“FOREWORD TO THE 1993 REPRINT · (…) Published comments on the ICIDH include such remarks as : "[The ICIDH] concepts provide the key to rational management of chronic diseases" ; at the same time, however, concern has been expressed that the ICIDH does not state clearly enough the role of social and physical environment in the process of handicap and that it might be construed as encouraging "the medicalization of disablement". (The term "disablement" is used here to encompass the full range of impairment, disability, and handicap.) (…)
Some problems identified in the use of the ICIDH
An important task in the revision of the ICIDH will be to clarify the role and interrelationships of environmental factors in the definition and development of the different aspects addressed by the ICIDH, most notably - but not exclusively - handicap.
A report of the united Nations Commission on Human Rights for its Forty-third Session on Human Rights and Disability encouraged WHO to revise the ICIDH and to consider more specifically the role of the environment in the development of the handicap process.
Much work has addressed conceptual developments for this topic, notably the proposals issued by the Canadian Society for the ICIDH on the development of the handicap process.
The role of the social and physical environment is briefly addressed in the original introduction to the ICIDH (see page ]4) :
« Handicap is more problematical. The structure of the Handicap classification is radically different from all other ICD-related classifications. The items are not classified according to individuals or their attributes but rather according to the circumstances in which people with disabilities are likely to find themselves, circumstances that can be expected to place such individuals at a disadvantage in relation to their peers when viewed from the norms of society. »
This will require elaboration in the revised version. The Handicap classification is a classification of situations and not of individuals : the word « circumstances » is to be considered as referring not only to statistical aggregates of individuals, but also to characteristics of the physical and social environment. (…)
Some proposed changes to the ICIDH
(…) An "umbrella" term is needed to encompass the spectrum of experiences linked to impairment, disability, and handicap : the term "disablement" has been suggested, but is not universally accepted. In some languages there appears to be no single suitable term.
The official French-language version, for example, uses "handicap" as an umbrella term, stressing that it does not cover a monolithic reality, but is the result of different levels of experience ; this version also uses a term signifying "disadvantage" for the third level of experience in the classification (as do the Italian, Japanese, and Portuguese versions). French-speaking Canadians, on the other hand, appear to prefer the word "handicap" for this third level and do not make use of an umbrella term.
Agreement on the use of an existing term or on the introduction of a new term will require much thought and discussion during the revision of the ICIDH.
(…) The sequence underlying il1ness-related phenomena thus needs extension. This can be presented as
disease ==> impairment ==> disability ==> handicap
The nature of these different dimensions of the consequences of disease, their definition, and the basis for developing three separate classification schemes, will be considered in greater depth in the first section of this manual. (…)
[p. 14] Scope and structure of the manual
The manual contains three distinct and independent classifications, each relating to a different plane of experience consequent upon disease.
(a) Impairments (I code), concerned with abnormalities of body structure and appearance and with organ or system function) resulting from any cause ; in principle, impairments represent disturbances at the organ level.
(b) Disabilities (D code), reflecting the consequences of impairment in terms of functional performance and activity by the individual ; disabilities thus represent disturbances at the level of the person.
(c) Handicaps (H code), concerned with the disadvantages experienced by the individual as a result of impairments and disabilities ; handicaps thus reflect interaction with and adaptation to the individual’s surroundings.
Handicap is more problematical. The structure of the Handicap classification is radically different from all other ICD-related classifications. The items are not classified according to individuals or their attributes but rather according to the circumstances in which people with disabilities are likely to find themselves, circumstances that can be expected to place such individuals at a disadvantage in relation to their peers when viewed from the norms of society.
THE CONSEQUENCES OF DISEASE [p. 27]
In the context of health experience, an impairment is any loss
or abnormality of psychological, physiological, or anatomical
structure or function
Two aspects of this definition need to be stressed. First, the term "impairment" is more inclusive than "disorder’" in that it also covers losses ; e.g., the less of a leg is an impairment, but not a disorder. Secondly, in reaching agreement on terminology with other international agencies, it has been necessary to make certain modifications to the definitions included in a preliminary draft of this manual.1 In the draft, functional limitations were regarded as being elements of disability, whereas they have now been assimilated with impairments ; this alteration helps to resolve boundary distinctions that originally lacked clarity.
Impairment represents deviation from some norm in the individual’s biomedical status, and definition of its constituents is undertaken primarily by those qualified to judge physical and mental functioning according to generally accepted standards. Impairment is characterized by losses or abnormalities that may be temporary or permanent, and it includes the existence or occurrence of an anomaly, defect, or loss in a limb, organ, tissue, or other structure of the body, or a defect in a functional system or mechanism of the body, including the systems of mental function. Being concerned to describe identity at a particular point in time, impairment is neutral in regard to a number of associated features, and this needs to be stressed. Thus impairment is not contingent upon etiology, how the state arose or developed ; both ascribed and achieved status, such as genetic abnormality or the consequences of a road traffic accident, are included. Use of the term "impairment" does not necessarily indicate that disease is present or that the individual should be regarded as sick. Equally, the deviation from the norm does not need to be perceived by the impaired individual, as should be clear from what has been said above about exteriorization. On the same grounds, a concept of latent impairment constitutes a contradiction in terms - the individual exposed to or harbouring an extraneous etiological agent of disease is not impaired ; impairment ensues only when the agent has initiated a reaction by the body so that pathological processes develop.
In the context of health experience, a disability is 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
In providing the link between impairment and handicap, it is fairly easy for the concept of disability to appear somewhat vague, variab1e, or arbitrary. As already noted, however, functional limitation is now regarded as an aspect of impairment, and this should resolve most of the difficulties. Impairment is concerned with individual functions of the parts of the body ; as such it tends to be a somewhat idealistic notion, reflecting potential in abso1ute terms. Disability, on the other hand, is concerned with compound or integrated activities expected of the person or of the body as a whole, such as are represented by tasks, skills, and behaviours. (…)
In the context of health experience, a handicap is 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 cultural factors) for that individual
Three important features of this concept should be borne in mind :
(i) some value is attached to departure from a structural, functional, or performance norm, either by the individual himself or by his peers in a group to which he relates ;
(ii) the valuation is dependent on cultural norms, so that a person may be handicapped in one group and not in another - time, place, status, and role are all contributory ;
(iii) in the first instance, the valuation is usually to the disadvantage of the affected individual.
The state of being handicapped is relative to other people - hence the importance of existing societal values, which, in turn, are influenced by the institutional arrangements of society. Thus the attitudes and responses of the non-handicapped play a central role in modelling the ego concept, and defining the possibilities, of an individual who is potentially handicapped - the latter has a very limited freedom to determine or modify his own reality. In this context it is relevant to take note of differences in societal responses to visible as opposed to invisible impairments, and to serious as opposed to trivial disadvantages.
Handicap is characterized by a discordance between the individual’s performance or status and the expectations of the particular group of which he is a member. Disadvantage accrues as a result of his being unable to conform to the norms of his universe. Handicap is thus a social phenomenon, representing the social and environmental consequences for the individual stemming from the presence of impairments and disabilities. The essence of an adverse valuation by society is discrimination by other people, but the concept is, nevertheless, essentially neutral as regards its origins. Thus the individual’s own intention is of no immediate concern ; disadvantage can arise when the individual deviates in spite of his own wishes, but it can also develop when the deviation is inadvertent or the product of his own choice. The concept also assimilates phenomena such as invalidism or excessive dependence upon an institution.
Application of the concepts
(…) Although too much can be made of the importance of semantic distinctions, the acid-test for a preferred nomenclature is whether it promotes practical benefits. The latter should come about as a clearer description of processes reveals to what extent and in what way problems may be solved.
Considerable care has been applied to the selection of descriptive terms in this manual, so as to reinforce the conceptual distinctions. This effort can be seen at two levels :
(i) Avoidance of the same word to identify an impairment, a disability, and a handicap. In colloquia1 speech there has been a trend to euphemism with words being debased as mental retardation first became mental disability and then mental handicap. This succeeds only in blurring the distinctions ; the disadvantage experienced by individuals with psychological impairments can vary, so that it is inappropriate to refer to a handicap as "mental". Thus the descriptive adjectives ’’mental’’ and "physical" may correctly be applied to impairments, but their use in relation to disabilities is loose and to handicaps quite unsuitable. It is perhaps vain to hope that the tide of careless usage can be reversed, but at least in serious discourse the logic of terminology should be exploited to reinforce the conceptual framework.
ii) In addition to seeking different descriptive terms, the use of different parts of speech also seemed to be appropriate. Thus for the qualities represented by impairments an adjective derived from a substantive is apposite, but for the activities included as disabilities a participle was deemed more suitable, the "-ing" ending emphasizing the dynamic aspect. An exhaustive consistency in this regard has not been possible, but a trend should be apparent. (…)
Deviation from norms
All three of the concepts relevant to the consequences of disease
impairment, disability, and handicap - depend on deviations from norms. The amount of deviation regarded as being present depends on the operation of a definition of the norm in question, be the specification implicit or identified. There are three approaches to such definition :
(i) For quantitative phenomena, such as body height, the exploitation of statistical concepts of "the normal" and of deviations therefrom is of some help. (…)
(ii) Normative views, such as those just indicated, are detennined by reference to some ideal. This approach to the norm implicitly relates to threshold phenomena. (…)
(iii) Drawing further on the theory of deviance, yet other norms are determined by social responses. These are relevant to some disabilities and to most handicaps. In general, these norms are more difficult to categorize reproducibly, other than by recourse to cumbersome and highly arbitrary methods such as those used for determining eligibility for benefits. However, the particular relevance of social norms in the present context is that they indicate that an individual’s perceptions his belief that he has a problem - or the identity that other people attribute to the individual can both give rise to disadvantage.
IMPAIRMENT [p. 47]
In the context of health experience, an impairment is any loss or abnormality of psychological, physiological, or anatomical structure or function (Note : "Impairment" is more inclusive than "disorder" in that it covers losses - e.g., the loss of a leg is an
impairment, but not a disorder)
Impairment is characterized by losses or abnormalities that may be temporary or permanent, and that include the existence or occurrence of an anomaly, defect, or loss in a limb, organ, tissue, or other structure of the body, including the systems of mental function. Impairment. represents exteriorization of a pathological state, and in principle it reflects disturbances at the level of the organ
DISABILITY [p. 143]
In the context of health experience, a disability is any restriction or lack (resulting from an impainnent) of ability to perform an activity in the manner or within the range considered nonnal for a human being
Disability is characterized by excesses or deficiencies of customarily expected activity performance and behaviour, and these may be temporary or permanent, reversible or irreversible, and progressive or regressive. Disabilities may arise as a direct consequence of impairment or as a response by the individual, particularly psychologically, to a physical, sensory, or other impairment. Disability represents objectification of an impairment, and as such it reflects disturbances at the level of the person
Disability is concerned with abilities, in the form of composite activities and behaviours, that are generally accepted as essential components of everyday life. Examples include disturbances in behaving in an appropriate manner, in personal care (such as excretory control and the ability to wash and feed oneself), in the
performance of other activities of daily living, and in locomotor activities (such as the ability to walk)
Section 4 CLASSIFICATION OF HANDICAPS
Definition and characteristics …………………. 183
In the context of health experience, a handicap is 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
cultural factors) for that individual
Handicap is concerned with the value attached to an individual’s situation or experience when it departs from the
norm. It is characterized by a discordance between the
individual’s performance or status and the expectations of
the individual himself or of the particular group of which
he is a member. Handicap thus represents socialization of
an impairment or disability, and as such it reflects the consequences for the individual- cultural, social, economic, and environmental - that stem from the presence of impairment and disability
Disadvantage arises from failure or inability to conform to the expectations or norms of the individual’s universe. Handicap thus occurs when there is interference with the ability to sustain what might be designated as "survival roles" (see next page)
It is important to recognize that the handicap classification is neither a taxonomy of disadvantage nor a classification of individuals. Rather is it a classification of circumstances in which disabled people are likely to find themselves, circumstances that place such individuals at a disadvantage relative to their peers when viewed from the norms of society