attitude change stems from a small study conducted by Hall and
Hollins (1996) who evaluated the impact of a workshop lead by a professional actor with an intellectual disability on the
attitudes of medical students. Students attended a 2-h workshop and, in line with the conditions outlined by Allport (1954),
the facilitator was in a socially valued role. Using pre and post measures, participants were asked to rate their agreement
with 10 statements regarding Downs syndrome. Following the workshop participants showed more agreement with
positive items and less with negative items (change on seven items reached statistical signicance). For example,
participants showed less endorsement of people with Downs syndrome being poor communicators or frightening.
A direct contact intervention conducted by Nosse and Gavin (1991) found that contact increased favourable attitudes and
reduced anxieties. In this study 31 students in groups of 1012 housed and entertained individuals with intellectual
disabilities and their support staff over a two and a half day interaction. The experimental group were self-selected and
largely enrolled on health related courses whilst the control group predominately comprised of students from business
related courses. However, data from the control group was only collected at baseline as authors report that attempts to
resurvey this group were unsuccessful. Therefore statistical comparisons could only be examined prior to the experiential
interaction. Whilst positive ndings were reported for the role of contact, this should be viewed with caution as participants
volunteered to be in the experimental group and the majority of the experimental group studied health majors, which may
have inuenced their favourable attitudes. The authors acknowledged the potential bias of these factors on the ndings
alongside the fact that the majority of students in the experimental group personally knew the coordinators of the
intervention.
Melville et al. (2006) incorporated direct contact into their intervention for nurses by having a person with intellectual
disabilities co-facilitating a 3-h training event which included presentations and workshops on communication, capacity
and consent and health promotion. They reported positive effects on self-efcacy and knowledge following the training
compared to controls. This increase was greater for the group who received both the written training package and the
intervention than for the two groups who received either alone. Changes in clinical practice by the participants were also
reported following the training including providing longer appointment times (by 67.4% of the sample) and increased use of
visual communication aids (by 56% of the sample). However, the study is limited due to the potential for bias within the
sample as participants opted in and therefore are likely to have been more motivated individuals. Furthermore, whilst
sample characteristics in terms of the number of years the nurses had been qualied and working were presented,
descriptive statistics of the sample were not which hinder any conclusions about the ndings generalisability.
An earlier study which integrated direct contact into formal education did not nd any attitude change. Kobe and Mulicks
(1995) evaluation of a minimum of 20 h contact via an agency working with people with intellectual disabilities perhaps
surprisingly found that whether participating students had previous contact with people with intellectual disabilities or not
did not inuence attitudes or attitudinal change. However, participants showed an increase in self-reported knowledge
about intellectual disability after the course. The authors contended that attitudes may develop as a product of cumulative
experiences and therefore discrete attempts to provide education and contact may do little to alter them.
The notion that extended periods of sustained contact may be required for more balanced perceptions of people with
intellectual disabilities is suggested by Rimmerman et al. (2000). They evaluated the effect of controlled contact with
children with disabilities on student volunteers attitudes. At baseline volunteers who expressed a wish to tutor a child with
intellectual disabilities, regardless of prior contact or not, showed less rejection and anxiety in their perceptions. Following
the intervention only volunteers with prior and current contact had more favourable attitudes; those with current contact
alone showed less positive perceptions. The authors suggest that these ndings support the importance of time and length of
contact in predicting attitudes. Even though this study was longitudinal in its remit, the authors concluded that longer
contact may be necessary for sustained shifts in attitudes.
Five studies made use of sporting events for people with disabilities as a way of operationalising and exploring the impact
of direct contact on attitudes. The Special Olympics in the USA and the International Special Olympic Games provide
opportunities for sports training and competition for athletes with intellectual disabilities but also aim to educate the public
about the capabilities of people with intellectual disabilities, generate respect and promote inclusion (Freudenthal et al.,
2010). The earliest studies in this review that utilised the Special Olympics are by Roper (1990a, 1990b) who evaluated the
impact of contact with athletes on volunteers perceptions. No effect of contact on a measure of social distance was found; in
fact, frequent and sustained contact led to a reduction in positive attitudes (Roper, 1990a). Volunteers with the highest levels
of contact during the Special Olympics held more negative perceptions than those with less sustained contact, suggesting
that medium levels of contact (rather than no or extensive contact) may lead to more positive attitudes (Roper, 1990b). A
reason offered for this nding is that when contact situations arise out of dependency of the person with intellectual

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disabilities, a decrease in positive appraisals may develop (Roper, 1990b). Unfortunately the study is limited by its omission
of repeated measures or a control group.
A more recent study examined the effect of contact on attitudes among healthcare students and faculty volunteers
working at the Special Olympics (Freudenthal et al., 2010). Contact was provided by the volunteers being involved in
delivering healthcare promotion initiatives such as Healthy Hearing (audiology) and Opening Eyes (vision). They found no
signicant change in participants beliefs about intellectual disability following the contact intervention. Although
qualitative data suggested that the volunteering experience had produced more favourable perceptions of the athletes
abilities, this was only captured in relation to the tasks people with severe intellectual disabilities were expected to perform.
The ndings are limited by the fact that the belief scores at baseline had already reached a ceiling with scores at 26 out of a
possible 27, leaving no room for positive change. Moreover, the modest sample size would have affected statistical power.
Positive ndings are presented by Adler et al. (2005) who evaluated the impact of a screening programme for
ophthalmologists working at the Special Olympics against a control condition. All volunteers in the experimental condition
underwent a day of accredited training which included lectures and practice opportunities prior to screening the vision of
505 athletes over two to four days. The control group was a convenience sample of optometrists who received half a day of
lectures but no practical training or direct contact with people with intellectual disabilities. Interventions provided to both
groups appeared to lead to signicant improvements in self-rated knowledge of ophthalmic issues in this population. Both
groups also showed attitude change and a rise in condence in working with people with intellectual disabilities, with the
changes more pronounced in the contact group. A limitation of this study is that knowledge was measured using a single selfreported score rather than participants being asked knowledge-based questions, which may have been a more substantive
and accurate way to measure change. In addition, the authors acknowledge that the measure used had not been validated as
a means of attitudes measurement.
A recent study has also published promising ndings on the impact of contact with people with ID during the
International Special Olympics held in China. Li and Wang (2013) report that contact over one week during the games
enhanced volunteers attitudes in a positive direction and this effect was found to be maintained for up to a month. They
contend that this nding supports the role of contact an as effective way of enhancing attitudes and social inclusion although
they acknowledge that how this effect may have occurred was not examined. Further investigation into the nature of the
interaction between exposure and attitudes was recommended.
3.4. Measures used to evaluate intervention effects
A variety of measurement instruments were used in the studies included in this review and a brief summary is presented
here in order to appraise their properties and implications for the ndings presented above. Several scales used within the
review were originally developed to measure attitudes towards disability in general. The Interaction with Disabled Persons
Scale (IDP, Gething, 1994) measures respondents agreement with 20 statements designed to assess attitudes towards
people with disabilities. Three studies included in this review used the IDP (Campbell et al., 2003; Iacono et al., 2011; Tracy &
Iacono, 2008). The 20 items have been found to load on six stable factors; the measures reliability and validity are
acceptable, with internal consistency coefcients ranging from 0.74 to 0.86 (Campbell et al., 2003; Tracy & Iacono, 2008).
Although this is a valid and reliable measure, it does not specically capture attitudes towards people with intellectual
disabilities and therefore caution should be taken regarding the extent to which it measures the effectiveness of intellectual
disability specic interventions.
Another study reviewed used the Disability Factor Scale-General (DFS-G, Siller, Ferguson, Vann, & Holland, 1968), rather
than a measure specic to intellectual disability (Rimmerman et al., 2000). An additional limitation in the utility of this
measure is that it was constructed a few decades ago and as such one should be cautious as to the extent to which the
constructs it assesses remain appropriate and relevant to present day research. A similar limitation could be noted in relation
to Rae et al.s (2011) study which used a questionnaire adapted from previous research (McKenzie, Matheson, Patrick,
Paxton, & Murray, 2000) which was not developed for use with the population to which it was administered (teaching staff).
Two studies reviewed used the 32 item Attitudes to Mental Retardation and Eugenics questionnaire (AMRE, Antonak,
Fielder, & Mulick, 1993), which was developed to measure attitudes towards the reproductive rights of people with
intellectual disabilities. Good psychometric properties of the AMRE were reported by Kobe and Mulick (1995) and Bailey
et al. (2001).
The limitations of public attitude scales within the eld of intellectual disability research have been comprehensibly
reviewed by Werner et al. (2012). Of note, they concluded that many scales fail to include the multidimensionality inherent
to attitude formation and stigma, i.e. affective, behavioural and cognitive components. One scale, the Mental Retardation
Attitude Inventory-Revised (MRAI-R, Antonak & Harth, 1994) used by Li and Wang (2013) and MacDonald and MacIntyre
(1999), has usefully taken into account the multidimensionality of the attitude construct. The MRAI-R contains 29 items that
load onto four subscales: social distance, integrationsegregation, subtle derogatory beliefs and private rights. It has good
internal consistency and provides scope to explore stigma across different contexts (Werner et al., 2012).
Two of the studies reviewed used instruments that capture beliefs about intellectual disability; the Attitudes towards
Disabled Persons Scale (ADPS, Yuker, Block, & Young, 1970) and the Prognostic Belief Scale (PBS, Freudenthal et al., 2010). A
modied version of the original 20-item ADPS was used by Hall and Minnes (1999). The 27-item PBS (Wolraich & Siperstein,
1983) requires respondents to estimate the capabilities of individuals with mild, moderate and severe intellectual

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3493

disabilities in areas such as self-help skills and activities of daily living. Its psychometric properties are not reported by its
authors who questioned its sensitivity due to the ceiling effect noted earlier (Freudenthal et al., 2010).
A ve-item brief self-report questionnaire, the Attitude to Mental Illness Questionnaire (AMIQ, Luty, Fakuda, Umoh, &
Gallagher, 2006), was used in two studies (Varughese & Luty, 2010; Varughese et al., 2011). The AMIQ was developed to
study mental illness stigma, and despite reports of its good psychometric properties when used to study attitudes towards
intellectual disability (Varughese & Luty; 2010; Varughese et al., 2011), the extent to which it is suitable and valid for
assessing attitudes towards people with intellectual disabilities requires further consideration. Another key limitation of the
measure is that it relies on participants perceptions of a hypothetical individual presented in a vignette, rather than real
experience.
One study (Walker & Scior, 2013) used the short form of the Community Living Attitudes Scale-Intellectual Disability
version (CLAS-ID, Henry, Keys, Jopp, & Balcazar, 1996) and a 5-item social distance scale shown to have good psychometric
properties (Scior & Furnham, 2011).
Six studies developed their own measurement tools designed for the purposes of the respective study. Descriptions of
these varied in detail across the reports, making it difcult to evaluate their psychometric properties (Adler et al., 2005; Hall
& Hollins, 1996; Melville et al., 2006; Roper, 1990a, 1990b; Wong & Wong, 2008). Only Adler et al. (2005) and Wong and
Wong (2008) provided a copy of their measure as part of their report.
Nearly all the studies included in the review failed to report effect sizes. Furthermore, most of the studies only presented
psychometric data relating to the measures internal consistency, but no other data to test reliability or validity.
Consequently it is difcult to comprehensively appraise how robust these measures are. Furthermore, self-report methods
have been relied on heavily, which limit conclusions about the extent to which they are likely to measure any real life
changes in prejudice and discrimination. This is further compounded by the use of scales that measured disability in general
as opposed to intellectual disability specically, which begs the question of the appropriateness of their use in intellectual
disability research.
4. Discussion
The current review has summarised the ndings from a range of interventions that have been implemented to increase
knowledge and understanding of intellectual disability and tackle negative attitudes. Although a need to increase knowledge
and tackle negative attitudes towards people with disabilities has been widely recognised and explicitly set out in the
2006 UN Convention on the Rights of People with Disabilities, evidence on interventions with these aims is thin on the
ground. Based on the 22 studies reviewed the following conclusions can be drawn: (1) studies that provided some form of
education to increase knowledge about intellectual disabilities reported some benets, but none targeted general population
samples; (2) contact, both direct and indirect, with people with intellectual disabilities had favourable effects on attitudes in
most studies, but positive outcomes were not universal. Contact based interventions shown to have positive effects included
volunteering at Special Olympics event, a tutoring programme spanning several months, training delivered by presenters
with intellectual disabilities, an experiential task designed to develop empathy with people with intellectual disabilities and
their families, indirect contact through lm presentations delivered via the Internet, and exposure to images that contradict
stereotypes. The evidence to date is not sufciently robust to recommend one type of intervention over another.
Furthermore, the positive results reported in many of the studies should be viewed with some caution as most effects were
small, and most studies drew on convenience samples, mostly consisting of students and volunteers. Future research is
required that studies the effects of interventions on representative samples, and focuses on sections of the population whose
attitudes may be less positive than those of volunteers and students.
The association between contact and attitudes towards people with intellectual disabilities does not appear to be
straightforward. One question concerning contact is whether there is perhaps an optimal dose of contact, given that some
of the studies reviewed suggested that beyond a certain volume contact may in fact produce less favourable outcomes.
As noted, there are several shortcomings to the studies reviewed in this paper. The degree to which one can generalise
from the small body of literature is limited given the small scale nature of most studies and the limitations inherent in the
measurement tools and methodologies employed. The distinct lack of follow-up data in conjunction in many studies with
lack of baseline data makes it difcult to assess the ndings beyond what may be relatively surface level attitudinal changes.
This is further compounded by the well documented limitations of self-report measures and social desirability effects on
participants responses. Many of the studies, for example, asked participants to self-rate changes in their knowledge rather
than assessing this objectively. In some studies participants rated their knowledge immediately following the dissemination
of educational material; thus the extent to which changes observed are ecologically valid and sustained is questionable.
Moreover, and echoing the conclusions reached by Werner et al. (2012), our ability to progress and identify which
interventions may be benecial and what inuences their success is constrained by the dearth of appropriate attitude scales
that are specic to intellectual disability and assess the multidimensional nature of attitudes.
4.1. Limitations
A limitation of this review is that only articles published in English were included; important ndings published in other
languages may well exist but were not considered here. Similarly, it is highly likely that many interventions have been

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conducted aimed at increasing lay peoples knowledge and understanding and improving their attitudes towards people
with intellectual disabilities, but have not been formally evaluated or their ndings reported in the research literature. It
seems vital that rigorous evaluation is built into any future interventions in this area from the outset to advance our
understanding of effective mechanisms to shifting public awareness and attitudes in a positive direction.
4.2. Implications
This review raises the question as to what may be realistic aims for change initiatives and interventions relating to
intellectual disability; what exactly should future authors attempt to measure and how may this be best pursued? Evidence
in this area is in its infancy, and as such it is difcult to ascertain with any condence the direction research should take. In
the absence of valid measurement scales and appropriate resources to design research that is methodologically sound and
robust, it is difcult to conclude whether aiming to create shifts in attitudes is the most fruitful endeavour. Nevertheless,
several studies found support for the notion of contact as a vehicle for shaping attitudes. It would be benecial to re-appraise
the theoretical frameworks which underpin the aims of future studies pertaining to intellectual disability, for example
contact theory (Allport, 1954; Pettigrew, 1998). Whether there is indeed a risk that sustained contact with people with
intellectual disabilities may lead to less favourable attitudes (Roper, 1990a, 1990b), and/or a possible interaction between
the effect of duration and quality of contact on attitudes (Rimmerman et al., 2000), are important questions for future
research. Furthermore, what are valid and important goals for change interventions, and whether and how they can be
effectively achieved should be a topic for continued debate involving a range of stakeholders.
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