UNIT II Concepts and Theory

Types and causes of Impairment

"Although there is clearly a biological difference between the disabled and the
able-bodied, this is not the decisive difference between the two groups. Handicap
is a social construct. There is a biological sub-stratum, but what it means to be
handicapped to others and to oneself is overwhelmingly social and decisively
political" (Roth, 1983, p. 56). Knowledge about impairments and disabilities is
important to understand. The World Health Organization (WHO) suggested the
following definitions in 1980:

Impairment: a loss or abnormality of psychological, physiological, or anatomical

structure or function.

Disability: any restriction or lack (resulting from an impairment) of the 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, resulting from an impairment or

a disability, that limits or prevents the fulfilment of a role that is normal
(depending on age, sex, and social and culture factors) for that individual.

Impairments and disabilities may be temporary or permanent, reversible or

irreversible, and progressive or regressive. The situation people find themselves
in, may determine to what degree a disability is handicapping for them. It is
evident from the definitions above that a handicap is the result both of an
impairment and of environmental conditions. If environmental barriers are taken
away, the person will still be impaired, but not necessarily handicapped. It should
also be noted that the definition of disability as distinct from handicap is not
without problems, in particular the formulation "considered normal for a human
being", and many people with disabilities do not distinguish their use.

The functional ability of people who are diagnosed as having the same
impairment or disability may vary widely. For example, some people who are
legally blind may be able to utilize differences in light intensity, while others are
unable to perceive such differences. People who have clinically similar hearing
impairments, as shown on audiograms, may use quite different aspects of the
acoustic information available to them. The degree of handicap may vary
significantly and may be specific to certain situations.

In this brief review of impairment and disability, differences in degree are dealt
with only in a very general manner. The emphasis is on typical features rather
than variations. However, when assessing the needs of a single individual,
variation that may influence the handicapping effects of the condition must be
taken into account.

1.0 Visual Impairment

In medical terms, visual impairment can be defined as a total loss of, or reduced
ability to, perceive light and colour. The classic definition of blindness is a visual
acuity of 6/60 or less in the better eye with optimum correction, or visual acuity
of better than 6/60 if the widest diameter of field of vision subtends an angle no
larger than 20 degrees. Blindness implies a total or near total loss of the ability to
perceive form. Partial sight implies an ability to utilize some aspects of visual
perception, but with a great dependency on information from other modalities, in
particular touch and hearing. Reduced vision may handicap a person in situations
which put great demands on the use of vision, but in most situations the person
will not be handicapped by the visual impairment.

2.0 Hearing Impairment

Hearing impairment implies a total or partial loss of the ability to perceive

acoustic information. The impairment may affect the full range of hearing, or be
limited to only parts of the auditory spectrum, which for speech perception is the
region between 250 and 4000 Hz.

The term deaf is used to describe people with profound hearing losses while hard
of hearing is used for those with mild to severe hearing losses. Hearing loss is
expressed in decibel (Db) relative to an audiometric cero which is a standardized
normal threshold of hearing. Deafness is usually defined as an average hearing
loss of more than 92 Db in the speech area. A person with a hearing loss of 70-
90 Db is severely hard of hearing. A person with a hearing loss of 50-60 Db is
considered moderately hard of hearing (Davis, 1970). Measured losses of less
than 20 Db is considered normal acuity.

3.0 Impairment of Speech Production

Speech impairment refers to any reduction in a person's ability to use speech in a

functional and intelligible way. The impairment may influence speech in a
general way, or only certain aspects of it, such as fluency or voice volume. Speech
impairment may be due to a number of different factors. It may or may not be
linked with difficulties in speech perception or comprehension. Speech
impairment may be caused by developmental problems as in the case of moderate
to severe developmental language disorder (dysphasia), or by distorted speech
due to lack of muscular control (dysarthria). It may be an acquired impairment,
for example loss of expressive language skills (expressive aphasia) caused by a
stroke or brain tumour, or speech impairment after removal of the larynx
(laryngectomy). Acquired disorders are more prevalent with advancing age.

4.0 Impairment of Language Comprehension

This category contains a loss of, or a reduction in, the ability to understand
language. The disability may imply only an impairment of language, or it may be
associated with a more general intellectual impairment.

Several disorders of the central nervous system may include impairment of

language comprehension. Impaired language comprehension may be
developmental or acquired. In developmental disorders, the impairment of
comprehension will also have consequences for the ability of people to express
themselves. In some acquired conditions, it is mainly comprehension that is
affected while the people are able to express themselves. Aphasia, a language
disorder caused by stroke or trauma, may affect language comprehension and/or
use.

5.0 Intellectual Impairment

People with reduced intellectual ability constitute a very diverse group with a
range of sensory, motor and cognitive impairments; most impairments, including
visual and auditory impairment, have a higher incidence in the group that is called
intellectually impaired. One common trait is that they tend to do things slower
than other people, another that they have reduced comprehension of instructions
and language in general.

6.0 Reading Impairment

Dyslexia is a disorder manifested by difficulty in learning to read despite

conventional instruction, adequate intelligence, and socio-cultural opportunity. It
is dependent on fundamental cognitive disabilities, which are frequently of
constitutional origin. The reading impairment may or may not be associated with
other language disorders, such as developmental dysphasia and anarthria due to
cerebral palsy. Severe reading disorder may also be an acquired condition similar
to aphasia, and is then usually called alexia.

7.0 Reduced Function of Legs and Feet

A reduced function of legs and feet implies dependency on a wheelchair or other

mobility aid to help walking (e.g. crutch or stick). In general, a wheelchair user
is dependent on an even surface without any significant change of elevation. The
maximum abrupt change of level to be managed by somebody driving the
wheelchair himself is about 2.5-3 centimeters. Some users may manage an
uneven road surface, but it will be most unpleasant, and the wheelchair may break
down.

8.0 Reduced Function of Arms and Hands

Reduced function of arms and hands includes the lack of arms or hands, or
reduced ability to use them due to reduced strength or co-ordination. For a person
who lacks both arms, or the functional use of both arms, activities related to
moving, turning or pressing objects are often impossible, or may have to be
replaced by other methods, for example, a mouth stick. This does not influence
speech communication itself, but implies great difficulty in using a wide range of
technical and non-technical equipment.

A person who lacks one arm or who has lost the ability to use one arm in a
functional way, will typically be handicapped in manipulating equipment that
demands the simultaneous use of both hands. This includes a large range of
equipment, and especially the simultaneous pressing of two or three keys on
computer or terminal keyboards.

9.0 Impairment of Growth

Impairment of growth primarily includes adults who are significantly shorter than
the population mean. This condition is typically caused by malfunctioning of the
hormone system. In general, shortness adversely influences one's access to
equipment. Installations that are positioned high up may be difficult to use unless
some form of step is provided. Short people also tend to have short arms, which
makes manipulation of some types of equipment awkward or difficult.

10.0 Other Impairments and Disabilities

The above categories cover a wide range of impairments and disabilities. There
are, however, individuals who do not readily fit into any of these categories. For
instance, people who have to spend most of their time in bed cannot readily be
included in the category of wheelchair-dependent users. Their lack of mobility is
a significant difference in function, and it is necessary to consider the possible
problems this more special situation of being bedridden creates. British studies
indicate that at any given time, 0.5 percent of the population are in bed for a
limited period, due to disease or accident. This is only one example of a common
temporary disability.

Some people have multiple impairments; for example, combined visual and
hearing impairment, or hearing impairment and problems in controlling the
movement of their arms and hands. People with intellectual impairment typically
have several impairments. Within the scope of the present chapter, it has not been
possible to discuss such multiple impairments.

Factors That May Cause Impairment

The table below lists factors that could contribute to the causes of impairment of
an individual.

CATEGORY COMMON FACTORS CONTIBUTING TO IMPAIRMENT

 Alcohol (acute
Chemical intoxication, chronic Prescription drug use (side-
substance use abuse) effects of normal dose, effects
 Non-prescription drug of excessive use, acute
use. overdose).

 Unfamiliarity with
organisational structure,  Lack of motivation
work environment, or  Lack of training (basic /
Competence
work practices and refresher training not
issues
procedures. provided, inappropriate
 Loss of competence (skill recruitment / selection,
erosion, lack of refresher etc).
training, etc.)

May be secondary to physical overexertion or associated with

emotional stress, includes:

 Increasing job
 Environmental factors responsibilities
Fatigue (thermal factors, light /  Prolonged travelling to /
(physical / glare, noise, etc) from work
mental)  Shift work (night shifts,  Frequent and / or
inappropriate shift excessive sports or
frequency / rotation) recreational activities
 Excessive physical or  Social activities
intellectual workload.  Sleep deprivation
 Pregnant
 Gradual process injuries (e.g.
Acute traumatic injuries (e.g. tendon inflammation, lower
Injuries (work lacerations, fractures, burns, back pain, nerve entrapments,
and non-work head injuries, sprains / strains, overuse conditions etc).
related) acute contact dermatitis, etc)

 Stress associated with

personal relationship Secondary or tertiary
Non-work- issues employment; training / study
 Health issues of family / commitments etc.
related stress
friends
 Financial difficulties

 Minor infections and

 Blood-borne viral
other recurring
infections (e.g. Hepatitis
conditions
Physical illness B or C, HIV, etc)
 Chronic illness (e.g.
 Major acute illness
diabetes, asthma,
Pregnancy
epilepsy, arthritis, etc).

 Acute anxiety disorders /  Personality disorders

situational disturbances  Cognitive impairment
Mental Health  Depressive disorders not secondary to
disorders  Acute psychotic intoxication from
disorders chemical substances.

Stress associated with:

 Rate of change within Multi-skilling

organisation
 Employment contract
 Restructuring /
Work-related issues
redundancy
stress  Industrial relations
 Increasing or changing
issues
responsibilities
 Work relationship issues
 Shift-work and / or long
working hours.

Realms of impairment

(1) the realm of attachment (i.e., problems with distrust and suspiciousness,
perspective taking, boundary setting, social isolation, difficulty attuning to the
emotional state of another);
(2) the realm of biology (i.e., problems with somatization, sensorimotor
development, and an increase in medical problems across a wide span which
might include pelvic pain, skin problems, pseudo seizures, autoimmune
disorders, and asthma);

(3) the realm of affect regulation (i.e., difficulty being aware of internal states or
describing them, problems communicating needs and wishes, difficulty putting
labels on feelings and expressing them, trouble with emotional self-regulation;

(4) the realm of dissociation (i.e., alterations in states of consciousness that are
distinct, depersonalization, derealization, two or more distinct states of
consciousness, impaired memory of state-based events, amnesia);

(5) the realm of behavior control (i.e., self-destructive behavior, poor modulation
of impulses, aggression tendencies toward others, sleep disturbances, self-
soothing behaviors that are pathological, eating disorders, excessive compliance,
substance abuse, difficulties understanding and then complying with rules,
trauma reenactment in behavior or play);

(6) the realm of cognition (i.e., problems with the processing of new information,
difficulty focusing on and completing tasks, trouble with object constancy,
challenges with sustained curiosity, difficulty with attention regulation, problems
with planning/anticipating, difficulty understanding responsibility, problems
with language development, learning difficulties);

(7) the realm of self-concept (i.e., a poor sense of separateness, low self-esteem,
lack of a continuous and predictable sense of self, disturbances of body image,
struggles with guilt and shame).