Federal Approaches to Disability
United States legislation and policy has created upwards of sixty-seven definitions of “disability,” including variations in the term such as “handicap,” “disabled person,” and “individual with a disability.” There are overlaps among definitions, and some legislation uses more than one definition. For example, the Americans with Disabilities Act (ADA) (ADA, 1990) recognizes multiple dimensions of
31 C. E. Drum et al. / Californian Journal of Health Promotion 2005, Volume 3, Issue 3, 29-42 disability including pathology/impairment and functional and social role limitations. Under the ADA, a person with a disability is defined as an individual who: (a) has a physical or mental impairment that substantially limits at least one “major life activity,” or (b) has a record of such an impairment, or (c) is regarded as having such an impairment (29 U.S.C. 705). Examples of “major life activities” range from breathing, caring for one’s self, walking, seeing, hearing, and speaking to learning, working, and participating in daily community living.
Functional approaches to disability are present in a number of programs in the United States. For example, Section 223(d)(1) of the Social Security Act defines disability as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” The Act makes clear that it is the inability to engage in employment that creates a disability, not the presence of medically determinable physical or mental impairments.
On the other hand, using a medical model to establish eligibility for governmental services is usually considered efficient. In general, categorical assessments can be reproduced consistently and fairly simply in determining program or entitlement eligibility (Drum, 2004). One example of a program using a medical model is state Vocational Rehabilitation programs for people who are blind. The programs provide assistance in obtaining and retaining a job. Eligibility for these services is limited to people who are “legally blind.” Legal blindness refers to clinically measured visual acuity with correction that is 20/200 or less in the better eye, or where the visual field has contracted so that the widest diameter is 20 degrees or less (American Federation for the Blind, n.d.).
Integrated Approaches to Disability
A number of contemporary approaches combine medical, functional, and social approaches to disability. Consistent with this viewpoint, the Institute of Medicine disseminated its 1991 report, Disability in America, incorporating the terminology and well-regarded framework for understanding disability devised by sociologist Saad Nagi in the 1950s. In this report, disability is described as a process rather than as a static condition (Pope & Tarlov, 1991). The disabling process is conceptualized as consisting of four major dimensions: pathophysiology (“active pathology” for Nagi), impairment, functional limitation, and disability.
The National Center for Medical Rehabilitation Research (NCMRR) further expanded the notion of the disabling process by inserting an additional dimension of societal limitations. These are defined as a “restriction, attributable to social policy or barriers (structural or attitudinal), which limits fulfillment of roles or denies access to services and opportunities that are associated with full participation in society” (USDHHS, 1993).
The modified Nagi model is a disabling process model that illustrates the convergence of underlying intra personal factors with extra-personal factors of the physical, social, and cultural environment. The added dimension of societal limitations focuses attention on environmental barriers that contribute to the disabling process. The modified Nagi model illustrates the importance of the interaction effects between individual capacities and flexibility of the environment to express those capacities. The ability to assess functional status in a particular environmental context is essential for promoting the health and well-being of people.