Module: VII

Disability: Definition and classification of disability; psychosocial models of disability;

impact, needs and problems; issues related to assessment/certification of disability –
areas and measures
Definition and classification of disability:
A disability is an umbrella term, covering impairments, activity limitations, and participation
restrictions. It denotes the negative aspects of the interaction between an individual (with a
health condition), and the individual’s contextual factors (environmental and personal factors).
(WHO).
Any restriction or lack (resulting from an impairment) of ability to perform an activity in the
manner or within the range considered normal for a human being.
Activity Limitation replaces the term disability used in the 1980 version of ICIDH. Participation
restriction replaces the term handicap used in the 1980 version of ICIDH (International
Classification of Impairments, Disabilities and Handicaps).
Impairment: Any loss or abnormality of psychological, physiological or anatomical structure
or function.
Disability: Any restriction or lack (resulting from an impairment) of ability to perform an
activity in the manner or within the range considered normal for a human being.
Handicap: A disadvantage for a given individual that limits or prevents the fulfillment of a role
that is normal.
EXAMPLE:
Cindy is an 8-year-old who has extreme difficulty with reading (severe dyslexia). She has good
vision and hearing and scores well on tests of intelligence. She went to an excellent preschool
and several different special reading programs have been tried since early in kindergarten.
Impairment: While no brain injury or malformation has been identified, some impairment is
presumed to exist in how Cindy's brain puts together visual and auditory information. The
impairment may be inability to associate sounds with symbols.

Disability: In Cindy's case, the inability to read is a disability.

Handicap: Cindy already experiences a handicap as compared with other children in her class at
school, and she may fail third grade. Her condition will become more handicapping as she gets
older if an effective approach is not found to improve her reading or to teach her to compensate
for her reading difficulties
CLASSIFICATION OF DISABILITY:
Sensory Disability
Neuro Disablity
Physical Disability
Cognitive Disability
Psychiatric Disability
Visible or Invisible Disability
1. Sensory Disability:
A sensory disability affects one or more senses; sight, hearing, smell, touch, taste or spatial
awareness. Sight and hearing loss are common sensory disabilities. Often these would be
referred to as sensory impairments. A person does not have to have full loss of a sense to be
sensory impaired.

Types of sensory disabilities

Autism spectrum disorder (ASD)

Autism spectrum disorders are a lifelong developmental disability. They affect the way someone
interacts with the world around them, as well as with other people.

The effects of autism are wide ranging and can include difficulties in social interaction and
communication, restricted and repetitive interests and behaviours, and sensitivity to sensory
experiences – noise, light, touch etc. As autism can be very variable, the word ‘spectrum’
describes the range of difficulties that someone with autism may experience.

Blindness and low vision

A person is considered legally blind if they cannot see at six metres what someone with normal
vision can see at 60 metres or if their field of vision is less than 20 degrees in diameter

A person is said to have low vision when they have permanent vision loss which affects their day
to day and cannot be corrected with glasses.

Blindness and low vision can occur as a result of a number of different diseases, conditions, or
accidents. Some eye conditions are congenital (present at or near birth), while others are caused
later in life. Some specific causes of vision loss can include an injury to the eye, eye defects,
albinism, macular degeneration, diabetes, glaucoma, cataracts, and tumors.

Hearing loss and deafness

Hearing loss, also known as a hearing impairment, is the partial or total inability to hear. If
someone has very little or no hearing, the term ‘deaf’ may be used.

Damage to any part of the external, middle, or inner ear can cause hearing loss which can range
from being mild to profound.

Causes of hearing loss can be quite varied and can include problems with the bones within the
ear, damage to the cochlear nerve, exposure to noise, genetic disorders, exposure to diseases in
utero, age, trauma, and other diseases.

Sensory processing disorder

Sensory processing disorder is a condition where a person has trouble receiving and responding
to information that comes in through the senses. This may mean they misinterpret
everyday sensory information, such as touch, sound, and movement.
When someone has sensory processing disorder, they are able to sense the information, however,
the brain perceives and analyses the information in an unusual way. It may affect one sense only
or it may affect multiple senses.

Some people with sensory processing disorder are oversensitive to things in their environment.
Common sounds may be painful or overwhelming, and the feel of certain textures on the skin
may be very uncomfortable.

2. Neuro Disability:
Neuro-disability refers to the deficits or impairments an individual can experience when they
have been affected by a brain injury that can begin during the development process
(including conception, birth and periods of growth and last throughout an individual’s
lifetime)
Common conditions can include:

• Autism
• Cerebal palsy
• Downs Syndrome
• Epilepsy
• Multiple Sclerosis
• Rett syndrome
• Parkinsons Disease
• Huntington’s Disease
Brain damage can occur as a result of a wide range of injuries, illnesses, or conditions.
These can include:

• Car accidents
• Assaults
• Sports injuries
• Falls or accidents
• Poisoning
• Infection, such as encephalitis or meningitis
• Hydrocephalus (a build-up of fluid in the brain leading to increased pressure and causing
damage to the tissue)
• Hypoxia (the brain is deprived of adequate oxygen supply) from choking or drowning
• Stroke
• Heart attacks
• Tumours
• Aneurysms
• Neurological illnesses
Symptoms of neuro-disability are varied and diverse but can include:

• Paralysis or hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body)
• Co-ordination, posture and balance problems
• Sensory changes – especially anosmia (smell) and taste
 • Epilepsy fatigue
• Headaches
• Perceptual problems
• Dysphagia (swallowing problems)
• Poor nutritional status

Cognitive symptoms can include: Behavioural and emotional changes

include:
• Problems with memory and learning
• Poor attention and concentration • Irritability and anger, problems with
• Reasoning, problem-solving and aggression
decision-making difficulties • Loss of emotional control
• Poor planning and organisation • Being self-centred or childish
• Slow and inflexible thinking • Being impatient or impulsive
• Dysarthria (slurred speech) • Changes in personality
• Communication problems including • Inflexibility or stubbornness
difficulties expressing themselves or • Saying or doing things that are
understanding others inappropriate
• Less appreciation of the perspective of • Depression, anxiety or lack of
others
3. Physical Disability: motivation
• A lack of awareness

3. A person with a physical disability is constrained by his physical ability to perform an activity
independently such as walking, bathing, toileting, etc. A person can be physically disabled due to
two reasons: Congenital/Hereditary – the person has physical disability since birth or the
disability developed at a later stage due to genetic problems, problems with muscle cells or
injury during birth. Acquired – the person acquired the physical disability through road or
industrial accidents, infections such as polio or diseases and disorders such as stroke or cancer.
4. Cognitive Disability:
Cognitive disability (mental retardation) is a term used when a person has certain limitations in
mental functioning and in skills such as communicating, taking care of him or herself, and social
skills. These limitations will cause a child to learn and develop more slowly than a typical child.
Children with cognitive disabilities (mental retardation) may take longer to learn to speak, walk,
and take care of their personal needs such as dressing or eating. They are likely to have trouble
learning in school. They will learn, but it will take them longer. There may be some things they
cannot learn.
There are many signs of cognitive disabilities (mental retardation). For example, children with
cognitive disabilities (mental retardation) may:

• sit up, crawl, or walk later than other children;

• learn to talk later, or have trouble speaking,
• find it hard to remember things,
• not understand how to pay for things,
• have trouble understanding social rules,
 • have trouble seeing the consequences of their actions,
• have trouble solving problems, and/or
• have trouble thinking logically.

Cognitive disabilities" generally refers to any disability affecting mental processes. Examples
include:

• Mental retardation
• Attention-deficit hyperactivity disorder (ADHD)
• Dyslexia
• Aphasia
• Brain injury
• Language delay
• Learning disabilities
5. Psychiatric Disability:
Psychiatric disabilities cover a wide range of conditions, including eating disorders,
posttraumatic stress disorder, anxiety disorders, depression, and other psychiatric conditions.
Psychiatric disabilities are very common.
PSYCHOSOCIAL MODELS OF DISABILITY
1. THE ICF MODEL (International Classification of Functioning,Model)
An individual's functioning in a specific domain is an interaction or complex relationship
between the health condition and contextual factors (i.e. environmental and personal factors).
In the ICF, functioning and disability are multi-dimensional concepts, relating to:
The body functions and structures of people, and impairments thereof (functioning at the level
of the body);
The activities of people (functioning at the level of the individual) and the activity limitations
they experience;
The participation or involvement of people in all areas of life, and the participation restrictions
they experience (functioning of a person as a member of society);
The environmental factors which affect these experiences (and whether these factors are
facilitators or barriers).

The ICF conceptualizes a person's level of functioning as a dynamic interaction between her or
his health conditions, environmental factors, and personal factors. It is a biopsychosocial model
of disability, based on an integration of the social and medical models of disability.
ICF components:

Body functions - The physiological functions of body systems (including psychological

functions).

Body structures - Anatomical parts of the body such as organs, limbs and their components.

Impairments - Problems in body function and structure such as significant deviation or loss.
Impairments of structure can involve an anomaly, defect, loss or other significant deviation in
body structures. Impairments can be temporary or permanent; progressive, regressive or static;
intermittent or continuous

Activity - The execution of a task or action by an individual.

Participation - Involvement in a life situation.

Activity limitations - Difficulties an individual may have in executing activities.

Participation restrictions - Problems an individual may experience in involvement in life

situations.

The component can be used to denote activities (a) or participation (p) or both. The domains of
this component are qualified by the two qualifiers of performance and capacity.

The performance qualifier describes what an individual does in his or her current environment.,
performance can also be understood as "involvement in a life situation" or "the lived experience"
of people in the actual context in which they live.

The capacity qualifier describes an individual’s ability to execute a task or an action. This
construct aims to indicate the highest probable level of functioning that a person may reach in a
given domain at a given moment. To assess the full ability of the individual, one would need to
have a “standardized” environment to neutralize the varying impact of different environments

Contextual Factors represent the complete background of an individual’s life and living. They
include two components: Environmental Factors and Personal Factors – which may have an
impact on the individual with a health condition and that individual’s health and health-related
state.

Environmental factors make up the physical, social and attitudinal environment in which
people live and conduct their lives. These factors are external to individuals and can have a
positive or negative influence on the individual’s performance as a member of society, on the
individual’s capacity to execute actions or tasks, or on the individual’s body function or
structure.

Personal factors are the particular background of an individual’s life and living, and comprise
features of the individual that are not part of a health condition or health states. These factors
may include gender, race, age, other health conditions, fitness, lifestyle, habits, upbringing,
coping styles, social background, education, profession, past and current experience (past life
events and concurrent events), overall behaviour pattern and character style, individual
psychological assets and other characteristics, all or any of which may play a role in disability at
any level. Personal factors are not classified in ICF. However, they are included in Fig. 1 to show
their contribution, which may have an impact on the outcome of various interventions.

Environmental factors are organized in the classification to focus on two different levels:

(b) Individual – in the immediate environment of the individual, including settings such as home,
workplace and school. Included at this level are the physical and material features of the
environment that an individual comes face to face with, as well as direct contact with others
such as family, acquaintances, peers and strangers
(c) Societal – formal and informal social structures, services and overarching approaches or
systems in the community or society that have an impact on individuals. This level includes
organizations and services related to the work environment, community activities,
government agencies, communication and transportation services, and informal social
networks as well as laws, regulations, formal and informal rules, attitudes and ideologies.

Functioning- An umbrella term for body function, body structures, activities and participation. It
denotes the positive or neutral aspects of the interaction between a person’s health condition(s)
and that individual’s contextual factors (environmental and personal factors).

Disability-- It is an umbrella term for impairments, activity limitations and participation

restrictions. It denotes the negative aspects of the interaction between a person’s health
condition(s) and that individual’s contextual factors (environmental and personal factors).

2. THE NAGI MODEL:

This model was given by Saad Nagi.
The Nagi Disablement Model was adopted as means to describe how a disease or pathology
results in impairment, functional limitations, and disability, and how this may vary across
individuals. He recognized the importance of the environment and that family, society, and
community factors could all influence disability.

3. MEDICAL MODEL: Disability as a disease

The Medical Model holds that disability results from an individual person’s physical or mental
limitations, and is largely unconnected to the social or geographical environments. It is
sometimes referred to as the Biological-Inferiority or Functional-Limitation Model. Disability is
seen as a shortcoming, linked to the individual, that requires correction or accommodation.
4 SOCIAL MODEL: socially constructed phenomenon
According to the social model (sometimes also referred to as the minority model), it is society
‘which disables people with impairments, and therefore any meaningful solution must be
directed at societal change rather than individual adjustment and rehabilitation’

6. MORAL MODEL: DISABLITY AS AN ACT OF GOD

The moral/religious model of disability is the oldest model of disability and is found in a
number of religious traditions, including the Judeo-Christian tradition). According to one of
the primary forms of moral and/or religious models of disability, disability should be
regarded as a punishment from God for a particular sin or sins that may have been committed
by the person with disability.

7. THE CHARITY MODEL: DISABILITY AS VICTIMHOOD

According to the charity model, PWDs are victims of circumstance who should be pitied.
The Charity Model sees people with disabilities as victims of their impairment. Their
 situation is tragic, and they are suffering’. Able-bodied people should therefore assist PWDs
in whatever way possible, as ‘they need special services, special institutions, etc., because
they are different. In contrast with the moral and/or religious model of disability, which has a
largely negative view of PWDs, the charity model seeks to act to the benefit of PWDs,
encouraging ‘humane treatment of persons with disabilities. Many people in the disability
community regard the charity model in a very negative light. The model is often seen as
depicting PWDs as helpless, depressed and dependent on other people for care and
protection, contributing to the preservation of harmful stereotypes and misconceptions about
PWDs
8. THE IDENTITY MODEL: DISABILITY AS AN IDENTITY
This model shares the social model understands that the experience of disability is socially
constructed, but differs to the extent that it ‘claims disability as a positive identity. Brewer et
al. (2012) offer the following illuminating definition, which also explains how the identity
model departs from the social model’s approach
Under the identity model, disability is a marker of membership in a minority identity, much
like gender or race . . . Under an identity model, disability is primarily defined by a certain
type of experience in the world – a social and political experience of the effects of a social
system not designed with disabled people in mind . . . While the identity model owes much to
the social model, it is less interested in the ways environments, policies, and institutions
disable people, and more interested in forging a positive definition of disability identity based
on experiences and circumstances that have created a recognizable minority group called
‘people with disabilities’
9. THE HUMAN RIGHTS MODEL: DISABILITY AS A HUMAN RIGHTS ISSUE
The human rights model incorporates both first and second generation human rights, in the
sense that ‘it encompasses both sets of human rights, civil and political as well as economic,
social and cultural rights’. The human rights model recognizes the fact that properly
formulated prevention policy may be regarded as an instance of human rights protection for
PWDs.

10. THE ECONOMIC MODEL: DISABILITY AS A CHALLENGE TO

PRODUCTIVITY
The economic model of disability approaches disability from the viewpoint of economic
analysis, focusing on ‘the various disabling effects of impairment on a person’s capabilities,
and in particular on labor and employment capabilities’ While the economic model insists on
the importance of ‘respect, accommodations, and civil rights to people with disabilities’, such
concerns are subservient to the economic model’s estimation of a disabled person’s ability to
work and contribute to the economy.
The economic model of disability has been criticized for framing disability almost
exclusively in terms of a cost– benefit analysis, neglecting to take other important factors
into account. Such an economic focus may contribute to the dehumanization of the person
with disability as someone who is somehow ‘missing parts’
11. THE LIMITS MODEL: DISABILITY AS EMBODIED EXPERIENCE
According to the limits model, it is important that people accept the fact that all human
beings experience some level of limitation in their everyday lives. Moreover, such limits are
experienced to varying degrees during all the phases of our life. Rather than being something
foreign to human experience, limits are as a matter of fact ‘a common, indeed quite
 unsurprising, aspect of being human’ .Indeed, Creamer prefers to utilize the neologism
‘limit-ness’ – as opposed to the terms ‘limitation’ or ‘limitedness’ – in order to emphasize
that ‘human limits need not (and perhaps ought not) be seen as negative or as something that
is not or that cannot be done’, but rather as ‘an important part of being human’. Furthermore,
as people experience ‘various formations’ of embodiment, ‘disabled embodiment’ is one of
those formations of embodiment.

CERTIFICATION OF DISABILITY
Measurement of Disability for mental illness
The assessment tools have already been existed for the visually impaired, hearing impaired and
orthopedic handicap and persons with mental retardation. These people are certified by the
authentic body and become eligible by having disability certificates to avail the benefits under
the PWD Act 1995. But there was no assessment tools for the certification of mentally ill people
and yet these people are not availed any benefits even as disabled. Looking that perspective and
to justify these people rehabilitation committee of Indian Psychiatric Society has developed the
assessment tool for disability certification in 2002. This tool is known as Indian Disability
Evaluation and Assessment Scale in short IDEAS. This IDEA has opened new horizon for
mentally ill people. This committee has developed clear guideline to make use of it very easy.
General Guidelines: IDEAS are suited best for the purpose of measuring and certifying
Disability, It is therefore a brief and simple instrument, which can be used, even in busy clinical
settings. Some training is required in the use of IDEAS. This is to be used only on out patients
and those living in the community. Not appropriate for in- patients. Rating should be done only
based on interviews of the Primary Care Givers. Case records and patients interviews can be
used to supplement information. Only in rare instances when no primary care giver is available
should be the rating is based only on patient interview. This should then be documented. The
gender specification “he” has been used for convenience and refers to both genders. Patients with
only the following diagnosis as per ICD or DSM criteria are eligible for disability benefits:
Schizophrenia, Bipolar Disorder, Dementia, and Obsessive Compulsive Disorder. Duration of
illness: The total duration of illness should be least two years. For the purpose of scoring, the
number of months the patients was symptomatic in the last two years (MI 2Y –months of illness
in the last two years) should be determined.
Only the Psychiatrist can do diagnosis and certification. Trained social workers, psychologist, or
occupational therapists can do administration of IDEAS. Psychiatric Disability will be reassessed
every two years and re-certified. The feasibility of doing this in the rural areas will however have
to be examined. Items in IDEAS:
Self-care: Includes taking care of body hygiene, grooming, and health including bathing,
toileting, eating and taking care of one’s health.
Interpersonal Activities (Social Relationship): Includes initiating and maintaining interactions
with others in a contextual and socially appropriate manner.
Communication and Understanding: Includes communication and conversation with others by
producing and comprehending spoken/ written/ nonverbal messages.
Work: Three areas are Employment/ House work/ Education measures any one aspect. 1-
Performing in Work/ Job: Performing in work / employment (paid) employment / self-
employment family concern or otherwise. Measures ability to perform tasks at employment
completely and efficiently and in proper time. Includes seeking employment. 2- Performing in
Housework: Maintaining household including cooking, caring for other people at home, taking
care of belongings etc. Measures ability to take responsibility for and perform household tasks
completely and efficiently and in proper time. 3- Performing in school / college: measures
performance in education related tasks.
Scoring: 0 – No Disability,
1 – Mild Disability
2 – Moderate Disability
3 – Serve Disability,
4 – Profound Disability.
Total Score (range 0-20). Percentage: For the purpose of welfare benefits, 40% will be cut off
point. The scores above 40% have been categorized as Moderate, Severe, and profound based on
the Global disability score. This grading will be used to measures change overtime. 0-No
disability = 0% , 1-7 – Mild Disability = < 40%, 8 and above = > 40%, (8-13 moderate disability;
14- 19 Severe Disability; 20 Profound Disability)

Criterion validity was established by comparing IDEAS with SAPD (Schedule for the
Assessment of Psychiatric Disability) which has been standardized in India. IDEAS can be used
only for evaluation of four mental illnesses:
1. Schizophrenia
2. Bipolar Affective Disorder
3. Obsessive Compulsive Disorder
4. Dementia

ADPMR scale: Assessment of Disability in Persons with Mental Retardation.

ASSESSMENT OF DISABILITY IN PERSONS WITH MENTAL RETARDATION (ADPMR)
IQ as a measure of disability is not appropriate and conceptually it is quite different (Flynn 1991;
ICF 2001).Based on IQ there is no clear guideline to assess the percentage of disability in mental
retardation and it cannot be used in multiple disability seen in many cases of MR. Also it takes
clinical psychologists who are too few to measure IQ. In view of these constraints ADPMR scale
was developed as a unified scale keeping in view certification purposes laid down by the
Government of India. It is a 5 point anchored rating scale that can be completed in a short time
(about 10 minutes) in most setups. It takes into account adaptive functioning too. It can be
administered by professionals, health workers, special teachers etc. It gives numerical disability
score as well as in percentage. This scale needs some training before it can be administered and
=40% disability is required to get concession and benefits.