The Review of Disability Studies: An International Journal Volume 3, Issue 4 Copyright 2007 Table of Contents In Memoriam Frank Bowe Rolf Bergfors Research Articles: Focus on the Middle East The Scale of Attitudes Towards Disabled Persons (SADP): Cross-cultural Validation in a Middle Income Arab Country, Jordan Kozue Kay Nagata USA Barriers to Education for People with Disabilities in Bekaa, Lebanon Samantha Webhi Canada Jordan and Disability Rights: A Pioneering Leader in the Arab World Kenneth R. Rutherford USA Adolescents with Hearing Impairment: Coping with Environmental Stressors Miri Cohen Israel Book Reviews Developments in Direct Payments By Janet Lee & Joanna Bornat, Eds. Reviewed by Kevin Dierks BlindSight: Come and See By Jane L. Toleno Reviewed by Steven E. Brown Culture and Disability: Providing Culturally Competent Services By John H. Stone, Ed. Reviewed by Katherine T. Ratliffe Elegy for a Disease: A Personal and Cultural History of Polio By Anne Finger Reviewed by Steven E. Brown Alcoholism, Drug Addiction, and the Road to Recovery: Life on the Edge By Barry Stimmel, M.D. Reviewed by J. Gary Linn RDS Information Subscription Form In Memoriam Frank Bowe, an RDS Distinguished Fellow, passed away on August 21, 2007, after a brief illness. He was a Professor of Counseling, Research, Special Education and Rehabilitation (CRSR) in Hofstra University’s School of Education and Allied Human Services in Hempstead, Long Island, New York. Frank was one of the first national disability rights leaders I met in the early 1980s, when he came to Norman, Oklahoma to participate in an independent living conference. He was a gracious man, who certainly inspired me by his leadership, advocacy, and gentle way of being in the world.  Frank promoted cross-disability advocacy, which fit in well with Oklahoma’s disability politics. He was one of the forces behind the 504 demonstrations across the United States, in his role as the Director of the American Coalition of Citizens with Disabilities. The most successful of these protests was in San Francisco in 1977.  The 2nd most successful was the one he led in Washington, D.C.  Unlike the folks in San Francisco’s federal building, the Washington demonstrators were denied food and forced to disperse.   Bowe's 1978 book, Handicapping America: Barriers to Disabled People, was the first disability rights book I ever read.  It was one of the few publications about disability I could find in the Norman, Oklahoma card catalog (for those who remember those). Frank and I communicated over the years and he enthusiastically joined RDS as a Distinguished Fellow from the very beginning of its journey. Tributes to Frank from students, former students, and colleagues may be found at: http://www.hofstra.edu/home/News/PressReleases/082307_frankbowe.html Steven E. Brown Rolf Bergfors, an RDS Distinguished Fellow, passed away in May 2006 at his home in Gothenburg, Sweden. A man of dry wit and fierce commitment to the principle of self-determination, in his own life and professional interests, Rolf was the force behind the creation of the Gothenburg Cooperative for Independent Living (GIL) and one of the leaders in the Swedish Independent Living Movement. Rolf was co-founder of the Independent Living Institute and served on its board since its beginning. His friend and colleague, and RDS Distinguished Fellow Adolf Ratzka of Stockholm, noted that 100 Movement people came to Rolf’s funeral in Gothenburg to commemorate him, and which led to a meeting to reevaluate Sweden’s independent living movement. Steven E. Brown and Adolf Ratzka RESEARCH ARTICLES: FOCUS ON THE MIDDLE EAST The Scale of Attitudes Towards Disabled Persons (SADP): Cross-cultural Validation in a Middle Income Arab Country, Jordan Kozue Kay Nagata Senior Economic Affairs Officer of the Development Cooperation Branch United Nations Department of Economic and Social Affairs Abstract: The purpose of this pilot study was to assess the level of the existing attitudinal barriers towards disabled persons in four communities of Jordan. Jordan is a middle income Arab country, with a PPP-adjusted GDP/capita of US$ 4320.i The study attempted to determine the present level as a baseline of prejudice against people with a disability in Jordan, and to examine the relationship between the randomly selected participants’ attitudes and their previous exposure to and experience with disability. The Scale of Attitudes towards Disabled Persons (SADP) was selected as the instrument. An Arabic translated version of the Scale was used for 191 participants. The respondents showed overall negative attitudes towards disabled persons, as illustrated by previous documented materials. The result of this survey was highly correlated with the collective opinion expressed by the focus group that was conducted by the author in Amman in January, 2005. Thus, the cross-cultural validity of this instrument has been confirmed, and the major findings of this pilot study could inform future policy directions and public awareness raising strategies to foster positive public attitudes. Key Words: disability, Jordan, attitudes Background The social model of disability is becoming widely accepted by many in academic circles as well as within the community of both developed and developing countries. The author argues that the strength of the social model is due to its examination and analysis beyond specific impairments of individuals. It can encompass socioeconomic, cultural, and legal dimensions of disability from human and civil rights perspectives. This complexity of the model will require coherent action for carrying out research on the existing social barrier level (e.g., the level of acceptance, recognition and discrimination), and campaigning to confront social prejudice and discrimination. For the theoretical framework for this pilot study, however, the World Health Organization International Classification of Functioning, Disability and Health (WHO-ICF, 2001) model was used (WHO 2001), which is based on an integration of two opposing models, the medical model and the social model, and emphasizes a dynamic process between a disabled individual and his or her social environment. Negative attitudes of non-disabled people can inhibit disabled peoples' social integration and their empowerment, including the development of their positive selves, irrespective of the type and degree of impairment. Roush (1986) reported that negative attitudes towards disabled people are common in society, but are not directly voiced. There is agreement that those who have had previous exposure to disabled people, and with proper professional training, tend to have more positive attitudes towards disabled people. Paris (1993) reported that health-care professionals with constant exposure to disabled people have positive attitudes towards people with physical impairments. It is believed that the variation in attitudes towards different categories of disabled people result from cultural values, living environment, age and exposure to disabled people. Therefore it is important for each community to collect its own data. The attitudes towards the disabled have been studied worldwide, but not so in Jordan and the Arab region. A study undertaken in Saudi Arabia in 2003, using the SADP, concluded that Saudi Arabian healthcare professionals displayed positive attitudes towards people with disabilities as do other professionals and caregivers worldwide (Al-Abdulwahab & Al-Gain, 2003). Qaryouti (1984) concluded through his research on special education that the attitudes of Jordanian rural people towards persons with disabilities were generally negative. Turmusani (2003) argued that persons with disabilities (particularly disabled women) in Jordan were treated with cultural prejudice, isolated, and hidden sometimes within the family. He attributed this discrimination to the ambivalence of the Qur’an, which sometimes emphasizes equality and at other times associates persons with disabilities with the wicked of the society. Aims A major objective of this pilot study was to establish the current level of acceptance/recognition of disabled people for future comparison, and to examine the relationships between nondisabled peoples' attitudes with different sociodemographic characteristics and experience of interaction with disabled people, for the purpose of informing possible public awareness policy interventions in the future. In order to establish the concurrent validity, the result of this survey was compared with the collective opinion expressed by the focus group (composed of 30 participants, 21 disabled people and 9 parents) that took place in Amman in January, 2005. The result can also be correlated to the previous documented materials about the cultural barriers existing in Jordan and the Arab region. Methods The Arabic version of the Scale of Attitudes Toward Disabled People (SADP) was personally administered with a total sample of 191 individuals with valid data. The data was collected from four communities of Jordan, namely, Amman (the capital), Karak, Irbed, and Madaba with almost the same proportion, 25% from each community. The research employed a stratified proportional sampling method to balance the residential characteristics of the respondents. The sample size was relatively well spread across different socioeconomic characteristics. For instance, the gender balance was almost equal. The mean age was 33 years with SD of 13.37, similar to the national norm. To eliminate the sampling bias, on the street of each community, people passing by were selected and asked to answer the questionnaire, in a systematic manner, thus maintaining a certain level of random selection The SADP is a reliable self-report scale that consists of 24 items, developed by Antonak (1982, 1998). The 24 items of the SADP are expressed as statements to which respondents answer on a Likert-type scale. A Likert-type scale consists of a series of declarative statements. The subject is asked to indicate whether he or she agrees or disagrees with each statement. Commonly, five options are provided: "strongly agree," "agree," "undecided," "disagree," and "strongly disagree." Other Likert-type scales include four or six steps rather than five, excluding the undecided position. It provides a convenient and effective tool for the evaluation of attitudes towards people with disabilities. In the SADP, the participants were asked to choose the most appropriate number, with 6 scaled options, that best corresponds with how they feel about each statement. There were no "right" or "wrong” answers. There was no time limit. For instance, in Question number 8, which is a negative question, participants were asked to react to the statement, “Disabled people are in many ways like children,” and they could choose their answer ranging from, “I disagree very much,”ii to “I agree very much.” Any incomplete questionnaire was eliminated from the study. The total score ranged from 0, indicative of a very negative attitude, to 144, indicative of a very favorable attitude. An ANOVA and the descriptive statistics of the Kruskal-Wallis Test were used to analyze the data using SPSS statistical software. The reliability alpha showed a moderate level of reliability of 0.56. Results of the SADP Two hundred and five people responded to the SADP as requested, out of which, 191 data sets were complete and valid, with 95 males and 96 females with a mean age of 33 with a SD of 13.37. The respondents had overall negative attitudes towards disabled persons with the mean score of 88.67, with a SD of 14.63, as seen in Table 1.iii There was no significant difference found, based on the demographic and socioeconomic characteristics of the respondents. However, their responses were particularly negative to those questions relating to “misconceptions” and “stereotypes.” The only characteristics to which a difference in attitudes could be attributed were the participants’ residential communities and their personal experience of interaction with disabled family members. With respect to communities, the mean score of the respondents from the capital city, Amman was rated the highest (most positive score, 95.63) in contrast with the equivalent of the town of Karak (82.94), the most suburban and rural community of the four places. The difference was statistically significant at p<0.01, as seen in Table 1. The respondents in interaction with disabled family members scored higher (94.38) than those without (87.53, p<0.01). Those who had watched or participated in some disability awareness programs/campaigns also scored higher (93.01) than those who had not (86.44, p<0.01). All other public education schemes had no impact on their attitudes. Those whose impression about disabled people came from personal experiences with disabled people scored higher (94.38) than those who did not (87.53) (p<0.05). The findings supported the common and global view that disabled people living in rural communities tend to face more serious discrimination and prejudice than those in urban communities. Also, exposure to personal experience with people with disabilities and public awareness programs was associated with positive attitudes towards people with disabilities. Table 1: The Result of the Scale of the Attitudes towards Disabled People (SADP) in four communities of Jordan among 191 non-disabled persons (N=191) (POPULATION ESTIMATED IN 1997) N THE SADP RESULT TURKEY HSD *** SCHEFFE POST HOC **** MEAN * MEAN RANK ** SD Karak (23,466) ***** 47 82.94 75.79 12.77 Karak – Amman Karak – Amman Irbed (327, 543) 46 88.70 95.47 15.22 None None Madaba (87,534) 49 87.20 89.91 13.08 Madaba- Amman Madaba- Amman Amman (capital) (1,331, 028) 49 95.63 121.98 14.80 Amman- Karak Amman- Madaba Amman-Karak Amman-Madaba Total (5,759,732) ***** 191 88.67 14.63 * ANOVA: F=6.846, p<0.01. Significance of mean differences found among the cities. ** Mean rank scores and non-parametric Kruskal-Wallis Test indicated the significance of differences among the cities, p<0.01 *** Post Hoc Turkey HSD found the significance between Amman-Karak and Amman-Madaba **** Post Hoc Scheffe found the significance between Amman-Karak and Amman- Madaba. ***** Population of each city was estimated in 1997 (World Gazetteer, 2007) ****** Total population of Jordan was estimated in 1995 (Yahoo Education, 2007) Results of the Focus Group The following is a summary of the participatory focus group conducted by the author that took place in January, 2005.iv For triangulation and co-validation, three participatory focus group sessions were conducted by the author, assisted by an Arabic-English Jordanian interpreter, who is a social worker and activist with physical impairment, with 30 participants: one group with 10 blind persons and 6 with physical disability, another group with 3 mildly intellectually disabled persons and 9 parents, and a small session of 2 multiply disabled persons of which one has deafness and slight intellectual disability. Respondents with intellectual disability and with multiple disabilities were assisted by their parents and associates and the questions were provided in the most appropriate modes of communication. In addition, a small supplementary focus group session of professionals on disability and Official Development Assistance (ODA) workers was conducted. A few standard techniques of the Participatory Rural Appraisal (PRA) were used, such as semi-structured group questions, drawing a disability chronology, open ended discussion and observation. For example, in the open-ended discussion, questions were asked such as “What kind of proactive measures are most effective to improve public attitudes towards disabled people in Jordan and how can we improve the current public awareness program?” or “Do you think disabled people in rural communities are more discriminated against, and if so, what are the major reasons for this tendency?” The following key points made by the above-mentioned focus groups reply to those questions and co-validate the empirical findings of this study: a) The overall negative elements of Jordanian culture towards disability, particularly towards disabled women and other marginalized disability groups (e.g. intellectually disabled people and those with psycho-social disability); b) Particularly negative attitudes of residents in rural or suburban communities of Jordan, due to their limited exposure to the global development of human rights concepts and the social model of disability as well as Western cultures in general; c) The importance of including disability concerns and the concept of the social model of disability into school curricula; d) The need to promote better understanding of the family of disabled children and adults; e) The importance of direct exposure to and personal experiences with people with disabilities (e.g. disabled peers, disabled colleagues, etc.); f) Jordan’s failing to attempt to utilize pop singers or celebrities on air to boost public awareness; g) The participants’ preference for disability mainstreaming into regular and popular TV programsv, over the current too educational, boring targeted TV programming, which is still based on a charity-based framework; h) The importance of mutual interaction between disabled people and the surrounding society, mandating a dual- track intervention. The dual- track approach is a comprehensive strategy of the empowerment and capacity development of people with disabilities and the removal of all kinds of social barriers (e.g. adoption of universal design, eliminating the legal and institutional barriers) as a means of changing attitudes; i) Diversity among different disabilities (e.g. deaf culture, disabled veteran culture and martyrdom, conflicts between the grass-roots people and English- speaking urban elites). People with intellectual disabilities and/or psychosocial disability, disabled Palestinian refugees, as well as disabled women, are most severely discriminated against. Conclusion The results of this study demonstrate the cultural validity of the SADP instrument that is the most widely used in the USA, Europe, and some Arab Gulf countries. Also, the findings of the present study, both the quantitative and qualitative parts, echoed previous research such as Hong Kong Equal Opportunity Commission (2000), Rosenbaum, Armstrong, and King (1986), Al-Abdulwahab and Al-Gain (2003), and Kabbarah (2005), in that they demonstrate that attitudes should be treated as a multidimensional construct, consisting of the interlocking facets of cognitive and affective process as well as direct exposure to disability. The findings of the focus group also exhibited diversity among disabilities and different types of disabled people. The findings of the present study may inform a new strategy for policy makers, educators, social workers, and mass media experts in careful rethinking of the core messages to be delivered in public awareness programs. In particular, it is important that due attention be paid to the need to improve the current public awareness strategy, which is considered to be too educational and boring. The focus group informed us that it is worthwhile to explore a more innovative and engaging strategy appealing to wider audience, such as mainstreaming of “disabled characters” into ordinary drama series or effective use of pop singers and celebrities to boost awareness. Also, the public awareness effort may target rural or suburban populations who have limited access to global media coverage, thus not knowing the international trend of disability and human rights. Following the findings of this small scale pilot study, a nationwide publicly funded survey with a bigger, less biased and more representative sample should be conducted in both the urban and rural communities of Jordan, and elsewhere in the Arab region. The limitation of this research includes a small sample size, potential sample bias towards voluntary participants in the focus group, lack of randomness, and a question regarding the accuracy of the Arabic translation of the two instruments. The participatory focus groups were conducted partially with an interpreter (Arabic and English, as well as sign language), so a cultural and linguistic shortcoming should be added to the limitation. In order to cover a nationwide disabled population without sample bias, a larger-scale and more systematic follow-up (preferably publicly-funded) study should be conducted, based on the preliminary baseline constructed in this research. Kozue Kay Nagata is a Senior Economic Affairs Officer of the Development Cooperation Branch, Office of ECOSOC Support and Coordination, United Nations Department of Economic and Social Affairs, UN HQ, New York. However, the views expressed in this article are those of the author and do not necessarily reflect the views of the United Nations. This study is a part of the comprehensive doctoral dissertation on disability and development in Jordan and Lebanon, by the author, to be submitted in Japanese language to the Graduate School of International Social Development, Nihon Fukushi Univeristy, Nagoya, Japan. The author lived in Amman Jordan for 7 years. References Al-Abdulwahab, S., & Al-Gain S. I. (2003). Attitudes of Saudi Arabia care professionals towards people with physical disabilities. Asia Pacific Disability Rehabilitation Journal, 14, 63-70. Antonak, R. F. (1982). Development and psychometric analysis of the Scale of Attitudes toward Disabled Persons. The Journal of Applied Rehabilitation Counseling, 13, 22-29. Antonak, R. F., & Livneh, H. (1998). The measurement of attitudes toward people with disabilities: methods, psychometrics, and scales. Springfield, IL: C.C. Thomas. Hong Kong, Equal Opportunity Commission (2000). A baseline survey of students’ attitudes towards people with a disability. Hong Kong: EOC. Kabbarah, N. (2005). A study on the situation of disabled persons and the Arab Decade of Disabled Persons (2004-2013). Retrieved September 28, 2007, from http://www.jica.go.jp/branch/ific/jigyo/report/kyakuin/200506_01.html Paris M. J. (1993). Attitudes of medical students and health-care professionals towards persons with disabilities, California School of Professional Psychology, Berkeley/Alameda. Arch Phys Med Rehabilitation, 74, 818-825. Quryouti, Y. (1984). Special education for Jordan: A present status of needs assessment study, Unpublished doctoral dissertation, University of Jordan. Rosenbaum P. L., Armstrong R.W., & King S.M. (1986). Children’s attitudes toward disabled peers: A self-report measure. Journal of Pediatric Psychology, 11(4), 517-530 Roush S. E. (1986). Health professionals as contributors to attitudes towards persons with disabilities. A special communication, Physical Therapy, 10, 1551-1554. Turmusani M. (2003). Disabled people and economic needs in the developing world: A political perspective from Jordan. Ashgate: UK. World Gazetteer (2007). Jordan: Largest cities and towns and statistics of their population. Retrieved September 28, 2007, from http://www.world- gazetteer.com/wg.php?x=&men=gcis&lng=en&dat=32&srt=npan&col=aohdq&geo=- 110 World Health Organization (2001). International Classification of Functioning, Disability and Health (WHO-ICF). Geneva: WHO. Yahoo Education (2007). Jordan people: Population. Retrieved September 28, 2007, from http://education.yahoo.com/reference/factbook/jo/popula.html Barriers to Education for People with Disabilities in Bekaa, Lebanon Samantha Wehbi, MSW, Ph.D. School of Social Work Ryerson University Abstract: This paper presents the findings of a recent study on the educational situation of people with disabilities in Lebanon. The main findings of a survey conducted with 200 participants in the impoverished rural Bekaa region illustrate the inadequate educational situation of people with disabilities. The focus of the paper is on a discussion of the barriers that people with disabilities face in pursuing their education. Participants identified the following difficulties in pursuing their education: educational system barriers, inadequate finances, health issues, transportation difficulties, and family pressures. Although the focus of the article is not on factors that can facilitate educational achievement, some of these supports are identified, including family support and personal motivation. The article concludes with a discussion of current and planned community responses such as the development of an interdisciplinary community action network (The Inclusion Network), the provision of literacy courses, and a pilot project to foster the inclusion of children with disabilities in mainstream schools. Key Words: Lebanon, education, disability rights Introduction This paper addresses the issue of education for people with disabilities in Lebanon by describing the findings of a recent study and discussing efforts to deal with some of the problems that this population group is facing. The findings presented here are part of a larger study conducted by the author of this paper as part of the work of the Lebanese Physical Handicapped Union (LPHU), a grassroots non-governmental organization (NGO) founded by and for people with disabilities in 1981. The larger study examined the educational and employment situation of people with disabilities in the Bekaa region, one of Lebanon’s most impoverished regions. As with many other “Third World” countries, social and economic development in Lebanon has favored urban areas at the expense of rural regions such as the Bekaa. Considering the important link between poverty, marginalization and inadequate educational opportunities (UNDP, 2003), the present study sought to explore the types of barriers that people with disabilities experienced in their attempts to pursue education in an impoverished area such as Bekaa. The study aimed to identify these barriers with the hope of better targeting community development and policy-making efforts. In a discussion of global rights legislation, Manderson (2004) highlighted the marginalization experienced by people with disabilities in areas such as work and education. She noted that 80% of people with disabilities live in resource-poor societies where they are typically marginalized because they are deemed incapable of contributing to society. In an issue of this journal focusing on a critical exploration of special education, Conway (2005) emphasized that “people with disabilities have an on-going fight for the right to be educated and to have the full range of opportunities for employment and daily living that are available to the majority of the population” (p. 6). Speaking of the American context, Scotch and Schriner (1997) maintained that it is marginalization and exclusion from schooling that has greatly contributed to disadvantages experienced by people with disabilities. In Lebanon, the situation is similar in that people with disabilities have historically been prevented from participation in mainstream society and notably in the mainstream educational system; this situation has also contributed to their marginalization. Several NGOs, including those founded by and for people with disabilities, have lobbied for societal changes including the passing of Law 220 that clearly stipulates for the right of people with disabilities to be included in mainstream society, including public or private schools. However, despite the passing of this Law in 2000, not much has changed and children with disabilities are mostly inadequately educated within special care institutional settings (Lakkis & Thomas, 2003). Yet, governmental funding through the Ministry of Social Affairs is still directed towards these types of institutions despite an official law that seeks to promote inclusion in the mainstream educational system. Indeed, as Harlan and Robert (1998) noted in their discussion of the Americans with Disabilities Act, “There is a great difference between passing a law and the social process that leads to actualization of the intended reform” (p. 398). In Lebanon, community organizations such as LPHU have engaged in sustained advocacy efforts to push for the implementation of this Law. An important component of their efforts is research such as the study discussed in this article. Within a context of widespread marginalization and some would say “invisibility” (Mansour, 2001) of people with disabilities, there is a need to better understand their experiences as an important step in addressing the societal barriers that undermine the effectiveness of legislative changes and keep them from being able to fully participate in mainstream society. Literature Review While there is a dearth of studies on the educational situation of people with disabilities in Lebanon, studies across the world have identified the types of difficulties that this population in general may face. As Barnes (2005) notes, it is important to try to understand the problems that people with disabilities encounter, not as being due to personal deficits related to impairments, but as being rooted in broader disabling social environments. As such, several authors have identified social and cultural perceptions of disability as impacting on educational experience (Baker & Donnelly, 2001; Chimedza, 1998; Harry, 1992). These perceptions are crucial in influencing whether children with disabilities are seen as capable or even worthy of pursuing education. Barriers Within the Educational System Studies have highlighted a number of barriers for people with disabilities within the educational system, such as inadequate teacher training or preparation to work with children with disabilities (Forlin, Hattie and Douglas, 1996; Johnstone, 2005; Scruggs & Mastropieri, 1996; Wong, Pearson, Ip & Lo, 1999). A study conducted in Lesotho with 140 teachers found that disability was understood from a deficit approach and students with disabilities were automatically expected to be able to do less than others (Johnstone, 2005). A Hong Kong study on the educational experiences of children with disabilities in 224 schools found a lack of resources and inadequate training for educators (Wong et al., 1999). Another study conducted with 273 educators confirmed the great stress they experience in working with children with disabilities (Forlin et al., 1996). These findings are echoed in a meta-analysis of 28 research reports which found that educators lack the necessary time and expertise to work with children with disabilities (Scruggs & Mastropieri, 1996). The Impact of Socio-Cultural Perceptions Among the studies focused on educational barriers are two studies that demonstrate the impact of socio-cultural perceptions of disability on educational and other experiences (Phelps & Hanley-Maxwell, 1997; Phillips, 1990). A study by Phillips (1990) explored the narratives of 33 men and women with disabilities over an 18 month period. Findings indicated prevalent societal misconceptions that limit educational opportunities. For example, participants were often discouraged from pursuing higher education by school counselors even if they had excelled in school, because they were simply seen as “incapable” due to having a disability. A similar finding was echoed in a review of research studies conducted over a ten-year period on the educational and employment outcomes of youth with disabilities (Phelps & Hanley-Maxwell, 1997). Findings indicated significantly higher school dropout rates for youth with disabilities, as well as much less access to higher education and employment. The Role of Parents and Peers Also discussed in the literature are the important roles that parents and peers play in educational success (Keller, 1999; Pal, Chaudhury, Sengupta & Das, 2002; Woodard, 1995). Based on a survey of 92 parents of elementary age school children with disabilities, the study identified family stress as an important factor impacting children’s educational experiences (Keller, 1999). Another study confirmed the important role of parents in the overall societal integration of their children with disabilities (Pal et al., 2002). Findings indicated that beyond impairments associated with the disability, the lives of children with disabilities, including school attendance, are also limited by parental perceptions of their children’s capacities. Another study by Woodard (1995) explored the attitudes of 33 children toward participating in a recreational activity with a peer having a disability. Findings indicated varying degrees of reluctance to engage in such activities, impacted upon by children’s perceptions of the disability type. The Lebanese Context In Lebanon, there has been a growing interest in examining the educational needs of children with disabilities, as part of a movement of parents and civil society actors seeking to promote inclusion. Most of the studies that have been conducted on this topic are available in unpublished or organizational reports, the findings of which are described below. It is important to preface this discussion by highlighting the absence of any reliable official statistics on matters related to people with disabilities. Indeed, while the Central Administration of Statistics estimates the percentage of people with disabilities to be 1.5% of the population, a UN survey estimates the number to be 10% of the general population. This discrepancy has been attributed to differing classification systems as well as the marginalization of people with disabilities (Mansour, 2001). In 1999, a needs assessment of the Lebanese educational system in the field of special education was conducted by UNESCO experts (McBride, Dirani & Mukalid, 1999). The study estimated that there are approximately 310,118 children who could benefit from special education in Lebanon. The authors discussed the marginalization of children with disabilities and recommended the development of an educational delivery system that would promote inclusion of students in mainstream educational settings. Another study presented at the Second National Conference on the Education of Persons with Special Needs in Lebanon found that most schools are not yet open or equipped to working with children with disabilities. For example, the study identified that there is a lack of openness to the idea of inclusion as well as lack of adequate qualifications of teaching staff (Brousse-Chamichian, Murphy, Makarem & Marji, 2000). The official governmental policy has been to relegate the education of children with disabilities to the domain of the Ministry of Social Affairs (not the Ministry of Education). Hence, the focus has been on provision of care not education. As a result, people with disabilities have not had access to adequate educational opportunities. The findings of a study exploring educational and vocational attainment conducted by LPHU with 200 graduates of special care institutions indicated that almost half were not promoted from primary school (Lakkis & Thomas, 2003). This is an alarming statistic considering that the national promotion rate in 1999 was 87.7% (CRDP, 1999). Moreover, the authors report that the illiteracy rates for younger members of the sample were 23% for those aged 14-26, compared to 3.7% of the general population between the ages of 15-23. A more recent study conducted by this author on behalf of a consortium of NGOs was part of a World Bank funded project promoting inclusion in social, vocational and educational domains (Wehbi, 2006). Through interviews, surveys and focus groups with parents, children, educators, NGOs, and policy-makers, the study aimed to identify available information, current policies and legislation, main stakeholders and existing programs on inclusion of people with disabilities. Findings indicated a lack of awareness of the rights and experiences of people with disabilities, in addition to a shortage of qualified educators. In short, the above-mentioned studies from Lebanon and elsewhere point to a variety of possible barriers that can hinder or negatively impact the educational experience of people with disabilities. The role of the socio-cultural context, support for teachers and parents, qualifications of educational staff, parental perceptions, openness of educational institutions to inclusion, as well as peer interaction, can all be important in understanding what could hinder or facilitate the educational attainment of children with disabilities. Studies from Lebanon tend to describe the educational attainment of people with disabilities or to focus on the topic of inclusion. Moreover, these studies tend to be national in scope without particular attention accorded to specific regions. The study described in this article is the first of its kind to explore in-depth the actual barriers that may hinder the educational experience of people with disabilities in a specific region, the Bekaa. Methodology The exploratory study described in this article was conducted as one of the activities in a larger project that saw the establishment of an LPHU job center in Bekaa geared towards people with disabilities, in consideration of their marginalization in the mainstream job search and placement field, and in Lebanese society in general. The study aimed to provide the background information necessary to better target the center’s interventions. In addition, the study aimed to contribute to the advancement of knowledge on the situation of people with disabilities in Lebanon, in the hope of developing better policies and practices. Study findings focusing on the employment situation are published in a separate article (Wehbi & El-Lahib, forthcoming). This study relied on quantitative methods using a survey for data collection. While most of the data collected was quantitative in nature, some questions asked for qualitative information in order to gain a more in-depth understanding of the issues confronting people with disabilities. The sample was composed of 200 participants selected from a list of people with disabilities registered under Law 220 for tax-break purposes with local municipalities in Bekaa. Selection was purposive and aimed to ensure a diversity of the sample in terms of geographic location within Bekaa, type of impairment, age and gender. Surveys were conducted by research assistants and the author of this article in a location chosen by the participant, usually the home or workplace. Study Sample The final sample included participants from 33 villages in the West and Central Bekaa regions, the two areas of Bekaa targeted by the job centre project—the remote area of North Bekaa is not part of the project. In addition, sample selection sought participants with a diversity of impairments, while being aware that an official survey estimated the incidence of mobility impairments to be the highest percentage (48.8%) of people with disabilities in Lebanon (Central Administration of Statistics, 1997). The percentages of people with other types of impairments according to official statistics are the following: 20% sensory (speech/hearing), 17.8% developmental, and 4.4% visual. In comparison, our final sample was composed of participants with the following impairments: 54% mobility, 18% sensory, 19% developmental, and 9% visual. In indicating the type of impairment on a participant’s survey, the research assistants relied on the Ministry of Social Affairs’ classification indicated on a participant’s “disability identification card” issued to people with disabilities in Lebanon. It is important to note that an effort was made to speak to a participant with developmental disability directly. In a handful of cases, parents were present and answered questions on behalf of the participant. In terms of age distribution, the sample focused on people of working age considering the connection of the study to the job centre project. However, a range of ages was sought to increase the diversity of the sample. In the final sample, participants ranged in age from 18 to 66, with the average age being 32 years. The sample included 74 participants between the ages of 18 and 26, 89 participants between 27 and 40, and 38 participants over 40. Considering the particular marginalization and issues facing women with disabilities in Lebanese society (Abu-Habib, 1998), a special effort was made to ensure as equal a representation in the sample as possible. At the outset of sample selection, we were aware of the difficulty in achieving this equal distribution, especially since the larger study sought as much as possible to identify a mixture of employed and unemployed participants. This difficulty reflects the reality of the underemployment and invisibility of women with disabilities in the mainstream labor market. The final sample included 86 women (43% of the sample). Study Limitations A word is in order about the limitations of the study. An important limitation concerns participant selection. It can be argued that by relying on official tax-break records to locate participants with disabilities, the sample was biased in terms of social class. Perhaps those who are not in financial need may not register with the municipality to receive a tax break. However, the reality in Lebanon is that most people with disabilities are among the poorest of the poor (Central Administration of Statistics, 1997). Nonetheless, future explorations could try to locate people with disabilities from affluent families to assess differences in experience from those in poorer families. Indeed, it would be interesting to better understand the link between poverty, marginalization and educational attainment. Another important limitation concerns the focus of the study on barriers to educational achievement. While the study asked participants what may have facilitated their educational experience, only 24 participants answered this question, and in a less detailed way than those who indicated having experienced barriers. It would be useful for future explorations to place more emphasis on what facilitates the educational attainment of people with disabilities as this information could be useful in developing policy and practice responses that could reinforce existing supports. Findings and Discussion Education Level and Literacy The main findings of the study illustrate the inadequate educational situation of people with disabilities. The majority (54%) of the study’s participants had only reached an educational level below intermediate school, only 7% had attained a vocational certificate and only 6% had university degrees. These figures compare unfavorably to those of the general population aged 15-24 where approximately 25% have vocational training and 25% of those aged 20-24 are enrolled in university (Al-Yassir et al., 1998)—this official UNDP report does not provide promotion rates or details about the type or level of vocational training. In terms of rates of illiteracy, findings indicate a rate of 50%, where 26% of participants indicated that they were illiterate, another 24% indicated that while they had some schooling and were counted in the figure of 54% above, they could not read nor write, or could barely do so. While we do not claim the study's sample to be representative of the population of people with disabilities, the findings in terms of educational attainment are quite telling. Clearly, the majority of the study's sample had below intermediate education. This finding confirms previous demographic studies such as the one by the Lebanese Central Administration of Statistics (1997) that found over 50% of people with disabilities to be illiterate. In addition to their attainment through formal education, 50 participants (25% of the sample) had also received some form of vocational training with some participants receiving more than one type of training. It is noteworthy that for most, the training remained at the beginner level. In general, 47% of those who had received vocational training had beginner-level computer or typing training. Another 21% had some form of arts or crafts training, and 11% had training in sewing. The remaining participants had training in nursing, first aid, photography, hairdressing and accounting. When asked if they felt they needed more training to be able to have better job opportunities, many indicated that they needed computer and foreign language skills. In addition, a few participants indicated that they needed to take literacy courses, considering that they were illiterate or had forgotten the little they had been taught at school. As noted earlier, the likelihood that a person with a disability will not complete her or his education is higher than for the general population. In this study, we attempted to find out what some of the difficulties on the educational path might be. In fact, 162 out of 186 participants who answered the question asking them whether they had experienced barriers to continuing their education indicated experiencing one or more obstacle. In general, the most cited difficulties were the following: educational system barriers (59%), inadequate finances (47%), health issues (28%), family pressure (23%), and transportation difficulties (13%). Barriers in the Educational System The most important obstacle faced by the study's participants appears to be located within the educational system itself. More specifically, many participants were unable to continue their education either because the school could not adjust to their disabilities or because they had studied in specialized institutions or public schools and still came out illiterate. In the first case, many participants were either unable to attend school or had reached a stage where the school was no longer able to accommodate them. Many villages do not have schools, let alone accessible ones and their academic programs are not geared to a diverse student body. For example, one participant who is Deaf gradually lost his hearing and was forced to leave school when he could no longer hear the teacher. As noted in the review of previous studies cited in this paper, schools appear to be lacking in qualified personnel or in the ability to make the necessary accommodations for students with disabilities. These students with disabilities are thus deprived of the possibility of continuing their education in the mainstream educational system. The necessity of funding schools in rural regions is evermore highlighted in the case of children with disabilities, as part of a solution that would address some of the barriers that they face. Moreover, when enrolled in mainstream schools, participants indicated that they still left the school as practically illiterate. This could be due to the non-adaptation of school curricula to the additional needs of students with disabilities. As an example, one participant with cerebral palsy and speech difficulties went to school until the third elementary but still came out illiterate. She describes how she was cast aside in the classroom and was only sent to school so that she would not be a “burden” in the household. Another participant describes how she felt that her classmates and teachers did not accept her because of her disability. As noted in the literature review, there seems to be a lack of awareness on the part of peers and educators of the needs of students with disabilities, which is compounded by a lack of awareness by parents themselves. In many other cases, students with disabilities are forced to stop their education because the schools in their village only reach a certain academic level and they are unable to secure the necessary transportation to go to another village or to the city to continue their education. This is especially the case for women who are often prevented by their families from leaving the village. More about this difficulty and transportation issues will be discussed below. A related obstacle is that of the physical inaccessibility of educational institutions. For some study participants, ambitions of continuing their education either at the school level or at the level of university were curbed due to the physical inaccessibility of the educational institution. Because the few accessible schools or universities were outside the village or the region, many were unable or unwilling to leave their villages to pursue their education. It is important to note that leaving home before marriage is not the norm in Lebanese society, and this is especially the case for women. This prohibition of leaving home is further exacerbated for people with disabilities and especially women, who are seen as incapable of taking care of themselves. This aspect of the socio-cultural context is important to keep in mind when attempting to address educational barriers; specifically, any policy or community development solutions that attempt to address this barrier by simply increasing funding without taking into account local conceptions would be amiss. As for others who had studied in specialized institutions, they left school as either illiterate or could barely read and write. Indeed, some participants indicated that they did not continue their education because when the mainstream school could no longer adapt to their needs, they refused to go into a specialized school. In some cases, parents refused to send their children away from the village to an institution. For many participants, the experience of being in a specialized school was one of being inadequately provided for in terms of education. For others, the experience was one of abuse. The parent of one participant with multiple disabilities pulled her daughter out of a reputed special care institution when she discovered that her daughter was being given pills to block her bowel movements so that the attendant did not have to worry about taking her to the bathroom. Whether through inadequate education or through abuse, there is a reinforcement of the idea that people with disabilities are not fit for, nor worthy of participation in society. Other barriers in the educational system appear to be at the level of policy. More specifically, one participant who was studying in a vocational school and later developed muscular dystrophy tried switching into a less physically taxing academic program. He was unable to do so because current educational policies do not permit switching from the vocational to the academic track. Another participant faced a different sort of policy-related barrier. This young woman studied in a special care institution until she became engaged at the age of 17. At that point, she was told that she could no longer be enrolled in the school. Realizing the importance of having an education, she tried negotiating her stay in the school but the administration refused citing institutional policies. This case can be seen as an example of the impact of the socio-cultural context on the educational experiences of people with disabilities. More specifically, it can be argued that this policy is informed by a limited perception of women’s primary roles in Lebanese society. Seen to have fulfilled her primary role of becoming a wife (or being on the road to it), this participant was no longer deemed to be in need of an education. Moreover, with a husband to support her, she is no longer seen to be in need of the support of a special care institution. Interestingly, she was divorced after a year of marriage and found herself without the vocational or academic skills needed in the marketplace to support herself. Inadequate Finances The second most important obstacle faced by the study's participants is related to finances. As previously mentioned, the Bekaa region is characterized by high rates of poverty. While public school has minimal associated tuition fees, these can be beyond the reach of many families. Not surprisingly, many participants indicated that poor finances prevented their families from sending them to school or prevented them from continuing on to higher education. For some families, finances deteriorated when their child developed a disability. Family income was increasingly spent on treatment or medications and less on education. While health policy in Lebanon makes provision for medical insurance for people with disabilities registered with the Ministry of Social Affairs, this is rarely honored by medical institutions. As a result, people with disabilities who can afford to pay for treatments do so at their own expense. For many, the absence from their region of schools adapted to their additional needs meant that they would have had to enroll in specialized institutions or in private schools. Without the financial means to do so, their learning opportunities were quite restricted. The gap between those who can afford to send their children to school and those who cannot is put in relief. The impact of inadequate finances on the educational experience of people with disabilities highlights the direct link between poverty and marginalization. Without a proper education, people with disabilities are further marginalized in a society that already discriminates against them due to long-held misconceptions of their inadequacy. Health Reasons Related to the Disability Another important barrier to education is related to the impact on health engendered by a disability. Several participants indicated that they had spent lengthy amounts of time in surgeries and in treatment which prevented them from pursuing their education. Considering that the mainstream educational system is not adapted to allow in its programming for the additional needs of students with disabilities, any absence on their part threatens their ability to pursue their education. This problem is further compounded when the inadequacy of finances of many families is taken into account. Moreover, if a school already lacks the openness to accept students with disabilities, any absence on their part may be construed as a sufficient excuse for their dismissal. Ironically, students with disabilities who face obstacles related to the educational system’s inability to respond to their differing needs are made responsible for the shortcomings of the system. It is seen as their responsibility to persevere in their studies, but they are not provided with the necessary supports. This situation provides a clear example of “blaming the victim” that is often the lot of members of marginalized groups facing systemic oppression. Furthermore, it is important not to reduce this barrier to a criticism of a specific educational institution. The barriers people with disabilities face are tied to a systemic problem of the inadaptability of the educational system to their differing abilities and health situations. Family Pressure An important finding concerns the role that parents play in the educational experience of their children. At a primary level, the few parents who participated in the survey spoke about their children, specifically those with developmental disabilities, as being incapable of learning and of working. As reported in the literature review section, parents' beliefs and attitudes appear to be an important obstacle that can greatly limit their children's learning potential. Perhaps this is not surprising considering that parents, like others, are subject to societal misconceptions about people with disabilities. Other parents prevented their children from pursuing an education out of (often justified) fear. Some parents indicated that they would not allow their children to leave their sight or to leave the village out of fear for their safety. In terms of the situation of girls with disabilities, parents seem to be caught in a double bind. On the one hand, parents have a right to fear for the safety of their daughters, especially considering that as in many other societies, girls and women are subjected to harassment and violence in Lebanon. A previous study by the author of this article on sexual violence in Lebanon highlighted the vulnerability of women with disabilities who are seen as “unmarriageable” and thus the “legitimate” targets of sexual violence (Wehbi, 2002). On the other hand, extreme fear for their safety can greatly limit their educational possibilities and future potential. By preventing girls from pursuing an education, parents inadvertently further contribute to the marginalization of their children. Other types of family pressures that can become difficulties include a sickness or death in the family, and once again, girls are most likely to suffer the consequences. Some participants indicated that they left school when a family member died or became ill. As girls, they were seen by other family members as having the responsibility to care for the ill family member and to take care of the housekeeping. A word of caution is necessary in this discussion: If we blame parents for their protectiveness or for the misconceptions they may hold, we fail to see the full picture and we devise responses that will undoubtedly be limited. For example, while awareness-raising among parents of children with disabilities is an important aspect of redressing misconceptions, it is not enough. As with individual educational institutions, targeting individual parents misses the point: The barrier facing people with disabilities is systemic in nature and transcends an individual family. Social structures such as the labor market that thrives on the unpaid or underpaid work of women, laws and social strictures that continue to condone directly or indirectly the sexual exploitation of women, as well as society’s disregard for people with developmental disabilities, are all examples of what needs to be addressed to end the marginalization of people with disabilities. Transportation Difficulties A final important obstacle to educational attainment is lack of transportation. In the best of cases, transportation between and within villages in the Bekaa is quite challenging. There are limited means of public transport and those that do exist do not cover all possible routes. As previously mentioned, social and economic development in Lebanon has tended to favor urban areas. Rural regions such as Bekaa still lack an organized and reliable transportation infrastructure accessible to the population of the region as a whole. The situation is even worse for people with disabilities, as no adapted means of public transportation exist. These transportation difficulties mean that people with disabilities wishing to continue their education have to possess means of transportation to be able to go to schools that are willing to accept them. Obviously, in a region where poverty rates are quite high, this option is not within the reach of many. As for women, transportation difficulties are exacerbated as they are often limited by their families from using public means of transportation. Parents who participated in the survey often indicated that they would not send their daughters with just whomever to school because they fear for their safety from harassment or exploitation. As mentioned earlier, parents’ fears are likely justified but do restrict girls’ chances of pursuing an education. In short, most participants indicated that they had faced difficulties in continuing their education, while a very small number (24) indicated having faced none. Among these participants are youths who are still studying and participants who had gained university degrees. Also included are those who had completed their studies prior to developing a disability and those who had made a personal decision to leave school. A relatively small number indicated that they were helped to continue their education through the support of their family members or through their own motivation. A small number as well indicated that their facility of movement permitted them to continue school despite their movement-related impairments. Taking these difficulties and supports into consideration, community efforts have aimed to redress this problematic situation through a variety of responses. Considering the multi-faceted nature of the problems faced by people with disabilities in pursuing their education, these responses have been interdisciplinary and are described below. Concluding Thoughts: Current and Future Responses As seen from the studies discussed earlier in this paper, there are similar problems experienced by people with disabilities in Lebanon as those experienced in other countries. More specifically, institutional barriers such as those at the level of the educational system, socio-cultural misconceptions and factors, as well as family-related issues are key obstacles that are played out in their own specificity according to the Lebanese context. Other obstacles that relate to transportation or finances appear to be quite specific to the Bekaa region, a rural area with an underdeveloped transportation infrastructure and high rates of unemployment and poverty. Moreover, it is important to highlight the impact of sexism on the experiences of women with disabilities attempting to pursue an education. More specifically, they are subject to family pressure and role expectations with regards to household and caring tasks that hinder their educational achievement. They are also subject to restrictions on their movement due to fear for their safety or to socio-cultural expectations of propriety that prevent them from freely pursuing an education on an equal footing as men. Taking all these obstacles into account, several responses have been developed by civil society actors. Described below are community responses developed by NGOs composed of people with disabilities and NGOs working with people with disabilities. Because these actors understand that the marginalization of people with disabilities is not due to individual circumstances but to larger societal and institutional obstacles, responses have sought to change existing social conditions that prevent people with disabilities from successfully pursuing an education. Beyond working on individual-level rehabilitation efforts, community responses to many of the obstacles identified in the Bekaa study have included the following: the development of an interdisciplinary community action and advocacy network (The Inclusion Network), the provision of literacy courses, and a pilot project to foster the inclusion of children with disabilities in mainstream schools through the combined efforts of social workers, special educators, occupational therapists, vocational therapists, and early intervention specialists. It is important to note that knowledge about these community-based responses has been gained by the author of this article through involvement in the work of disability rights NGOs in Lebanon. These responses have not been documented elsewhere (with the exception of some local organizational reports) and are therefore important to present here to a broader audience of academics, policy-makers and practitioners. The Inclusion Network The Inclusion Network came to life as a result of the efforts of parents, people with disabilities, professionals, educators as well as national and international NGO’s. Members of the Network are concerned about the exclusion of people with disabilities from participating in mainstream Lebanese society in many key areas including education and employment. The Inclusion Network has been active in addressing institutional and socio-cultural obstacles. More specifically, the Network has been instrumental in lobbying for legislative and policy changes within the educational system, in conducting awareness-raising campaigns to challenge societal misconceptions surrounding people with disabilities, and in conducting research to better understand the situation of inclusion in education in Lebanon. Literacy Courses Another important community response is the implementation of literacy courses offered to people with disabilities as part of the afore-mentioned job center project in the Bekaa region. LPHU, the NGO that developed and implemented this project sought to address some of the impacts of educational system barriers on the educational attainment of people with disabilities. More specifically, realizing the marginalization that people with disabilities face and the high rates of illiteracy especially in rural regions, the center offered literacy courses initially open to adults with disabilities in the region. In addition to the literacy courses, participants are also able to benefit from follow-up by the center’s social workers should they choose to pursue further educational or employment opportunities. The courses were so popular that both daytime and afternoon sessions filled up very quickly. It is important to note that this result was also helped by the fact that transportation was arranged for and funded in collaboration with local municipalities. Also important to note is that the classes attracted people without disabilities who found out about the courses from their neighbors who have disabilities. Considering that the goal of the program is to promote inclusion of people with disabilities in mainstream society, up to 15% of spaces in both classes were open to people without disabilities. It is ironic within the Lebanese context that a program for people with disabilities was able to provide learning opportunities to people without disabilities. A final community response worth mentioning is the national pilot project funded by the World Bank and run by a consortium of an international NGO (Save the Children Sweden) and three local disability-rights NGOs (LPHU, Youth Association of the Blind and the Lebanese Down Syndrome Association). This 18-month project which is in its mid-point at the time of writing this article is implemented by a staff of social workers, special educators, occupational therapists and other educational and vocational professionals. The project assumes a logical connection between three distinct but interconnected domains: the social, the educational and the vocational. Work on the social domain sees the establishment and training of community advocacy committees composed of parents and people with disabilities to work on awareness-raising and lobby for changes related to educational and vocational inclusion. The educational domain is composed of efforts to include children with disabilities in ten schools across Lebanon while providing them and their families with the supports of special educators and social workers. This component also sees the development and implementation of teacher trainings and peer supports within the schools. Finally, the vocational domain would provide the supports necessary to people with disabilities to enable them to become participating members of the mainstream labor market. The multi-faceted efforts of professionals working together with NGOs of people with disabilities hold a promise for change in existing social conditions that keep people with disabilities marginalized. It is too early in the history of inclusion in Lebanon to see all of these efforts bearing fruit on a large scale. However, what is certain is the need to continue to work towards full inclusion of people with disabilities not only in the educational sector but in all areas of life. 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Rutherford, PhD, MBA Missouri State University Abstract: This article investigates Jordan’s rationale for assuming a leadership role on the disability rights issue in the Arab World. Tens of millions of people, including over ten percent of Arab families, are impacted and impoverished because of disability. To address this substantial challenge, the Jordan Royal family has leveraged Jordan’s tradition of openness and generosity coupled with one of the best educational systems in the Arab World to promote disability issues. As a result, Jordan is recognized by the international community as leading the Arab World in promoting disability rights. Jordan’s international and regional leadership on disability rights was recognized in 2005 when Jordan received the Franklin Delano Roosevelt International Disability Award. Key Words: disability rights, Jordan, Middle East “Jordan’s overall achievement in the field of disability provides a fine example of a human rights approach combined with leadership at the highest level. It draws inspiration from a rich variety of material – ranging from Arab-Islamic tradition to the modern Jordanian constitution and the Universal Declaration on Human Rights.” U.N. Secretary-General Kofi Annan, remarks at the FDR International Disability Award Ceremony for the Hashemite Kingdom of Jordan, United Nations, New York, N.Y., March 23, 2005. Despite Jordan’s location in one of the most volatile and insecure parts of the world, it plays a leading international and regional role in alleviating suffering and protecting the rights of people with disabilities (PWD).vi Jordan’s leadership on disability rights was recognized in 2005 when it received the Franklin Delano Roosevelt International Disability Award, named for the U.S. president who was a polio survivor and used a wheelchair for many years. On March 23, 2005, the award was presented at the U.N. headquarters ceremony to Jordan’s King Abdullah II by the president’s granddaughter, Anna Eleanor Roosevelt, who commended Jordan for putting the disabled “in the forefront of its national agenda” and for providing inspiration by example in eliminating obstacles that “all too often prevent those with disabilities from joining the mainstream of civil society.” The award is presented annually to a nation that makes noteworthy progress toward the goal of the United Nations World Program of Action Concerning Disabled Persons: the full and equal participation of the world’s 600 million people with disabilities in the life of their societies. Jordan is the sixth country and first Arab or Islamic state to receive the award. At the FDR International Disability Award Ceremony, Michael R. Deland, chairman of the National Organization on Disabilities, remarked that one reason Jordan received the award was that, in 1993, it was the first country in the Arab World to pass legislation based on the Americans with Disabilities Act (ADA), which was adopted by the United States in 1990. Jordan’s disability law recognizes that people with disabilities need legal protections and social opportunities. While Jordan has already achieved disability legislation, Jordan’s Prince Ra’ed, Chief Chamberlain at the Royal Hashemite Court, and President of the Higher Committee for Managing Projects for People with Disabilities, said that “other Arab countries are just starting and it will be [a] long process” (personal communication, March 17, 2005). Many of those who live in the Arab world, such as Jordan, have a hard life. Those who have lost limbs or faculties in those countries -- be it from war or other causes -- have the hardest life of all. People with disabilities must deal with trauma, physical pain, and with an environment in which there are often few to no laws protecting their rights and serving their medical or rehabilitative requirements. Their disabilities usually result in the loss of jobs, inability to go to school, and the impoverishment of their entire families. This is not just because of physical barriers. There are profound social barriers as well. Most Arab governments have steadfastly refused to pass sweeping anti-discrimination disability laws, albeit in recent years, several Arab governments have made dramatic steps toward passing domestic disability rights laws. Jordan has continued to set the standard in the Arab World for disability rights. For example, it is currently improving existing vocational training programs to integrate PWD and other underemployed or marginalized groups by a) revising training curriculum and enhancing job-placement capabilities, b) raising awareness of structural and legal barriers that restrict the ability of people with disabilities to fully participate in society, and c) accessing economic opportunity by building a regional coalition of advocates and organizations that is working to expand opportunities for people with disabilities in the Arab World. This article examines why Jordan became the first state in the Arab World to adopt disability legislation, which has provided a model in the Arab world.vii In addition, it considers why Jordan has become a regional and international leader on the disability rights issue, including the recently completed UN negotiations that resulted in the UN Convention on the Rights of Persons with Disabilities, which opened for signature on March 30, 2007.viii This article attempts to explain the genesis and development of Jordan’s work on disability rights. Such an investigation yields lessons for other regional states to apply in helping their disabled communities. An important substantive inference is how lessons learned from Jordan’s policy experience with disability issues can be applied in other Arab states. People with disabilities only present policy problems, as they put financial strain on their families and hinder societal development, if they are not incorporated into society. The article’s broader significance for the study of comparative foreign policy is that it may help predict the success or failure of current United Nations efforts to address disability rights comparatively. If Jordan indeed provides a significant role model for the Arab region and international community, it becomes more relevant to examine the conditions under which Jordan was able to generate domestic and governmental support for disability rights. One of the implications is that under certain conditions, Arab governments can contribute to setting the international political agenda, especially in the development of domestic disability rights laws, which in turn effect state behavioral changes. This article discusses three factors contributing to Jordan’s success in disability rights: an enlightened royal family, a national tradition of openness and generosity, and one of the best educational systems in the Middle East. Members of the royal family have leveraged their roles to promote civic participation and remove barriers to equal opportunity, empowering people with disabilities through employment training, job opportunities, and rights awareness. As a result, Jordan is recognized by the international community as leading the Arab world in promoting disability rights.ix Factor One: Hashemite Royal Family In the early 20th century, the Hashemite Family led the Arabs toward independence from outsiders, succeeded in building an Arab order, and laid the foundation for an Arab unity intended to guarantee rights, regulate duties and protect human dignity and sovereignty. During its reign, the family has continued to emphasize Jordan’s Hashemite roots and, therefore, its support for Arab unity. The late King Hussein highlighted this view when he addressed the European Parliament in 1983, which explains Jordan’s view of itself as being part of a greater national project: “The country which I have had the honor to have served the greater part of my life, the Hashemite Kingdom of Jordan, is a part of the greater Arab nation. The Arab and Hashemite struggle throughout history has been one and the same. I am a proud descendent of the prophet Mohammed, of the house of Hashemite, of the tribe of Qureish, the oldest and the most eminent family in Arabia. I am the great grandson of Hussein Bin Ali, the chosen leader of the great Arab Revolt often known as the great Arab revival, which started at the beginning of this century. I am the grandson of Abdullah, the founder of the Hashemite Kingdom of Jordan. Throughout my life I have felt, and continue to feel, humbled before the example of my forefathers for their total dedication and commitment to the honorable and just cause of peace. My country has committed itself to the defense of Arab freedom, security, stability and the right to progress in the entire Arab world.” The royal family’s tolerance and openness provided the conditions that allowed the disability issue to emerge and receive attention. There was a contract between state and society as it developed in the Transjordan. It was based on the monarchy, which allowed a modern constitution to develop. The late King Hussein believed that Jordan's people were its greatest asset, and throughout his reign he encouraged people, including the less fortunate, the disabled and the orphaned, to achieve more for themselves and their country. According to Prince Mir’ed, a member of the royal family, King Hussein “always tried to make people feel part and parcel of the country and help each other. The idea of promoting disability rights fit into our family’s philosophy” (personal communication, March 8, 2005). Asked why the royal family is so instrumental in social concerns, Prince Mir’ed replied: “[W]e have [a] small family. Maybe 20-25 males. In Saudi Arabia, there are many princes. For us it is taboo for our family to go into business, but to serve. Not like in Saudi Arabia where there are so many royal family members – thousands – that many need to go into business. My family said you can’t call yourself a prince and sit and enjoy the privileges without giving something back. Sense of service is important. Taboo to go into business. My grandfather Zeid said ‘ya tijara aw imara’ (‘either business or being an emir/leadership.’) My father brought us up with a sense of duty to help whoever you can. But it came very natural to us, it was not planned out. It’s just something you have. All members of [the] family have sense of duty to the people. My immediate family is into disabilities. Other relatives deal with poverty eradication. The common factor is social connections with the people and not placing ourselves on a pedestal” (personal communication, March 8, 2005). The relative peace promoted by Jordan’s royal family greatly benefits Jordan’s people with disabilities. Jordan is known for its security and stability, which, according to Eman S. Abu-Rous, Executive Director of Jordan’s Al-Hussein Society for the Rehabilitation of the Physically Challenged, “Allows disability programs to flourish without interruption due to violence or political chaos” (personal communication, March 1, 2005). What does this mean? According to a prominent Jordan’s children’s advocate Rosemary Bdeir, “Peace is continuation. If war breaks out then it breaks everything and everything comes to a total stop” (personal communication, March 1, 2005). Due to major instability in the region, in part due to the on-going Arab-Israeli conflict, King Abdullah II stated in a speech at Georgetown University on March 21, 2005 that many Arab countries, such as Jordan, find it challenging to “build solid reforms where violent shock waves are constantly churning.” Jordan’s royal family has therefore attempted to balance peace and development, sometimes at the criticism of the Arab street by appealing to its Arab Revolt roots … namely that all Arabs are welcome in Jordan. For example, at Jordan’s founding, King Abdullah I saw Jordan as a pan-Arab government, which is why he called his military the Arab Legion, al-Jaysh al-‘Arabi, and it retains the name today. According to the former crown prince, Prince Hassan, “[I]n a sense Jordan is a melting-pot country. The bad news is we’re a runt state. Some say we’re [the] southern part of Syria or [the] center of Palestine or [the] north of Saudi Arabia” (personal communication, May 2, 2005). According to King Abdullah II, this view of Jordan as a homeland for all Arabs, helps propel Jordan’s royal family to “set standards to develop the community and to be a model in the region” (“King in US”, 2005). According to Prince Hassan, who as Crown Prince worked closely with his brother, the late King Hussein on the human development of Jordan, “We focused on policies, not politics, to benefit people. We focus on winning the peace” (personal communication, May 2, 2005). On February 6, 2007, King Abdullah II announced a new strategy for the disabled. It is a very comprehensive and ambitious plan that will be funded by 65 million Jordanian dinars and under the direction of Prince Ra’ed.x The King said he will personally oversee periodic meetings to receive implementation updates during the eight year plan, which is designed to reduce the rates of disability by 5% during the plan’s first stage (2007-2009) and 15% during the second stage (2010-2015) by strengthening early detection and health awareness programs, and establishing more healthcare centers to service people with disabilities. In addition, King Abdullah said that one of the main goals of the National Strategy for People with Disabilities, which he announced on February 6, 2007, is to reduce the unemployment rate among people with disabilities from the current 40% to the national unemployment rate average for all Jordanians by 2015. Factor Two: Education Investing in Human Beings Besides the royal family, Jordan’s humanitarian leadership on disability rights has also benefited from Jordan’s strong education system. Jordan’s policy of “investing in human beings” in order to compete with neighboring countries that are larger and/or have more natural resources explains why Jordan is better able to address its disability needs than its neighbors. According to the World Bank, “[N]otwithstanding the difficulty of the regional political environment, and the lack of resources, the Jordanian population enjoys today one of the highest per-capita disposable income levels compared to other emerging countries in the region” (World Bank Group, 2005, p. 1). In terms of disability rights and programs in the Arab region, Jordan has set the standard according to Suha Tabbal, special education trainer at the Amman-based Social Development Training Centre of the Queen Zein Al Sharaf Institute for Development: “We think we are the strongest in the Arab world. I prefer not to compare Jordan to the Arab world. I prefer to go with international law. We can’t compare to Arab world, I think we are better than them. If we compare ourselves to Arab laws, Jordan will never improve” (personal communication, March 3, 2005). According to Sabri Rbeihat, Jordan’s Minister of Political Development and Minister of Parliamentary Affairs, Jordan’s focus on educating its citizens is all the more striking when compared to other Arab countries. For example, he says that “while Jordan has 2 percent of the world’s Arab population, numbering around 5.5 million people, there are 23 universities in Jordan, accounting for about 16 percent of the universities in the Arab world. More than 94 percent of Jordan’s high school graduates go on to university education, which is the highest percentage in the world” (personal communication, June 18, 2006). Because of its higher rate of education and inclusion of PWD in the educational system, Jordan has been able to better address the needs of PWD in its educational system than most of its neighbors.xi For example, the National Strategy for People with Disabilities announced February 7, 2007 calls for increasing enrollment of children with disabilities from the current 57% to more than 80% by 2015 by redesigning school buildings, introducing Braille curricula, and bringing in other educational tools for students with disabilities. According to Prince Ra’ed, this strategy was based on input from service providers and families of children with disabilities. (“King Calls for Speedy Implementation”, 2007). Further emphasizing Jordan’s high education level compared to other Arab countries, Jordanian births are attended by skilled health staff who are able to give necessary supervision, care and advice to women during pregnancy, labor, and the postpartum period, to conduct deliveries on their own, and to care for the newborn and the infant. According to the World Bank Group Database of Gender Statistics, 100% of births in Jordan in 2004 were attended by skilled health staff, more than 28% higher than the average for the Middle East and North Africa (World Bank Group Database of Gender Statistics, 2003). Prince Ra’ed believes that one of the reasons for Jordan’s policy of investing in human beings is Jordan’s small size and limited natural and economic resources, resulting in the question: “What are leaders to do?” The answer, according to Prince Ra’ed, is that Jordan has made it a point to invest in human resources. Part of this legacy goes back to the days of the Arab Revolt of 1916, when positive seeds were left for “the development of man; his rights, his commitment to society which he works and as a country as a whole” (personal communication, April 17, 2005). Princess Basma Bint Talal, who is chairperson of the Jordanian Hashemite Fund for Human Development, concurs that investing in Jordan’s citizens is critical to maintaining the royal family’s view of development, which “is not only about providing people with facilities and opportunities, it is about learning from each other. Above all, it is about maintaining human dignity at all cost” (The Jordanian Hashemite Fund for Human Development, 1999, p. 3). Post-Secondary Education At its founding Jordan did not have Arab-focused education. It did not have an American University, as did Egypt’s Cairo or Lebanon’s Beirut. Jordan also did not have a center of ancient learning such as Iraq’s Baghdad or Syria’s Damascus. The colonial experience under the Ottomans and the British laid the groundwork for an educated population. The Jordan region was more educated than the rest of Arabia because, before World War I, it had more contacts with Istanbul than most of the Arab world. The region’s geographical proximity to Istanbul, the capital of the Ottoman Empire, resulted in higher social, economic and political development, especially related to the rest of Arabia. Then, during the British trusteeship of Palestine, the British introduced a system of education in Jordan. Finally, according to Prince Ra’ed, “During the 1920s King Abdullah I determined that education and a focus on the individual was the key for his country’s survival” (personal communication, April 17, 2005). The University of Jordan was established in 1962, and several years later it started a Special Education Department, which was the first in the Arab world. By the 1980s, the University of Jordan became the leading regional specialist in the disability education field, helping Jordan to become the first Arab country to adopt the “partial inclusion of disabled students enrolled in resource classrooms,” which included after school tutoring and speech therapy (World Bank Human Development Department, 2002, p. 18).The influx of Palestinians and other refugees also increased educational levels. For example, in 1991, more than 500,000 Palestinians, who were mostly educated, returned to Jordan from the Persian Gulf in light of King Hussein’s support for Saddam Hussein. According to Evelyn Zakhary, Chief of the Social Services Division in the Department of Relief and Social Services at the Jordan headquarters of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), many of the Palestinian refugees were educated and “out of their exile, they developed comradeship in solidarity with their own group, which positively influence the educational nature of Jordan society.” Sabri Rbeihat, Jordan’s Minister of Political Development and Minister of Parliamentary Affairs also concurs that the Kuwaiti-expelled Palestinians were a “fuel for education because they helped start universities with Palestinian money” (personal communication, June 18, 2006). Regional Focus One of the major contributing factors to Jordan’s support for disability rights is its advanced educational system designed for regional rather than local needs. Unlike many of its regional neighbors, Jordan has no known extensive oil reserve on which to rely. Rather, Jordan exports its educated populace to work and they remit money back to Jordan. One of Jordan’s current policies is to strengthen the relationship between Jordan and the more than 1 million Jordanians abroad, which, in turn, will further propel Jordan’s educational system. Their remittances play an important role in Jordan’s economy and are typically underestimated. For example, Gulf States actively recruit Jordanians to work in the health field in their countries. In early March 2005, the Saudi Arabian Health Ministry visited Jordan to negotiate 500 contracts with Jordanian medics. Abdul Karim Sayegh, chairman of the Saudi committee and the lead negotiator on contracting with Jordanian doctors, nurses and technicians, said the move seeks to replace foreign labor in Saudi Arabia with Arabs, particularly from neighboring countries (Saudi Delegation Negotiating Contracts”, 2005). A few months later, in May 2005, Saudi Arabia gave “vocationally qualified Jordanians exclusive privileges in its labour market, equal to that of Saudi nationals” (VTC to Supply Saudi Arabia”, 2005). Jordan and Saudi Arabia signed an agreement whereby Jordan would supply 1,000 trainers from the Vocational Training Center (VTC) for the next two years and help in establishing 50 vocational training centers. In addition, “Jordanian specialists will also design, implement and assess training curricula for Saudi Arabia, with VTC experts going there to oversee the implementation of these programmes… The VTC will train 50 Saudi vocational trainers every year in various technical and vocational training fields” (“Saudi Delegation Negotiating Contracts”, 2005). One of the most important disability rights problems in other Arab states is that the educated in the disability services field do not like direct contact with the disabled. For example, according to Suha Tabbal, Special Education Trainer at the Queen Zein Al Sharaf Institute for Development in Jordan, who has worked with the disabled in Jordan and Saudi Arabia, “Saudis don’t like hands on work with the disabled, especially if they have a Bachelor’s degree. Their idea of work is different. You train them, but then they don’t want to work with the people” (personal communication, March 3, 2005). As a result, many Jordanians with special education training are recruited to help support disability projects in other Arab states, including Saudi Arabia, which usually do not have the local capacity to serve the requirements and rights of their disabled populations. The high levels of education in Jordan have allowed Jordanians themselves to better serve its disabled community. They take foreign ideas and programs and then tailor them to Jordanian needs. Ali M. Alshawahin, Organizational Development Manager, Middle East and North Africa Region, Special Olympics believes that due to their higher education, Jordanians are better able to leverage their country’s minimal resources to better serve the disabled. He says that “Jordanians don’t have lots of dollars, but they do a lot with a little” (personal correspondence, February 18, 2005). Alshawahin’s views are confirmed by a 2005 World Bank’s Jordan Country Brief, which characterizes Jordan’s achievement in human development as “remarkable” and “at the top of comparable countries.” The analysis notes that: “These positive social results were based on ensuring a high level of gender parity in the access to basic public services. Jordan spends more than 25% of GDP on human development (education, health, pensions, social safety nets) and its outcomes are generally better than comparators worldwide at similar levels of GDP. Jordan’s achievements in human development are impressive. Life expectancy at birth has increased to 72 years and adult literacy rose sharply to 90 percent. Youth literacy rate is about 99 percent, compared with 88 percent for the region. The ratio of girls to boys in primary and secondary enrollment is 100%. The number of children dying before age one fell by nearly 50% to 26 since 1975, and fertility rates are declining. The poverty rate was cut by a third from 21% in 1997 to 14% in 2003. Overall, Jordan has made excellent progress toward achieving the Millennium Development Goals” (World Bank Group, 2005, p. 1). Factor Three: Openness to Foreigners Multicultural Acceptance The multicultural focused educational system and the participation of non-Trans-Jordanian Arabs in the founding of Jordan helps explain why Jordan is more open to foreigners and their ideas than many other Middle Eastern states. This multiculturalism contributes to the third factor that helps to explain Jordan’s prominent role in disability rights: hospitality and openness to outsiders. Because of its location at the intersection of the Middle East, Jordan continues as a very important transportation and commerce link among states in the region. More than most other Arab states, Jordan was integrated within a sundry of empires, including those ruled from Assyria, Babylon, Egypt, Greece, Rome, Byzantium, and Persia. Centuries later, Jordan was under the control of empires ruled from Istanbul and London. Most recently, Jordan’s population has increased and diversified by a series of immigration waves from the Arabian Peninsula, Palestinians fleeing the Arab-Israeli conflict, Iraqis escaping the post-Saddam Hussein violence, and other minorities, such as the Circassians, Armenians and Druzes. This foreign influence contributed to today’s tolerance for outsiders. Part of this was due to Western missionaries who, developing “an extensive network in Mount Lebanon, the Syrian coastal plain and the Palestinian highlands, came to view Transjordan as a particularly fertile field for their activities … [who] had never encountered such a tolerant society”(Rogan, 1999, p.124). One explanation for religious toleration could also be that the Transjordanian villagers “distrusted Ottoman-run schools, fearing that once their children’s names were entered into the rolls they would be called up for military service. Consequently, Muslim and Christian parents alike preferred to send their children to missionary schools, where they received a multidisciplinary education that was widely admired” (Rogan, p.131). Another influence contributing to Jordan’s openness to foreigners is the Arab Revolt (1916-1918), which included Arabs from across the Arab world. Jordan is a creation of the Arab Revolt and, according to Dr. Naim Ajlouni, Dean at the Amman Arab University for Graduate Studies, “We like to continue promoting the ideals of the Arab Revolt and take in Arabs from all Arab countries. Our doors are open. We cannot discriminate and do not want to. Palestinians have citizenship in Jordan and we cannot discriminate against them. These are the ideals of the Arab Revolt” (personal communication, June 9, 2007). This openness is one of the reasons that Jordan has became a haven for hundreds of thousands of refugees, including more than 600,000 Iraqi refugees who arrived since the 2003 US invasion, who have contributed to the diversity and tolerance for foreign ideas and traditions. Jordan’s tolerance of foreigners is evidenced in the number of Jordanians marrying foreigners and then allowing them to take the lead on social issues. For example, King Hussein was married to Egyptian, British, and American women, while the current king is married to a Palestinian of Jordanian origin. Even in old Hashemite days, the royal family had Circassian and Turkish wives. This acceptance promotes the idea of Jordan as a melting pot of people and their ideas. The Influence of Foreign Wives Many ideas about serving the cause of people with disabilities came from foreign wives. The prominent foreign women who took leadership roles in working with people with disabilities include Queen Noor, Princess Muna, Princess Sarvath, Princess Majda, Karen Asfour, Rosemary Bdeir, and Rebecca Salti.xii Influenced by their foreign wives, the men of the royal family “got the ball going in a lot of different directions to help people with disabilities,” according to American Rebecca Salti, who married a Palestinian and has lived and worked in Jordan since 1972, including serving as Jordan Field Office Director for Save the Children from 1984-1994 (personal communication, June 15, 2005). The women working on disability issues prefer the human rights approach to various extents. Utilizing the 1992 Jordan disability law, they are able to leverage attention to help change perceptions of PWD and secure funding to promote their charities. According to Mona Abdeljawad, Middle East Regional Coordinator for the Landmine Survivors Network, the foreign wives efforts on behalf of PWD is helping make positive changes in how Jordanian society behaves toward people with disabilities, including educating Jordanians that there is diversity within the PWD community (personal communication, February 12, 2007). For example, Princess Sarvath (from Pakistan) focuses on developing schools for people with developmental disabilities, Queen Muna (Great Britain) focuses on nursing, Princess Majda (Sweden) focuses on children with physical disabilities, and Queen Noor (United States) focuses on people disabled from land mines. Princess Majda Princess Majda’s work highlights how foreigners have made a positive difference in the lives of Jordan’s disabled population. After marrying Prince Ra’ed, she arrived in the 1960s from the welfare state of Sweden, where according to her son, Prince Mir’ed, “No one needs anything because there are cradle-to-grave benefits” (personal communication, March 8, 2005). While she arrived in Jordan in 1963, her work with PWD didn’t start in earnest until the 1967 Arab-Israeli war, when she started working with Palestinians in refugee camps. According to one of her sons, “My mother comes from a privileged society in Sweden. She realized the difference and what should be done. If you don’t know the difference or how things should be it is like being born blind from birth and you don’t know what [it’s like to see]” (personal communication, March 8, 2005). Her humanitarian relief efforts eventually led to a cooperative and coordinating relationship with the Ministry of Social Development and the United Nations, both of whom were involved in providing relief to the displaced Palestinians. Based on her Swedish experience of social welfare, Princess Majda started promoting services to orphans and physically disabled children. One of Princess Majda’s humanitarian projects was helping to start the government orphanage, and then collecting money with a small informal group of women, including many foreigners who had married Jordanians, to upgrade orphanages. One of the women, Rosemary Bdeir, who is from the United States, discusses the feelings of the foreign women trying to start the orphanage for disabled children: “In the beginning we were just a small group of women. Most of us were transplants. By this I mean most of us had been born in another country other than Jordan. We had passed through the trauma of leaving our homeland and families. We had learned to live in a new country and a new culture. Our roots had taken, our children had started to grow up and we had time on our hands” (personal communication, March 3, 2005). In 1971, the women opened the Al-Hussein Society, which was one of the first in the country to provide housing, education and physical therapy for the disabled. At that time, Amman had only one facility for children with disabilities, the Cheshire Home, and it was about to close. The women continued monitoring the government orphanage in Ashruf and supplying groups of volunteers. According to Rosemary, they also continued managing their own center, which was a rented house “in Jabal Amman near the Fifth Circle” neighborhood, where many of them lived. They got a government permit to open a 15-bed boarding home with a house mother and a physical therapist. There was a waiting list of 45 children (personal communication, March 3, 2005). Subsequently, the women officially registered themselves as the Al-Hussein Society for Child Welfare. After successful registration and fundraising efforts, they realized that they needed a larger society. In 1973, an American woman, Karen Asfour, joined the group and became one of the society’s more active volunteers for the next three decades. She currently serves on the center’s board of directors and continually assists with advocacy and fundraising efforts. She credits Princess Majda with being the main impetus behind the society’s success. Karen believes that Jordan is different from other Arab states. As an American married to a Jordanian and living in Jordan for nearly five decades and one of the leading advocates for Jordan’s children with physical disabilities, she thinks Jordan is an easier place than other Arab countries for a foreigner to make a positive difference: “Jordan is [a] multicultural mix, and the royal family reflects this diversity… If you have new ideas and [are] willing to implement, you can do it here” (personal communication, February 27, 2005). Princess Majda’s work with disabled children in the orphanages was a catalyst for her husband, Prince Ra’ed, to promote the rights of the disabled. Before her intervention, people hid their disabled children, but now there is more education and awareness of disabilities in Jordan as a result of her and her husband’s work. Prince Ra’ed later became known as the “Godfather of Disabilities” in Jordan. According to Prince Ra’ed, my wife “got me involved in the blind issue, where to date we’ve provided more than 250,000 corneas. We had an eye bank in what is now the West Bank but was then part of Jordan, and after the 1967 war we moved it to Amman”(personal communication, April 17, 2005). Princess Majda explains why she got her husband involved: “[T]he teachers at the school started up a blind association and asked me to head it. It was too much for me. So I asked my husband, Prince Ra’ed. He responded that ‘I’m not a doctor; I don’t know anything about the blind.’ This was in mid-1970s, maybe late 1970s. He went to meet some blind [people] and he formed [the] Friendship Association for the Blind. We had an eye bank. He had heard that Sri Lanka had corneas so he signed an agreement and then went to Sri Lanka to get some corneas. There were times where we had corneas and eyes in the ice box. He then became head of the federation for the disabled” (personal communication, February 27, 2005). Prince Mir’ed, son of Prince Ra’ed and Princess Majda, further explains the role his mother played in getting his father involved in disability issues: “[When] my mother introduced disabilities to my father, he immediately realized it was a vast ocean of tremendous challenges because no one was doing anything about it on a national scale. He quickly realized that in his position he could have an impact on people’s lives and that he could directly positively affect people’s lives. My father always says that services for people with disabilities is not charity, it is their rights. A disabled person, he said, has a right to go to cinema, school, just like anyone else. Providing accessibility to Jordanians [is] for people with disabilities to pursue their dreams and aspirations” (personal communication, March 8, 2005). Princess Sarvath Prince Hassan, who served as Crown Prince from 1964-1999, was fresh from Oxford University having just finished an honors degree in Oriental Studies and Hebrew, when he undertook his first “hands on” involvement in public service. He personally supervised the creation of the Jordanian Palestinian refugee camps after the 1967 Arab-Israeli War. This work marked the beginning of his lifelong quest to serve and advocate for the right of all to a life of dignity and peace. The following year, in 1968, Prince Hassan married Sarvath Ikramullah, a Pakistani woman from a politically active family. Princess Sarvath remarks that: “I arrived in Jordan, a bruised and battered country, in my early 20s and soon thereafter, sometime around 1968-1969, was asked to take over the Young Muslim Women’s Association (YMWA). I agreed to lead the YMWA because I wanted to do something different than just what they were currently doing … not just the usual sewing, typing. Looking around I recognized that although Princess Majda was working for people with physical disabilities and a Swedish organization was working with the severely mentally disabled, there was nothing for the educable, mentally handicapped, either in Jordan or indeed in the region. I wanted to do something for these members of our community and decided to make this the focus of the YMWA. Jordan was reeling from the aftermath of the war and a large influx of refugees, and had little money to spare for new projects. Therefore, if something was going to be done about a new initiative I needed to find the funding myself. The ladies of YMWA and I raised $20,000 making and selling jams and jellies. I, myself, made soft toys and candles, and dozens and dozens of them. This $20,000 was then personally matched by my husband, Prince Hassan. First, the YMWA hired three local women, all regular teachers, and sent them for further education in the U.S. and Norway. Upon their return in 1974, the organization rented an apartment and started a center, the YMWA for the Handicapped, with 20 moderately handicapped pupils” (personal communication, June 14, 2007). Princess Sarvath went on to explain: “When this effort began in the late 60’s, people were skeptical; not least those who believed that the effort and resources would be better spent educating children without disabilities. Standard practice in those days was to keep these children hidden from the public eye, and therefore, the work of the YMWA included introducing new ways of thinking and acting. This socially entrepreneurial way of operating the center which included mixed gender staff working side by side and co-educational classes was not supported by some and affected the YMWA’s funding efforts” (personal communication, June 14, 2007). Yet, not to be deterred by funding challenges and resistance to new ways of thinking, Princess Sarvath kept encouraging innovative approaches to education. The center initiated multicultural instruction and vocational training, including developing more local and Arabic-sensitive materials for training teachers. A few years later, the Princess founded the Princess Sarvath Community College, also under the aegis of the YWMA, to prepare young women to enter the workforce. Princess Sarvath’s efforts to continue to bring education innovation to Jordan led her to found the Amman Baccalaureate School, which pioneered a new style of bilingual, multicultural and yet Arab education that proved to be a catalyst within Jordan and the region. Amman Baccalaureate also pioneered a community services program as part of its curriculum which included work with the handicapped and disabled. Through her involvement with these two educational institutions, Princess Sarvath discovered there was no provision within the existing educational systems for children with learning disabilities such as dyslexia. A parent with a child with learning difficulties had no choice, but to either send a child out of the country to obtain an education or hire a personal tutor. These were options only for the wealthy. As a result, the YMWA pioneered a learning disabilities program to train specialist teachers. This program included sending Jordanians to Canada for specialized inputs, not only in regard to learning disabilities, but curriculum development. These trained professionals, who included educational physiologists, were then able to not only translate, but also to culturally adapt the battery of tests necessary for the correct evaluation of these children’s problems. Hitherto, the tests were designed to relate to a Western child’s experiences. For example, Princess Sarvath wondered how many young Jordanians could answer the questions: “How much would a jar of peanut butter cost? Or, what a bowling alley was or a coin operated public telephone? These things did not exist in the Arab world twenty years ago” (personal communication, May 2, 2005). In 1995, the YMWA opened the National Centre for Learning Difficulties, which today offers both diagnostic and remedial services to pupils throughout the country. In addition to the original 9 teachers who were trained in Canada, the Centre has graduated 800 remedial teachers who are working in both Jordan and the region. In addition, the Centre regularly organizes workshops in the subject in Oman, Yemen, Syria, Lebanon and Egypt. In addition, YMWA Center for the Handicapped continued to grow and expand its services and outreach. In 1981 the Center became YMWA Centre for Special Education when it moved to a new location. It was then that it undertook the creation of a vocational center, the first in Jordan, to combine training with production. In that first year of operation, it served 18 students. Today, the Bunayat Center has a student body of 175 students from preschool through to pre-vocational training, with a long waiting list. Several students also have some degree of physical disability as well. In addition to academic and vocational training, the pupils enjoy an extensive extracurricular program that helps integrate them within the community. In addition to bussing students to and from school, and providing one hot meal daily, as well as four sets of clothes annually, the YMWA runs a program to assist the families of pupils who come from the poorest sectors of society. There is an early intervention program through which the Center’s teachers reach out to very young children with disabilities, training mothers to enhance their children’s development and give them needed support and guidance from birth. In 1987, the YMWA established a Sheltered Workshop for young mentally challenged adults in the industrial area of Jordan. The International Labor Organization (ILO) commended this Workshop as a model for the region. To further promote the productive contribution of the disabled in society, the YWMA joined efforts with the government run Vocational Training Cooperation (VTC) in 2004. Now students of the VTC are trained alongside students with special needs, thus creating a platform for integration of special needs persons within the community. Nearly 1000 young people have benefited from YWMA vocational programs and many of them have gone on to find mainstream employment. Princess Sarvath has learned from her family to never flag in the face of opposition to good causes. Asked why, she was so involved in promoting education for people with disabilities, she replied: “My brother was disabled. He had Asperger’s Syndrome, which is a form of autism. He died in 2004, at the age of 70, but was fortunate enough to have parents and a family that had the means and understanding to cope with his disability. Luckily, he was able to lead a full and productive life. As a result, we all realized very early on that a disabled person must be given the opportunity to live as part of a family and a community. Also, my family has always worked in education. My great grandfather founded one of the first international style schools in India in the 1870’s realizing even then that education would be to key to mutual understanding and respect amongst peoples. He also believed that men and women should have the right to an equal education. His daughter, my great aunt, was a graduate in the early 1900’s and herself founded two girls’ schools. My mother [Shaista Suhrawardy Ikramullah] was London University’s first Asian woman to obtain a PhD. She was Pakistan’s first woman member of Parliament in 1947, its Ambassador to Morocco [1964 to 1967], and participated in many U.N. sessions, including working with Eleanor Roosevelt in 1948 to draft the Declaration of Human Rights and the Convention Against” (personal communication, May 2, 2005). Most recently, Princess Sarvath has been involved in raising awareness of the complications caused by Phenylketonuria (PKU), a rare inherited metabolic disease which can cause mental disabilities if the conditions are not identified early, and appropriate measures taken. As a result of her lobbying, the Guthrie test that identifies this condition is now done on all newborn babies in five of Jordan’s twelve governorates to date and by the end of 2007 or early 2008 it is hoped that all newborns in the remaining seven governorates will be screened for this treatable illness (personal communication, June 14, 2007).xiii Jordan’s Humanitarian Leadership Legacy In 1981, Prince Hassan as the Crown Prince of Jordan under the late King Hussein, addressed the United Nations proposing the establishment of the New International Humanitarian Order. He advocated the urgent need to bring the expertise and experience that is usually accorded with economic and security issues to humanitarian concerns. Prince Hassan expressed his strong belief that economic growth is only valuable if it is accompanied by adequate social development. Thus, on this international stage, Jordan publicly expressed its strong commitment to promoting humanitarian goals. Therefore, becoming the first country in the Arab region to adopt disability legislation is in character with Jordan’s past statements and behaviors on humanitarian issues.xiv For example, Jordan was the third country in the Middle East to sign the 1997 Mine Ban Treaty and one of the first Arab governments to sign and ratify the 1997 Mine Ban Treaty. Jordan does not manufacture or export anti-personal landmines, and it is actively disarming thousands of mines placed on its western and northern borders. The treaty also includes legal requirements to support the economic and social integration of landmine survivors, many of whom are disabled, into society. Another example of Jordan setting the region’s standard on humanitarian issues is its behavior toward the International Criminal Court (ICC). If success is measured by the number of countries joining the ICC, countries in the Middle East and North Africa (MENA) are the most underrepresented. In October 1998, Jordan was the first Arab country to sign and ratify the Rome Statute, the treaty that established the ICC. Further highlighting Jordan’s prominent leadership role not only in the Arab region world but also internationally, Prince Zeid Ben Ra’ed, former permanent representative of Jordan to the United Nations, was selected as the president of the Assembly of States Parties, the ICC’s governing body, and Queen Raina was named as a board member of the Victims Trust Fund of the ICC.xv Jordan has also received regional recognition for its human rights leadership. The Arab Permanent Committee for Human Rights commended Jordan’s approval of the Arab Charter for Human Rights and requested that Arab countries follow Jordan’s example and endorse the charter, which needs the signatures of seven Arab countries to be put into effect. The United Nations High Commissioner for Human Rights also commended Jordan’s strides in the field of human rights, and for teaching human-rights principles in schools and universities (Jordan’s Edorsement of Arab Charter”, 2005). Therefore, Jordan’s work on disability rights is not an isolated example of its humanitarian leadership. On disability rights, Jordan has participated in all the meetings related to the U.N. Convention on the Rights of Persons with Disabilities and has been at the forefront of the 77 countries pushing “throughout the process and has fully supported the substantiation of the Convention” (Prince Ra’ed speech presented on the occasion of the 37th International Paralympic Symposium on Human Rights that took place on September 17, 2004, which was the first day of the Athens 2004 Paralympic Games). According to Mona Abdeljawad, who attended many of the UN disability rights negotiating sessions and coordinated many of the disability rights conferences in the Arab World through her work as the Middle East Regional Coordinator for the Landmine Survivors Network, “Jordan has participated in almost all the sessions headed by the general secretary of the Ministry of Social development” (personal communication, April 12, 2005). Jordan also included persons with disabilities -- Adnan Al Aboudi, Landmine Survivors Network (LSN), Jordan Office Director, and Alia Zureikat from the Higher Council of Family Affairs -- as part of their official delegations as experts. Jordan was one of the first Arab countries to include PWD on their official delegations. According to Prince Ra’ed, one of the reasons for integrating Jordan’s UN delegation with PWD is the Jordan Government’s “firm belief in the active participation of people with disabilities and their representative organizations in the drafting of this convention, and in its monitoring and implementation. There is no excuse for leaving people with disabilities outside the room as their treaty is being negotiated” (Prince Ra’ed speech). This article examines how the Jordanian royal family’s role in domestic politics helped to instigate government action to address the rights of the disabled, which eventually led to the first comprehensive Arab law to protect people with disabilities. In explaining this proposition, the article demonstrates how Jordan’s royal family affected domestic legal rules on disabilities by changing the debate from a social to a national issue and educating its people about the unlimited potential to include people with disabilities in the Jordanian nation. This article’s tentative conclusion suggests that the Jordanian disability case illustrates how Arab governments can initiate a norm and translate it into a powerful instrument with lasting influence by initiating the disabilityrights issue and then ensuring that it is placed on the national political agenda. Kenneth R. Rutherford, Ph.D., MBA, is Associate Professor of Political Science at Missouri State University. In 1993, Dr. Rutherford lost both his legs to a landmine in Somalia. He has testified before Congress and published articles in numerous academic and policy journals, including World Politics, and co-edited two books: Reframing the Agenda: The Impact of NGO and Middle Power Cooperation in International Security Policy (Greenwood Press) and Landmines and Human Security: The International Movement to Ban Landmines (State University of New York Press). He has worked for the Peace Corps (Mauritania), United Nations High Commissioner for Refugees (Senegal), and International Rescue Committee (Kenya and Somalia) and is co-founder of the Landmine Survivors Network (LSN) (www.landminesurvivors.org). LSN played a leadership role in the Nobel Peace Prize-winning coalition that spearheaded the 1997 Mine Ban Treaty, and chaired the US Campaign to Ban Landmines from 2000 to 2002. LSN also played a crucial leadership role in the treaty negotiations on the UN Convention on the Rights of Persons with Disabilities and contributed significantly to the text. In 2005, Dr. Rutherford served as a Fulbright Scholar in Jordan and was appointed to the faculty at the University of Jordan in Amman, where he researched Jordan’s leadership role in human rights. References Al Abed, M. (2005, May 20). VTC to supply Saudi Arabia with 1,000 trainers. Jordan Times, 30(8979), 3. Jordan’s endorsement of Arab charter for human rights commended. (2005, February 11-12). Jordan Times, 30(8896), 2. Jordanian Hashemite Fund for Human Development. (1999). The Jordanian Hashemite Fund for human development: Where people build the future. King in US: Jordan going ahead with reform. (2005, March 20). Jordan Times, 30(8927), 1. King calls for speedy implementation of National Strategy for People with Disabilities. (2007, February 8). Jordan Times. Rogan, E. (1999). Frontiers of the State in the Late Ottoman Empire: Transjordan, 1850-1921. New York: Cambridge University Press. Saudi delegation negotiating contracts with 500 Jordanian medics. (2005, March 6). Jordan Times, 30(8915), 3. World Bank Group. (2003). GenderStats: Database of gender statistics. Retrieved February 5, 2007, from http://devdata.worldbank.org/genderstats/ World Bank Group. (2005, September). Jordan Country Brief. World Bank Human Development Department. (2002, June 30). Note on disability issues in the Middle East and North Africa. Adolescents with Hearing Impairment: Coping with Environmental Stressors Miri Cohen Haifa University, Israel Abstract: Aims - To assess the effect of two different environmental stressors, impending tests and the threat of terror bombing attacks, on adolescents with and without hearing impairment and to compare coping strategies and psychological reactions to the stressors between the two groups. Method - Eleven adolescents with hearing impairment and 65 hearing adolescents, aged 13-15, learning at an inclusive school completed the demographic Coping Across Situation Questionnaire, the Test Anxiety Inventory, and a terror-bombing-related stress symptoms questionnaire. Results - Higher levels of test stress and terror-related stress symptoms were found in the adolescents with hearing impairment. They used more avoidant coping and less active coping than the hearing adolescents. Higher use of avoidant coping was related to higher levels of test and terror-related symptoms, internal coping was related to higher test stress only, and active coping was related to lower terror-related symptoms. Conclusions - Identifying and targeting the factors related to developing avoidant coping styles by adolescents with hearing impairment could help them to adopt more efficient coping strategies. Programs should be initiated to teach the adolescents coping strategies, such as problem solving and sharing concerns with significant others, as well as stress management skills. Key Words: hearing impairment, coping strategies, environmental stressors Introduction Research on children and adolescents with hearing impairment has tended to focus on cognitive factors, such as language acquisition, communication skills, or academic development (e.g., Luckner & Muir, 2001), or developmental factors, such as self-esteem (Jambor & Elliot, 2005), self-identity (Kent, 2003), or adjustment to the hearing society (Polat, 2003). Much less is evident in the research literature on the ways children with hearing impairment cope with environmental or developmental stressors experienced alike by all children of similar age groups. Yet, to understand developmental issues of children and adolescents with hearing impairment, this must be assessed in relation to the nature of their interaction with their environment and the nature of the stressors emanating from their environment (Garbarino & Abramowitz, 1992). Two kinds of persistent stressors were assessed in the present study. One is test stress, often referred to as test anxiety (Folkman & Lazarus, 1985; Zeidner, 1994, 1996), ever-present in students during their years of schooling and higher education. The other is stress generated by the threat of terrorist attacks, continuous in Israel for decades but recently coming to be shared by other countries. Both are major environmental stressors, but consist of different elements. Literature Review Test Stress Test stress is transient in nature, but it tends to recur before each examination period. It consists of elements such as preparation for the impending threat, confrontation with the stressor, uncertainty about the outcome, and coping with its consequences (Folkman & Lazarus, 1985; Zeidner, 1994, 1996). Past studies found that tests constitute a stressful situation that initiates anxiety (Carver & Scheier, 1994; Folkman & Lazarus, 1985; Zeidner, 1996). Test stress is as an emotional state, characterized by feelings of worry and autonomic system arousal (high pulse rate, sweating, stomachaches, irritability) (Spielberger, Gonzales, Taylor, Anton, Algaze, & Ross, 1980). A high level of stress proved to be associated with poorer performance and poorer achievement in the tests (e.g., Cassady & Johnson, 2002; Dutke & Stober, 2001). Also higher levels of test anxiety were related to perceptions of the self, such as lower sense of self-efficacy (McIlroy, Bunting & Adamson, 2000) or lower self-esteem (Sarason & Sarason, 1990) and the use of avoidant coping (Aysan, Thompson & Hamarat, 2001; Zeidner, 1994). Test stress, as far as it is known, has not so far been assessed in adolescents with hearing impairment. However, it can be hypothesized that adolescents with hearing impairment may experience lower sense of self-efficacy or self-confidence (Dessele, 1994), factors which may increase their test stress. Stress of Terrorist Attacks In contrast to the transient nature of test stress, the stress stemming from the threat of terrorist attacks is never-ending. Children and adolescents in Israel live with a constant feeling of vulnerability, namely that they or their family members could be the victims of a terror attack. They are exposed time and again, through media broadcasts and through acquaintances, to the horror of these atrocities. Several studies have demonstrated that indirect exposure to a violent attack, through knowing a person involved or through seeing it on TV may stimulate the same reaction as direct exposure to the attack, due to the intensive coverage of suffering and personal vulnerability (Pfefferbaum et al., 2001; Pynoos et al., 1987; Singer, Slovak, Frierson & York, 1998). This exposure shatters the assumption of being safe that most individuals nurture to retain (Baum & Dougall, 2002). This situation has negative effects similar to that of living in dangerous neighborhoods (Jenkins & Bell, 1997; Pynoos & Nader, 1990). The effect of continuous exposure to constant traumatic events may produce in children stress symptoms or even posttraumatic stress disorder (PTSD), including re-experiencing intrusive thoughts, avoidance, and arousal and somatic complaints such as headaches, stomachaches, fatigue, attention difficulties, or behavior problems (Barenbaum, Ruchkin & Schwab-Stone, 2004). Enduring psychological distress or PTSD can be caused in adolescents by even indirect exposure to a single violent event, such as the Oklahoma City bombing (Pfefferbaum et al., 2001) or a sniper attack on a school playground (Pynoos et al., 1987). After the World Trade Center disaster a survey of a representative sample of parents throughout the US found that 35% of children had one stress symptom or more (Schuster et al., 2001). Coping Strategies The psychological reaction to environmental stressors varies among individuals. A major factor consistently found to affect the psychological reaction is the coping strategies used. Folkman and Lazarus (1985) conceptualized coping with stressful events as the cognitive and behavioral efforts initiated by an individual to manage external or internal demands that are appraised as threatening or exceeding his or her resources. This is a transactional model, in which the coping strategies used by an individual derive from personal characteristics and resources, as well as the characteristics of the environment and of the specific stressful event, and from a cognitive appraisal of the situation (Folkman & Lazarus, 1985). Based on empirical results, Seiffge-Krenke (1993) suggests three dimensions of adolescent coping: active-external coping, by means of social resources; internal coping, which focuses on thinking about and looking for solutions, and avoidant coping, which consists of denial, repression, or fatalistic attitudes (Seiffge-Krenke, 1993). Much research centers on adolescents' coping with major life events and everyday hassles (reviewed in Compas, Connor-Smith, Saltzman, Thomsen & Wadsworth, 2001) and on how adolescents and children with hearing impairment manage the difficulties of the hearing impairment itself (Jambor & Elliott, 2005). No literature is available on adolescents' with hearing impairment coping strategies for environmental stressors. Based on Folkman and Lazarus' (1985) coping theory, it may be assumed that due to higher everyday stressors encountered by adolescents with hearing impairment (such as communication problems, strain in interactions with hearing adolescents) (Desselle, 1994; Polat, 2003; Powers, 2003; Rachford & Furth, 1986) and the complexity of handling the developmental tasks of adolescence (Hillburn, Marini & Slate,1997; Jambor & Elliot, 2005; Kent, 2003), adolescents with hearing impairment may experience lower personal resources and a lower sense of competence in managing environmental stressors. However, according to resilience theory, the reality of coping with the unique challenges of hearing impairment may equip these adolescents with more efficient skills to tackle additional environmental stressors (Masten & Coatsworth, 1998). At present we lack empirical knowledge of these issues. Gaining understanding of the ways adolescents with hearing impairment cope with environmental stressors may help in devising intervention plans to impart to them efficient coping strategies. Knowledge of this understudied issue may also qualify teachers, social workers and parents to promote efficient coping in the face of environmental stressors. Deaf Society in Israel Deaf society in Israel consists of approximately 10,000 people. Most communicate bilingually, using oral communication and sign language. Deaf people with lower education or older people tend to rely more on sign language. The deaf community in Israel has a strong deaf culture and many organized activities. Many of the more educated deaf are not part of it and their social connections are within the hearing community or in separate small peer groups. Most adolescents with hearing impairment study in the inclusive elementary and high school system. The integration of students with hearing impairment in schools is based on their abilities and their needs. Most of them learn in separate classes, using sign and oral language. They participate in social activities and join the hearing children for some classes (e.g., arts, gymnastics). Some of the adolescents with hearing impairment are integrated wholly or partially into regular classes, with special aids according to their needs. This study sets out to extend our knowledge of how adolescents with hearing impairment cope with test anxiety, which is a transient stress, and the threat of terror bombings, which is an ongoing and life-threatening stressor. Their coping strategies and their psychological reactions are compared with those of their hearing fellows. Method Participants Participants were 11 adolescents with hearing impairment and 65 hearing adolescents, aged 12-13, at an inclusive high school in Israel. The hearing impairment was either deafness or severe hearing loss. Adolescents communicated using sign and oral language. They studied in separate classes but took several other classes with the hearing adolescents. Both groups studied on the same academic level toward full accomplishment of matriculation. No statistically significant differences emerged in the two groups' demographic characteristics, presented in Table 1, which indicated a good match for further comparisons. The groups were also similar in their exposure to terror events. None of them or their family members and friends had been injured in a terror attack. Of the hearing adolescents, 21.5% (N = 14) 27.3% (N = 3) of the adolescents with hearing impairment knew someone who had been involved in a terror attack and 81.8% (N = 9) and 93.8% (N = 61) respectively watched TV broadcasts at times of a terror event. Differences were not statistically significant. Table 1: Demographic characteristics of hearing impaired and hearing adolescents Hearing impaired adolescents Hearing adolescents N % N % Gender Male 4 36.4 31 47.7 Female 7 63.6 34 42.3 Grade 7th (13-14) 6 54.5 32 49.2 8th (14-15) 5 45.4 33 50.8 Father’s employment Employed 9 81.8 60 90.9 Not employed 2 18.2 5 8.1 Mother’s employment Employed 9 81.8 57 88.1 Not employed 2 18.2 8 11.9 Age (M + SD) 13.8)0.9) 13.2(0.6) Procedure The adolescents were approached in class. The study's background and aims were explained, after which the students were asked to complete the questionnaires. None of the students refused to participate. Agreement from parents and the Ministry of Education was obtained before the beginning of the study. All students filled paper-and-pencil questionnaires, with no need for modification or sign interpretation for the adolescents with hearing impairment. The study was conducted as the year-end school exams approached; it was also a time of frequent mass terror atrocities in Israel. Questionnaires Demographic data were obtained through a questionnaire constructed for the purpose of this study, including information on age, parents' employment and parents' familial status. Terror-Related Stress Terror-related stress symptoms were assessed by a seven-item scale questionnaire, based on the five-item version adopted by Schuster et al. (2001) from the PTSD scale of the Diagnostic Interview Schedule for Children, Version IV (Shaffer, Fisher, Lucas, Duclan & Schwab-Stone, 2000). Such use of shortened PTSD screening tools was previously reported (e.g., a four-item PEDS' PTSD scale: Saylor, Cowart, Jackson, & Finch, 2003). The measure represents the three symptoms of PTSD, probing their intensity in the previous month: intrusion ("Have you been having nightmares?"), avoidance ("Have you been avoiding thinking, talking or hearing about terror attacks?"), and arousal ("Have you been feeling irritable or lost your temper?" "Do you have trouble falling asleep?" "Do you have trouble keeping your mind on things and concentrating?"). Two items on somatic symptoms (headaches and stomachaches) were added. Intensity of symptoms in the previous week was rated on a scale from 0 (none) to 5 (extreme). A global stress-reaction symptoms score was calculated, ranging from 0 to 35. The following categorization of scores was used: 0-8 = none to low; 9-17 = mild; 18-26 = moderate; 27-35 = severe. Internal consistency (Cronbach’s alpha) of the questionnaire was .88. Test Anxiety Inventory (Speilberger et al., 1980) The 20-item Hebrew version was used to assess test stress (Zeidner, 1994, 1996). The scale includes two dimensions: worry, which consists of the cognitive aspects of the stress experience (e.g., "I have constant thoughts about failing the test"), and emotionality, which refers to arousal and its consequent physiological sensations (e.g., "I have stomachaches during exams"). Answers ranged from 1 = never to 4 = most of the time. Cronbach's alpha for the internal consistency of the total questionnaire was .91, for the worry subscale .87, and for emotionality, .77. Coping Across Situations Questionnaire (Seiffge-Krenke, 1993; Shulman, Seiffge-Krenke & Samet, 1987) The 20-item Hebrew version was used. The scale consists of three dimensions: active coping (e.g., "I discuss the problem with my friends"), internal coping (e.g., "I think about the problem and try to find solutions"), and avoidant coping (e.g., "I try not to think about the problem"). The three dimensions were confirmed in the present study by factor analysis. Answers ranged from 1 = almost never to 4 = most of the time. Cronbach's alpha for the internal consistency for the total questionnaire was .89 and for the sub-scales .86, .79, and .84 respectively. Statistical Analysis Descriptive statistics and frequencies were calculated. t-tests for continuous variables and ???test for dichotomous variables were used to assess differences between the adolescents with hearing impairment and hearing adolescents. A hierarchical multiple regression analysis was performed to assess the contribution of gender, group, and coping variables to predicting test stress and terror-related stress symptoms. A Skewness test was used to assess the normality of distribution, and in spite of the small sample, a normal distribution of the variables was affirmed. . Results Test and Terror-Related Stress and Coping Strategies Table 2 presents mean scores (±sd) and t-test results of the study variables. The adolescents with hearing impairment reported experiencing significantly higher levels of test stress than hearing adolescents. These differences were evident in both dimensions of the test stress: emotionality and worry. Adolescents with hearing impairment also reported significantly higher terror-related symptoms. Again, significant differences were observed on each of the stress symptom dimensions, namely intrusion, avoidance, arousal, and somatic symptoms. Table 2: Mean (S.D.) of test stress, terror-related stress, and coping in hearing impaired and hearing adolescents Hearing impaired adolescents Hearing adolescents M SD M SD t(74) Test stress (total) 2.53 1.09 1.67 0.88 -2.63* Emotionality 2.00 1.00 1.21 0.57 -3.74*** Worry 2.70 0.93 1. 56 0.98 -2.40* Terror-related stress symptoms (total) 2.48 0.77 1.53 0.51 -5.29*** Intrusion 2.91 0.83 1.96 0.94 -3.15** Avoidance 2.50 1.23 1.42 0.75 -3.80*** Arousal 2.0 1.34 1.17 0.46 -3.85*** Somatic symptoms 2.14 1.07 1.49 0.79 -2.08* Active coping 2.04 0.63 2.95 0.57 -.2.65* Internal coping 3.15 0.79 2.88 1.19 1.17 Avoidant coping 2.86 1.00 2.32 0.87 2.43* *p<.05, **p<.01, ***p<.001 Regarding coping strategies, hearing adolescents used significantly more active coping strategies, while adolescents with hearing impairment used more avoidant coping strategies. Higher use of internal coping strategies by the adolescents with hearing impairment was evident, but this difference did not reach statistical significance. Relationship Between Test Stress and Terror-Related Stress and Coping Strategies Table 3 displays the results of the regression analyses. Test stress was predicted by group, gender, and internal and avoidant coping strategies. Namely, having a hearing impairment, being a female, and using more internal and avoidant coping were significantly related to higher test stress. Active coping was not significantly related to test stress. Terror-related symptoms were predicted by gender, group, active coping and avoidant coping. Being a female, having a hearing impairment, more use of avoidant coping, and less use of active coping were related to higher level of terror-related symptoms. Internal coping was not significantly related to stress symptoms. The dependant variables accounted for a higher percentage of the variability of terror-related stress symptoms than for that of test stress symptoms. Table 3: Hierarchical regression analyses predicting test stress and terror-related stress symptoms Test stress Terror-related stress symptoms Variable beta t p beta t p Gender -.16 2.16 .04 .26 2.41 .02 Group .24 2.10 .04 .31 3.12 .003 Active coping -.07 -.64 .52 -.22 -2.31 .03 Internal coping .28 2.44 .01 .13 1.09 .28 Avoidant coping .29 2.58 .01 .31 2.94 .005 Total R2 Adjusted R2 .30 .23 0.42 0.36 Discussion The present study assessed the psychological reaction of adolescents with hearing impairment and hearing adolescents in Israel to two environmental stressors, school tests and the threat of terror-bombing attacks. Higher levels of test stress and terror-related stress symptoms were found in the adolescents with hearing impairment; they used more avoidant coping and less active coping than the hearing adolescents. While more use of avoidant coping was related to both higher level of both test stress and terror-related symptoms, internal coping was related to higher test stress only, and active coping was related to lower terror-related symptoms. Psychological Reaction to Tests and to the Threat of Terror Stressors This is apparently the first study to examine the way adolescents with hearing impairment cope and react to both tests and to the threat of terror-attacks stressors. The adolescents with hearing impairment reacted with higher level of cognitive, physical, and emotional symptoms to the environmental stressors than did the hearing adolescents. These results can be explained by Folkman and Lazarus' coping model (1985), according to which stress reaction appears when environmental demands exceed the individual's resources. In the case of adolescents with hearing impairment, environmental stressors pile up on top of everyday hassles and demands that adolescents with no hearing impairment are spared; examples are communication problems, difficulties in academic achievement, and problems in interactions with hearing society and peers (Desselle, 1994; Polat, 2003; Powers, 2003; Rachford & Furth, 1986). Moreover, in adolescents with hearing impairment the normative crises and tasks of adolescence, such as building a sense of identity, independence and self-esteem, are more complicated and require more personal energy and resources (Hillburn, Marini & Slate,1997; Jambor & Elliot, 2005; Kent, 2003), a situation which may diminish the personal resources available for dealing with other stressful situations. Appraisal of the stressor and of personal resources to cope with it is another central element in the transactional model. Children with hearing impairment often have less information about their environment (Georgy, 1998), including the stressors they encounter, and may ask for information less. The notion that they appraise their environment differently has empirical support also (Murdock & Lybarger, 1997; Rachford & Furth, 1986). Coping Strategies Used by Hearing Impaired and Hearing Adolescents Coping strategies are a major element in the transactional model (Folkman & Lazarus, 1985). The types of coping strategies used by the individual exert a major effect on the psychological reactions to stressors. According to Seiffge-Krenke (1993), active coping combines aspects of problem-focused coping by means of social resources. Numerous previous studies found that active and problem-focused coping or seeking social support (Folkman & Lazarus, 1985; Seiffge-Krenke, 1993; Seiffge-Krenke & Stemmler, 2003) were related to better adjustment to major life events. This active coping was less used by the adolescents with hearing impairment, possibly due to their difficulties in communication, or their being less confident in their ability to ask for help or advice (Georgy, 1998; Rachford & Furth, 1986). Active coping strategies necessitate communication and social skills; several studies have suggested that children with hearing impairment possess these in a lesser degree (Martin & Bat-Chava, 2003). This problem is exacerbated for children with hearing impairment in hearing families, in which communication difficulties exist inside the family circle too (Hindley, 1997). The literature argues that effective communication with parents is highly important for psychosocial development and acquiring social skills (Desselle & Pearlmutter, 1997; Hillburn et al., 1997). Also, avoidant coping, which was used more by adolescents with hearing impairment in this study, was previously found related to worse adjustment and higher psychological distress in stressful situations (Folkman & Lazarus, 1985; Seiffge-Krenke, 1993; Seiffge-Krenke & Stemmler, 2003). Relationship of Coping Strategies and Type of Environmental Stressor Interesting facets emerged regarding the relationship between coping strategies and the stressors examined. Higher test stress was associated with more avoidant and internal coping, but not with active coping. This finding resembles findings of previous studies that assessed the association between test stress and coping strategies according to the coping models of Carver and Scheier (1994; Zeidner, 1996) or Folkman and Lazarus (1985). On the other hand, active coping was strongly related to lower terror-related symptoms, presumably due to the relief that could be found in sharing and in disclosure of emotions to others. Avoidance already proved related to worse outcomes of exposure to trauma (Bryant, Harvey, Guthrie, & Moulds, 2000). The lack of association between internal coping and stress symptoms could be due to the characteristics of the threat of terror attacks, which might be less able to be mastered by thinking, analyzing, or looking for solutions. Gender Differences in Levels of Psychological Reaction to Stressors In keeping with previous studies, girls in this study experienced higher levels of test stress and terror-related symptoms (e.g., Aysan et al., 2001; Allen, 1998). However, other studies did not support the relationship between gender and psychological distress in adolescents coping with highly stressful situations (reviewed in De Jong, 2002). Limitations Some limitations of the study should be acknowledged. Foremost is the small number of adolescents with hearing impairment. This is particularly significant as levels of stress and coping strategies varied within the group of the adolescents with hearing impairment, as seen from the standard deviation figures. This calls for caution in interpreting the results. In addition, the small number of adolescents in this group made it impossible to assess mediating or moderating factors. Identifying these mediating/moderating factors would help in the development of intervention programs to strengthen the adolescents' coping resources. Yet another limitation is that the participants were all from the same school. This limits the study results' generalizability to other adolescents with hearing impairment. However, the importance of the present study lies in its primary description of the reactions to and coping with environmental stressors by adolescents with hearing impairment. Further studies are needed to gain better understanding. For example, we should improve our grasp of gender differences in stress reactions and coping in children and adolescents with hearing impairment. Also, longitudinal studies should be conducted to understand the development and change with time in reactions to stressors. Above all, we must learn how we can help adolescents with hearing impairment in developing resilience against life's stressors. Recommendations The main conclusion from the present study is that programs should be initiated and evaluated by means of research to teach adolescents with hearing impairment coping strategies, such as problem solving and sharing concerns and anxieties with significant others (Pincus & Friedman, 2004). Additional approaches should concentrate on teaching stress-management skills that address the emotional, cognitive, and physiological aspects of stress. Examples are teaching cognitive techniques of eliciting dysfunctional thoughts and reframing them (Graham, 1998) and teaching relaxation and guided imagery (Smith & Womack, 1987). Interventions should be applied to the more severe effects of the constant threat of terror onslaughts on adolescents with hearing impairment and to implement interventions to improve coping with this situation. Stress reactions to the threat of terror are augmented by lack of sense of control (Gidron, Kaplan, Velt & Shalem, 2004). This may be mitigated in adolescents with hearing impairment through a central system of information transfer using modern technology such as internet, cellular phones or pagers. For example, during the second Lebanon war pagers were distributed to deaf individuals that gave a warning and information about alerts. Other innovative solutions should be devised. Miri Cohen, Ph.D., is a senior lecturer at the Gerontology Department and school of Social Work, faculty of Social Welfare and Health Sciences, Haifa University and is the head of the Gerontology Department. Her research is in the area of illness and disability and the relationships between stress, coping and health. References Allen, J. (1998). Of resilience, vulnerability and a woman who never lived. Child and Adolescent Psychiatric Clinics of North America, 7, 53-71. Aysan, F., Thompson, D., & Hamarat, E. (2001). Test anxiety, coping strategies, and perceived health in a group of high school students: A Turkish sample. Journal of Genetic Psychology, 162, 402-411. Barenbaum, J., Ruchkin, V., Schwab-Stone, M. (2004). The psychosocial aspects of children exposed to war: Practice and policy initiatives. Journal of Child Psychology and Psychiatry, 45, 41-62. Baum, A., & Dougall A. L. (2002). Research on terrorism: What have we learned? Understanding and predicting effects of terrorism. 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Test anxiety inventory. Palo alto, CA: Consulting Psychologists Press. Zeidner, M. (1994). Personal and contextual determinants of coping and anxiety in an evaluative situation: A prospective study. Personality and Individual Differences, 16, 899-918. Zeidner, M. (1996). How do high school children and college students cope with test situations? British Journal of Educational Psychology, 66, 115-128 REVIEWS Book Review Title: Developments in Direct Payments Authors: Janet Lee & Joanna Bornat, Eds. Publisher: Bristol, UK: The Policy Press, 2006 Cloth, ISBN – 10-1-86134-654-9, 320 pages Paper, ISBN – 13-978-1-86134-654-4, 320 pages Cost: Cloth - $85.00 USD, Paper - $39.29 USD Reviewer: Kevin Dierks Developments in Direct Payments, an edited volume from Great Britain, chronicles the experiences of people with disabilities since the passage of the 1996 Community Care Direct Payments Act. The passage of this Act is the result of the advocacy work of organizations of people with disabilities, and allows government support money to be paid directly to the intended beneficiaries, age 18-65, rather than paid directly to service providers. Thirty-four authors contributed to this work, representing researchers, healthcare professionals, social workers, parents, and people with disabilities. The editors attempted to balance the philosophy and policy of direct payments with the real experiences of recipients and frontline workers. Direct payments are basically a simple concept--government assistance funding is allocated directly to the intended beneficiaries. This concept becomes overwhelmingly complicated when it clashes head on with a legacy system that includes institutionalization, segregated care, and an extensive stream of workers and middlemen accustomed to answering to an employer other than the person with a disability. Direct payments represent a dramatic paradigm shift for all parties and this book helps the reader understand this from the perspective of the people that live it. Direct payment users are people of all ages with a variety of disabilities and labels, and there are significant differences in enrollment and outcomes for different users. Anyone wishing to learn more about the results of ten years of experience with these systems will enjoy this collection. Despite a decade of implementation it is still found that “many key stakeholders do not know about or really understand direct payments” (p.26). This fact, combined with the advocacy driven aspect of direct payments, makes this a must read for anyone purporting to support people with disabilities. For US readers there are some comparisons to similar support models on this side of the Atlantic, but there is much to be learned from the UK experiences. The first two sections present an overview of the historical context in which this legislation appeared and the challenges and opportunities in going from policy to practice. In spite of the different levels of support people need to be successful with a direct payment budget, the biggest barrier appears to be lack of information. The next three sections report the experiences and wisdom of direct payment users and professionals. The most compelling arguments for direct payments come from the direct users and frontline workers. Their stories are interesting, enraging, amazing, and ordinary all at once. A highly controversial aspect of direct payments revolves around paying existing care providers, typically family or friends, for the support they provide. This issue is explored in Chapter 13, “Careers and Direct Payments.” Section 5 presents the perspectives of the growing workforce of individuals employed by a person receiving direct payments. Studies reported in this section indicate these workers have less stress and higher job satisfaction, while at the same time having lower pay and poorer working conditions. Personal stories and quotes help shed light on this apparent contradiction. The last section deals with the future of direct payments and paints an optimistic, yet realistic view. Direct payments are currently being challenged with funding limitations and the allowable scope of personal assistance workers by existing service providers, steeped in the medical model, seeking to stop direct payment users from purchasing therapy and other services that cross the line into nursing care. Direct payments are reported as a movement, a policy, a philosophy, a social model, and most definitely a work in progress. This book provides useful information for anyone who wants to learn more about this progression. Kevin Dierks has been working professionally helping people for over 15 years. He has worked assisting and supporting people with developmental disabilities for most of this time. Through this work he has been taught many things by people with disabilities, and has developed a personal philosophy and professional approach of partnering with people to support them to find and develop their own life solutions and directions. He currently works to support innovative approaches to helping people with disabilities at the Center on Disability Studies. Book Review Title: BlindSight: Come and See Author: Jane L. Toleno Publisher: Ely, MN: Singing River, 2006 Paper, ISBN: 0-9774831-4-2, 141 pages Cost: 14.95 Reviewer: Steven E. Brown BlindSight is a fascinating book, both for its content and its presentation. The author, who, along with her twin, lost most of her sight after a premature birth in the late 1940s when physicians had not yet learned about the dangers of too much oxygen, has spent a great deal of time in reflection about her life and situation. In the first of seven chapters, all of which invite us to come along with the author’s journeys, she relays her internal thoughts to a phone friend’s queries: “Must I have this conversation again? Don’t I ever get to take time out from blindness? Why are its fingerprints found throughout my whole person, life and culture?” (p. 2). Eventually Toleno, who has clearly thought a great deal about light, dark, seeing, and not seeing, decides, “There are layers upon layers to sift and sort, name and blend here. But I think we have to talk about blindness before we can talk about light and dark” (p.4). The author takes us along a journey exploring blindness, seasons, language, disability, and wholeness. Interspersed in her thoughts, which are by turns reflective, imploring, stern, gracious, patient, and always passionate, she includes poems essaying some of her ideas. In Toleno’s essay on seasons, a poem, “After the Thaws” concludes: “We got just enough snow To get a mile off meaning a world of work! It was just enough snow To force on boots, track up floors, And blot out pointers to spring. And there is such a hush all over the world. It is clean and good and deep and right. It is so quiet. Can it be trusted? Sometimes, after love-making, it is like this, too” (p. 61). This kind of unexpected juxtaposition is a hallmark of this book. Toleno plays with words and shares concepts of DarkLight, LightDark, see-ers and other ways of turning what many of us often conveniently think of as unassailable truths about perceiving the world into limitations we have been acculturated to accept. The author’s manner of taking common “truths” and portraying their falseness is the most compelling aspect of her story and makes BlindSight a valuable addition to any disability studies or autobiographical collection. Book Review Title: Culture and Disability: Providing Culturally Competent Services Author: John H. Stone, Ed. Publisher: Sage, 2005 Paper, ISBN: 9870-7619-3084-6, 272 pp. Cost: $39.95 Reviewer: Katherine T. Ratliffe Culture and Disability: Providing Culturally Competent Services is the 21st volume in Sage Publishing’s Multicultural Aspects of Counseling and Psychotherapy series. Edited by John Stone, the book is targeted to service providers, particularly counselors and social workers who work with people with both congenital and acquired disabilities and their families. Three chapters are organized around general information about working with immigrants from diverse cultures, and seven chapters address specific information about population groups from China, Vietnam, Korea, Mexico, Dominican Republic, Haiti, and Jamaica. One of a small number of books addressing culture and disability, Stone’s edited book addresses issues around working with individuals with disabilities and their families from diverse cultures. The authors define cultural sensitivity and cultural competence, place culture in the larger context of immigration patterns and globalization trends, and provide specific suggestions for service providers. For example, in their chapter introducing the concept of disability service providers as cultural brokers, Mary Ann Jezewski and Paula Sotnik present helpful strategies to bridge gaps between different cultural perspectives. Most of the book addresses the cultural perspectives of people from the seven nations listed above. Authors of each chapter consistently address historical immigration patterns, concepts of disability, roles of family, community and religion, time orientation, and communication; and all include specific suggestions for service providers. Individuals from the cultures addressed, or closely affiliated with them, wrote each chapter, giving the work credibility. The strength of the book lies in careful attention to aspects of each culture that are meaningful to disability service providers. Case studies in each chapter ground conceptual information in commonly encountered situations. Although the book’s detailed information is helpful, it addresses only selected immigrant groups, and does not discuss other cultures served by disability service providers such as those defined by gender, sexual identity, age, socioeconomic class, religion, and disability. The book also excludes other diverse ethnic groups in the United States such as Native Americans, African Americans, and people who immigrated from Europe, Eurasia, Oceania, Africa, or South America. The book, however, is scholarly, well written, provides comprehensive coverage of the targeted populations, and could be a valuable resource for disability service providers working with the seven immigrant groups addressed. Related Books Lynch, E. W. & Hanson, M. J. (2004). Developing Cross-Cultural Competence: A Guide for Working with Children and their Families, 3rd edition. Baltimore, MD: Brookes. Royeen, M. & Crabtree, J. L. (2005). Culture in Rehabilitation: From Competency to Proficiency. Upper Saddle River, NJ: Pearson/Prentice Hall. Book Review Title: Elegy for a Disease: A Personal and Cultural History of Polio Author: Anne Finger Publisher: New York: St. Martin’s, 2006 Cloth, ISBN – 0-312-34757-x, 287 pages Cost: Cloth: $25.95 Reviewer: Steven E. Brown I always look forward to Anne Finger’s work and this was no exception. Elegy might be viewed as a memoir primarily of Finger’s early years. This would be accurate, but incomplete. The bulk of the personal narrative is a remembrance of a full, but not very happy childhood. Finger’s bout with polio and its aftermath was partly responsible for this, but so too was an abusive family situation. There are interesting parallels between the violence Finger experienced as a child with a disability in her family, as a patient in the medical system, and as a person with a disability growing up in an ableist society in the 1950s and 60s in the eastern part of the United States. The most obvious commonalities are that in all situations she was the person who was powerless. She constantly rebelled against the family and medical situations, but could do very little about either one until she chose to leave her family home during her senior year in high school. She did not rebel against social norms related to disability until much later in her life. Finger discusses the disability rights movement and disability studies and how they did and did not impact her life. Like many of us who grew up with a disability in the time period she discusses, Finger consistently and purposely did all she could to avoid even being seen with other individuals with disabilities because she did not want to be labeled in that way. Finger also threads discussions about, and the history of, polio itself throughout the book. There is quite a lot about Sister Kenney, her background, methods, and persona. There is also a fascinating section toward the end of the book in which Finger explores polio’s potential effects on the brain. She also discusses how the nature of disease itself has evolved, particularly from the nineteenth to the twentieth centuries. One result of this changing perception was that those who had polio in the twentieth century were, like many of us with varying disabilities, expected to overcome our “deficiencies.” Elegy is a book packed with personal and social information and will be an excellent addition to libraries and to graduate classes in medicine, disability studies, history, and sociology, among other disciplines. Book Review Title: Alcoholism, Drug Addiction, and the Road to Recovery; Life on the Edge Author: Barry Stimmel, M.D. Publisher: Binghamton, NY: Haworth, 2002 ISBN: 0-7890-0552-2, 414 pages Cost: $39.95 Reviewer: J. Gary Linn, Ph.D. Alcoholism, Drug Addiction, and the Road to Recovery is an extensive, scientifically based reference tool on addiction medicine which has been written both for health professionals and those in the general public who want to know more about one of the transcending health problems of our society. Following the medical model, Dr. Stimmel takes the position that drug (and alcohol) addiction is a chronic relapsing condition like hypertension or diabetes that requires sustained treatment, not incarceration. A corollary of this argument is that possession of small amounts of drugs should be decriminalized, and that persons identified as users of illegal drugs should be referred to treatment, not the criminal justice system. Dr. Stimmel's goal is to medicalize the drug (and alcohol) problem and bring the individual who is addicted or dependent into the healthcare system for professional help. In Part I of the book, readers are introduced to basic concepts of drug (and alcohol) addiction. The pervasiveness of mood altering drug use across gender, ethnic, social class, and age groups is described with appropriate data. It is concluded that due to the ubiquity of mood altering drug use in our society and the high degree of pleasure derived from these drugs, they will never be eliminated. We learn that these drugs are classified by their availability, perceived harm to the public, effects perceived by the user, action on the brain, mood-altering effects, and legitimate medical use. Perhaps one of the most enlightening chapters of this section deals with habituation, dependency, and addiction. The discussion focuses on the physiology of drug addiction. We learn that chronic use of mood altering substances results in long-term changes in the brain, which can influence bodily processes responsible for physical dependency. Also, repeated use can produce increasing tolerance to drug effects in the brain resulting in greater amounts of the drug being needed to become high. Further, physical conditioning in the memory areas of the brain can produce craving for the drug even after the person has experienced withdrawal symptoms and achieved a state of abstinence. The key point made here is that even though scientific research has clearly described the physiology of drug (and alcohol) addiction/dependency, the public and some policy makers continue to view it primarily as a moral and/or social problem that can not be effectively treated. Despite the popular perception of the futility of drug and alcohol treatment, Dr. Stimmel argues convincingly that these treatment programs have compliance and success rates equal to treatment programs addressing other chronic health conditions, and they are exceedingly cost effective. He noted that in the Drug Abuse Treatment Outcome study (DATO), which followed over ten thousand drug abusers in 100 diverse programs, drug use significantly decreased by a minimum of 50 percent from a year before treatment to a year after treatment, however, longer-term success has yet to be documented. In comparison with drug treatment, he observed that less than 30 percent of patients with asthma, adult onset diabetes, and hypertension comply with directives on dietary or behavior change. Further, less than half of insulin dependent adult diabetics and only about 30 percent of hypertensives and asthmatics take their medicines as prescribed. Finally, he noted that recurrence of symptoms is quite high, ranging from 30 to 80 percent in these groups. On cost-effectiveness, Dr. Stimmel's data summaries are even more compelling. The cost of untreated drug dependency in the United States is over $400 billion because of lost productivity, healthcare, welfare, and law enforcement expenditures. Further, contrary to popular belief, the cost of drug treatment is far less than the usual alternative of incarceration. Annual treatment costs were reported to range from $1,800 for outpatient care to $6,800 for residential long-term care centers. A year of incarceration was found to be an average expense of $25,900. In spite of these positive treatment effectiveness and cost comparisons, we are told that public funding for support services for federal treatment programs is decreasing and insurance companies are cutting back covered benefits for drug users. The final chapter of this section also includes a thoughtful and well informed comparison of the legalization of illicit drugs vs. decriminalization of the simple possession of small amounts of controlled or illicit substances. Arguing against legalization, the author states that it would send an ambiguous or mixed message to adolescents about drug use, which might lead to greater usage at a crucial stage of their development. However, he skillfully makes a case for a limited decriminalization (simple possession), which he believes will lead to a decongestion of our courts and overcrowded prison system and would result in substantial public revenue savings that could be invested in treatment and prevention. At a time in our national history when policy makers and the public comprehend the massive failure of expensive drug interdiction programs and mandatory sentencing for possession of small amounts of illicit drugs, Dr. Stimmel's argument for limited decriminalization and expanded treatment programs in place of incarceration may begin to have greater influence on legislation. Part II of Alcoholism, Drug Addiction and the Road to Recovery provides a comprehensive overview of the mood-altering drugs currently used in our society. We learn about patterns of use, costs, physical and psychological effects, dependency and withdrawal, diagnoses, interactions with other drugs, and reasons for excessive use of a wide range of illicit and controlled substances. The discussion includes alcohol, antidepressants and anti-anxiety agents, powerful hallucinogens, marijuana, opiates and opioids, heroin, amphetamines and caffeine, cocaine, nicotine, volatile solvents, anesthetics, and organic nitrates. This is extremely useful reference information for health professionals (MDs, nurses, psychologists, and social workers) who encounter patients with substance abuse issues. Further, since this section (and the book as a whole) is clearly written and without scientific jargon, it can be recommended by a healthcare professional to a patient who wants/needs to learn more about a particular addiction/dependency. Part III of the book discusses areas of special concern. This includes chapters on multiple drug use; AIDS and drug use; drugs, pregnancy and the newborn; and drugs and sports. I found the discussion of AIDS and drug use very timely. Each year in the United States, we add approximately 40,000 new HIV infections. Dr. Stimmel observes that many new infections can be attributed to high risk behavior while under the influence of drugs and/or needle sharing while "shooting up" with an individual who is HIV positive. Further, substance abuse is a barrier to participation in programs of anti-retroviral therapy. The negative implications of drug addiction/dependence for HIV transmission and treatment is, as the author concludes, another strong argument for effective and free drug prevention and treatment programs to be made to the public on demand. The author has made no special effort to look at alcoholism and drug addiction among those with disabilities probably because there are relatively few existing empirical studies in this area. Nevertheless, given the pervasive abuse of mood altering drugs in all populations in our society, I believe that it is safe to assume that most of what Dr. Stimmel reports is relevant for persons with disabilities. Also, no apparent effort has been made to make the book accessible to people with disabilities, but I still believe that it is worth its $40 price. I recommend Alcoholism, Drug Addiction, and the Road to Recovery; Life on the Edge without qualification. J. Gary Linn, Ph.D., is a professor in the School of Nursing of Tennessee State University. RDS Information Information for Advertisers The Review of Disability Studies, published by the Center on Disability Studies at the University of Hawai‘i at Manoa, invites advertisements from (a) publishers of books, films, videos, and music, (b) employers with position announcements, and (c) producers and distributors of products and services. For questions or to advertise with RDS, please email rdsj@hawaii.edu or call 808-956-5688. Why Advertise With RDS? The Review of Disability Studies is the ideal vehicle for reaching an international audience in the field of disability studies. We have and are pursuing affiliations with other major organizations in the field. Subscribers are academics, advocates, and libraries. It is a highly receptive audience for appropriately targeted advertising. 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About the Center On Disability Studies The mission of the Center on Disability Studies (CDS), at the University of Hawai‘i at Manoa, is to support the quality of life, community integration, and self- determination of all persons accomplished through training, service, research, demonstration, evaluation, and dissemination activities in Hawai‘i, the Pacific Region, and the mainland United States. The Center on Disability Studies is the umbrella for some 25 funded projects. It originated as the Hawai‘i University Affiliated Program (UAP) funded by the Administration on Developmental Disabilities of the U.S. Department of Health and Human Services. It was established in 1988 as part of a network of over 60 UAPs in the United States. It is now a University Center for Excellence in Disability Education, Research, and Service. 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N=3=, F/M=13/17, Blind=10, Physically Disabled=6, Multiply Disabled=2. Intellectually Disabled=2, and Parents=9. v Disabled people themselves do not enjoy the current educational programs on disability awareness, and they do enjoy watching regular entertainment programs. viEndnotes vi According to the World Health Organization, the international rate of disabilities ranges from 7-10%, while the World Bank estimates that the rate of disabilities for the Middle East and North Africa is 4-5%, which indicates that based on Jordan’s 2005 population there are at least 194,000 PWD in Jordan (Jordan National Strategy for People with Disabilities, announced by His Majesty King Abdullah, February 6, 2007). According to the World Bank’s Human Development Department, Middle East and North Africa Region’s June 30, 2002 “Note on Disability Issues in the Middle East and North Africa” report, the range of PWD in Jordan is 196,100 to 524,700 (Table 1, p. 4). vii The impetus for this research project occurred while I was working with the international disability rights movement at conferences at U.N. Headquarters in New York and in the Arab region, I observed that Jordanian representatives were among the most active and assertive members of the international community in developing and promoting the rights of PWD. viii The UN Convention on the Rights of Persons with Disabilities opened for signature and ratification on March 30, 2007, at United Nations Headquarters. It was signed by a record 81 countries and the European Community and 44 signed the Convention’s Optional Protocol, a mechanism to address individual violations and make country visits. ix While this article examines the role of the royal family, education and openness in the disability rights agenda setting process, which resulted in national and international attention that eventually changed its behavior regarding people with disabilities, it does not seek to evaluate the contents or effectiveness of Jordan’s implementation of disability programs. x Based on the February 18, 2007 exchange rate of 1.48 US dollars to 1 Jordanian Dinar the total people with disabilities National Strategy for People with Disabilities announced by King Abdullah II February 6, 2007 is budgeted with 92,192,043 US Dollars. xixi My own disability as a result of a land mine in Somalia, and the numerous American laws, most especially the Americans with Disabilities Act (ADA), assisted me in achieving my doctorate and a better understanding of what PWD students face around the world. xii Princess Muna was a wife of King Hussein and mother of Jordan’s current King, Abdullah II. xiii Out of 3,000 babies screened thus far, two were diagnosed with PKU. xiv Egypt and Yemen also produced special laws regarding PWD during the 1990s. xv In spring 2007, Prince Zeid Ben Ra’ed was appointed Jordan’s Ambassador to the United States. He is the eldest son of Prince Ra’ed and Princess Majda, and older brother of Prince Mi’red. --------------- ------------------------------------------------------------ --------------- ------------------------------------------------------------ 1