Section Three
Module 10: Social and Systemic Factors in Health, Development, Disability, and Diverse Abilities
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How does society shape our clients’ health and abilities?
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After working with the material in this module, readers will be able to
describe the World Health Organization’s model of structural determinants of health equity for groups; name the U.S. Department of Health and Human Services’ five domains of social determinants of health for individuals, and provide an example from each domain; name several Adverse Childhood Experiences (ACEs); and compare the similarities and differences among these three models
explain the basic features of the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) as a model of a person’s or a group’s ability or inability to complete life activities; explain a social model of disability; and explain the importance of considering the needs of each individual separately
define ableism and discuss its implications for speech-language pathology
This module addresses several systemic, structural, social, and individual variables that are known to affect people’s lives, health, and quality of life. Module 11, later, considers similar issues for the area of education, especially the public schools. Regardless of your work setting, both of these modules might lead you to think about the many interacting elements that affect communities, healthcare, education, and individuals and therefore affect our clinical and professional practice in speech-language pathology.
Structural Determinants of Health Equity for Groups
Start by thinking about any subgroup or community of people to which you belong. Are you a White woman? Are you a Spanish-speaking ballet dancer in the Chicago area? Are you shorter than most other adults?
Now try imagining some extreme political and economic structures that would limit life opportunities for you and everyone else like you, within a larger set of circumstances that allows most other people to live freely and happily.
People like you are not allowed to hold elected office or even to vote, while everyone else in your larger society is allowed to vote and to seek elected office.
People like you might be allowed to earn daily wages for simple physical labor, but imagine that laws prevent you from applying for better-paying jobs, opening bank accounts, owning land, or owning houses.
Everyone in your subgroup is required to live in certain areas or neighborhoods, and the stores and other businesses in the larger society can legally refuse to work with people like you or can provide you with only limited options.
The children in your subgroup are not entitled to the publicly funded education that children in the larger society receive.
The larger society’s medical and emergency personnel are not required to assist people like you or to help in your neighborhoods.
Sounds terrible, doesn’t it? Imagine, as well, that the other people in the larger society find this overall situation to be reasonable; they feel no political, economic, social, ethical, or other incentive to change the systems that control the lives of your subgroup.
On the whole, would physical and mental health and overall well-being be equivalent for your subgroup, as compared with the other people in the larger society?
Of course not.
As the World Health Organization (WHO) addresses, health equity for groups of people around the world begins with large-scale structural determinants that include their political and macroeconomic contexts (Solar & Irwin, 2010; see Box 10.1). Not being allowed to vote, or not being allowed to have a bank account, does not cause illness as directly as a virus causes illness, but these meta- or macro-level features of living situations do establish possibilities and limitations for entire groups of people. The overall structure of every society, at full-scale political and economic levels, results in sets of circumstances that ultimately lead to predictable health outcomes for groups of people.
In their conceptual model of population-level health inequities, therefore, the WHO Commission on Social Determinants of Health (CSDH; Solar & Irwin, 2010) emphasized that thinking about health outcomes for people around the world begins with thinking about how political and macroeconomic realities shape other factors and circumstances for groups of people, as shown in the combination of Boxes 10.1 and 10.2.
Box 10.1. Summary of the Population Level Health Determinants Model, from the World Health Organization’s Commission on Social Determinants of Health (CSDH; Solar & Irwin, 2010)
Two initial categories of Structural Determinants of Population-Level Health, and one “emergent” category, create baseline health opportunities for a population and for its major subgroups.
> Political factors (political, military, or civic divisions)
> Macroeconomic factors (effects of the political, regional, or societal economy)
> Emergent socioeconomic factors (subdivisions that emerge based on occupation, gender, etc.)
The population-level structural determinants then influence the health of subgroups, and ultimately influence the personal health of individuals, through four categories of Intermediary Factors.
> Material circumstances (housing, work environments, clothing, food)
> Psychosocial stressors or supports (relationships with people in the community, at work, and at home)
> Behavioral and biological factors (nutrition, physical activity, alcohol, drugs)
> Healthcare systems (accessibility of professional assistance)
Box 10.2. Considering the Intermediary Factors of the Population Level Health Determinants Model, from the World Health Organization’s Commission on Social Determinants of Health (CSDH; Solar & Irwin, 2010): Structural determinants of group-level health inequities cause health outcomes for subgroups and ultimately for individuals through the intermediary factors.
Material Circumstances
Any group’s primary political, primary macroeconomic, and secondary emergent socioeconomic factors influence or limit that group’s material circumstances, including with respect to availability and quality of housing (e.g., structural soundness, protection from weather, the availability of water, and sanitation), clothing, and food, as well as the physical quality of work environments. The group’s material circumstances, in turn, affect the health of the individuals in the group: a group living with lower quality housing, clothing, and food will have less safe and less healthy lives, as a group and as individuals, as compared with people who have the political and macroeconomic ability to live and work in safe places with enough food and clean water.
Psychosocial Stressors and Behavioral and Biological Factors
Again, imagine knowing that everyone in your group is prevented from voting, accessing education, or owning property. Individuals will make different decisions and will react differently, but many members of groups living under such conditions are known to feel psychological stress; known to have biological responses such as high blood pressure; and known to use options like tobacco, alcohol, or other drugs as coping mechanisms. Psychosocial, behavioral, and biological factors are also affected by the material circumstances of the group’s situation; food scarcity can lead not only to poor nutrition but also to group-level competition for food and then overall combativeness, which can itself become a psychosocial stressor for the group.
The Health System Itself
The fourth set of intermediary factors in the WHO CSDH model (at the bottom of Box 10.1) is the health system itself, which will be less available or less useful to groups living under problematic large-scale political or macroeconomic limitations. Think globally: There are areas of the world without established or complete healthcare systems available to all people in the area. The resulting lack of consistent healthcare leads, predictably, to poorer health outcomes for groups, differentially for some subgroups, and ultimately for the individuals in those groups.
One important detail to notice, as we discuss the WHO CSDH model, is its emphasis on the influence of population- or group-level health statuses and inequities. The WHO addresses health issues for countries, regions, and population-level groups, on a global scale. As clinicians, we often think of health as a characteristic of individual people, but worldwide public-health models emphasize that groups of people who live under similar circumstances tend to share a group-level health profile (i.e., tend to occupy similar parts of continua such as nutrition or cardiovascular health and their complications, because they occupy similar parts of the underlying material, biological, psychosocial, and healthcare-systems continua). The overall point of the WHO’s CSDH model is that the macro-level structures influence the groups, meaning that groups and subgroups of people will have predictable group-level health tendencies or characteristics.
Your Turn
Think about several groups of people in your geographic area who live under different physical and mental health conditions as groups. Depending on where you live, examples might include people in certain neighborhoods of your city, people living on Native American reservation land, people living in a rural area outside of town, unhoused people downtown, immigrants from a certain area of the world, people with a certain religious background, people who work in a particular industry or type of profession, or other groups. Compare the largescale political and macroeconomic circumstances for these groups, and compare the groups, using the WHO’s four intermediary factors (use Boxes 10.1 and 10.2).
Social Determinants of Health for Individuals
Now go ahead and shift your thinking from groups to individuals.
What if you, as the individual that you are, fell into circumstances that required you to live alone, in an unheated tent, downstream from a poorly managed chemical plant, and downwind from an uncontained industrial incinerator? Your macro-level political circumstances and your geographic region have not changed, and you have your education and your skills and would like to work, but you as an individual do not have a car, a bus pass, a phone, or a shower. Would you be able to find and keep a job? Might you be relatively likely to develop respiratory problems, skin problems, or nutritional problems, and also relatively unlikely to have access to the doctors and medications you would need? Would you have the time and the resources to be engaging in safe and emotionally fulfilling recreational activities with friends? Would you be saving for retirement or anticipating being able to live comfortably in your old age?
What if, instead of living alone in a tent, you lived in a small apartment with your children in a neighborhood that was not only downstream from the chemical plant and downwind from the incinerator but also had crowded and poorly funded schools, no hospital, no full-size grocery store, and no fire department? Think about the range of neighborhoods that you might have experienced personally or that, depending on your journeys so far in your life, you might have only seen in news reports from areas stricken by war, natural disaster, or other extreme problems. Would your daily life, and the life you could be preparing your children for, be physically healthy and emotionally stable if your streets were barricaded and parts of your apartment complex were falling down around you? Or would the worries associated with making it through one more day be all you could manage, with little room for any sense of relief or progress?
What if you lived with or near the loving family or friends you have chosen to spend your time with? What if you also had steady employment in a career you find meaningful? Your community has well-supported school systems, hospital systems, parks, libraries, shopping, and transportation options. Your home is well built, in a safe area, with reliable electricity, safe water, and clean air. If you needed help, you would not hesitate to call your police department, your fire department, or your neighbors, and if you needed help with medical concerns you could probably see a healthcare provider the same day. No one’s life is perfect, but do you see that the social and environmental influences on your health would be a little different here than they were in the first two scenarios?
These examples demonstrate the issues known as the social determinants of health, which refers to the social and environmental factors known to affect the health, functioning, and quality of life of individual people (see Box 10.3.). Most sources, including the U.S. Department of Health and Human Services, recognize five domains of the social determinants of health for individuals. (Notice as you read Box 10.3 that they are similar to the intermediary factors described for groups by the WHO.)
Box 10.3. The Five Domains of the Social Determinants of Health for Individuals, as Described by the U.S. Department of Health and Human Services
Economic Stability
Employment opportunities, and the economic situations of individuals who have limited abilities to work (i.e., children, the elderly, and people with a range of physical, neurological, cognitive, or social-emotional abilities)
Education Access and Quality
Ability to attend high-quality schools from early childhood through high school graduation, and subsequent access to professional training or further education
Healthcare Access and Quality
Access to care itself, access to health insurance or other financial support for healthcare, support for timely and routine follow-ups with healthcare providers, and stable access to longterm support for chronic conditions
Neighborhood and Built Environment
Higher or lower levels of violence, polluted air, unsafe water, and other physical health and safety risks or supports in housing and in daily life
Social and Community Context
Relationships and interactions with family, friends, co-workers, and community members
Comparing and Combining the World Health Organization’s CSDH Model and the U.S. Department of Health and Human Services Social Determinants of Health
Did you notice as you read about the social determinants of health (in Box 10.3) that some of them can be interpreted as affecting either groups or individuals? The two models differ in their emphases, but the difference between the WHO’s CSDH model of structural determinants of health equity and the U.S. Department of Health and Human Services model of social determinants of health is not that one applies only to groups and the other applies only to individuals. The difference is that the WHO’s role and mission is to emphasize population-level groups, while the Department of Health and Human Services emphasizes the factors that affect individuals’ health and quality of life.
Notice also that the social determinants of health model does not assert that problems with any one or more of these factors are necessarily insurmountable. In fact, almost everyone has lived at one time or another with some of the problems listed in Box 10.3. (some level of economic instability, some problems in educational access or quality, or some difficulties in social support systems). As client-centered professionals, however, we need to be aware that groups and individuals who live with more, more severe, or more consistent problems within any one or more of the social determinants of health are known to have predictably lower physical and mental health outcomes as compared with groups and individuals who live in more positive economic, educational, healthcare, neighborhood, and social environments.
Even more importantly, in the U.S., we need to understand that potentially negative social determinants of health are not distributed randomly or equally.
The facts of current U.S. society are such that all available data make it abundantly clear that some groups and subgroups of people are disproportionately affected by the negative features of the social determinants of health (see Singh et al., 2017, for one comprehensive review). Specifically, members of those racial, ethnic, religious, or other culturally identifiable groups that have tended to be marginalized in the U.S., and people with some individual identities (including having mental illness, being gay or transgender, or having a physical disability), are much more likely to have lived in situations characterized by negative social determinants of health than are people whose backgrounds are closer to reflecting the combination of identities that Morgan (1996) placed at the top of her figure: White, educated, Christian, able-bodied, monolingual speakers of English, in stable financial situations.
Our attempts as speech-language pathologists to provide appropriate services to “all populations” need to take all of these issues into account, because they affect our abilities to meet our basic ethical and professional goal of providing effective, efficient, high-quality services to all clients. Political and macroeconomic structures, the WHO’s intermediary factors for group-level health outcomes, and the social determinants of health for individuals have all influenced our own health, our default views of health conditions and health-related behaviors, our beliefs about what is possible or desirable for which individuals or groups and why, the physical and mental health of our clients and colleagues, and our clients’ and potential clients’ abilities to access and benefit from our care. It’s a lot to think about.
Your Turn
In a distinctly circular way, your reactions to reading about the social determinants of health will have been influenced by your experiences with the social determinants of health. Has your journey so far in your life led you to be painfully aware, or maybe proudly aware, of how difficult it is for people to do well in school or at a job when several of the social determinants of health have combined to create obstacles for them? Or did you realize as you read the list that you have spent most of your life feeling relatively financially stable, with supportive relationships, in a physically safe community, and with access to education and to healthcare? Whatever your journey has been, try discussing your life or your extended family’s experiences with someone whose experiences have differed from yours in terms of the five social determinants of health. Be kind to yourself and to each other, as you listen to each other’s experiences. How can we learn from our own journeys and from each other’s? How can an awareness of the social determinants of health help you, as the clinician you are and on the journey you are on, to provide even better services to your clients?
Use our basic models from Module 2 to think about the social determinants of health: group-based dimensions, individual continua often perceived as identities, and the 16 Questions matrix. The WHO’s political and macroeconomic structures, the WHO’s intermediary factors for group-level health outcomes, and the U.S. Department of Health and Human Services’ social determinants of health all exist along continua (from greater to lesser political safety, environmental safety, access to education, etc.). Where do your experiences fall on those continua? What will you need to recognize, respect, and respond to, including about who or where you are from and who or what you are for, to be able to work with people whose experiences have been to either side of yours on those continua?)
For one thoughtful example from speech-language pathology of the influence of social determinants of health, listen to this ASHA Voices Podcast about a pediatric dysphagia team who made some important client-centered changes to their programs.
Adverse Childhood Experiences
A third and related model addresses the importance of adverse childhood experiences (ACEs; Center for Disease Control and Prevention, 2022), which can affect people’s lifelong health and well-being (Felitti, 1998). Like the social determinants of health model, the ACE model focuses primarily on the health and well-being of individuals, not population-level groups, while also providing important insights into health and well-being for groups of people.
(Tread carefully here, or even skip to the Your Turn questions or to the next module, if you need to; ACEs include straightforwardly traumatic topics such as the sexual abuse of children, and ACEs are common enough that many of you reading this section will have been personally affected by these issues.)
In general, ACEs include and refer to potentially traumatic social or interpersonal events that occur in childhood and that influence children’s lifelong development, achievements, and overall physical and mental health. ACEs are often divided into two or more categories, as shown in Box 10.4; some categories are combined or separated in some descriptions. Regardless of the number of categories used, all sources agree that ACEs include physical, sexual, or emotional abuse of the child; physical or emotional neglect of the child; family and household conditions; and other personal or community-based adversities.
Box 10.4. Adverse Childhood Experiences (ACEs): Potentially Traumatic Social or Interpersonal Events that Occur in Childhood and Influence Children’s Lifelong Development
Abuse or Neglect
abuse: any physical, sexual, or emotional action, or a failure to act, which results in harm or risk of imminent harm to a child, or any sexual exploitation of a child
neglect: the failure of an adult who is responsible for a child to provide for that child’s basic needs
Personal, Family, Household, and Community Conditions
divorce or separation of the child’s parents or other divisions of the people the child lives with
imprisonment, physical illness, mental illness, or death of a parent or other caregiver
living with, or routine interactions with, adults who have alcohol or drug problems
having a family member attempt suicide or die by suicide
surviving or witnessing interpersonal violence inside or outside the home, including elder abuse, violence outside the home, violence in the community, and/or gang-related activity
surviving or witnessing criminal activity inside or outside the home, often overlapping with other ACEs and including observing or being the victim of vandalism, theft, illegal drug use, and/or gang-related activity
bullying or social or emotional exclusion or abuse at school or from other children, especially about the child’s racial or ethnic background or another immutable personal identity (e.g., gay or transgender children or adolescents; and children with physical, cognitive, or other disabilities)
Abuse and neglect are among the most extreme of the ACEs and are known to cause long-term physical, emotional, and other traumas and difficulties, in many ways and for many reasons. The other categories or types of ACEs include a wide range of possibilities, some of which might not be as overtly problematic for children as abuse or neglect. Regardless of the degree of the problem, though, these household and community conditions are all known to negatively influence many children’s development, abilities, opportunities, and even lifelong physical and mental health.
Comparing Adverse Childhood Experiences and the Social Determinants of Health
You might have noticed, as you read Box 10.4, that many of the ACEs seemed similar to the social determinants of health. You are correct; they are.
One important difference, however, is that children often have less agency or ability than some adults might have under some circumstances to understand, control, remove themselves from, or manage the effects of a problematic situation. This is not to say that adults can control all of the social determinants of health that influence them; quite the opposite. The ACE model simply recognizes, in a reasonable and realistic way, that all children are vulnerable, deserving of consistent loving care, and influenced in lifelong ways by what they experience as children.
As we also mentioned for the social determinants of health, it is also important to be aware that no single ACE will necessarily cause irreparable harm in any given child, depending on the positive support systems and other circumstances that the child or the family has in place. Individual-, family-, and community-level protective factors can and do help, as we will address elsewhere (see Section Five). Nevertheless, the long-term stress placed on children who are living with multiple ACEs is undeniable, well researched, and well established.
Living with severe or multiple ACEs harms children’s nervous, endocrine, and immune systems (Stark et al. 2015); affects their developing attention, behavior, decision-making, learning, and emotional abilities (National Center for Injury Prevention and Control, 2019); and leads to what many authors refer to as long-term trauma for the children (see later parts of this module).
Living with severe or multiple ACEs increases children’s risk of becoming engaged in violence or illegal drug use themselves as adolescents or young adults, undermines their sense that life should be safe and stable, and ultimately reduces their long-term potential for jobs and earnings – a situation that can lead to other problems as a child grows up and then lead to the recurrence of similar ACEs in the next generations.
The ACEs are even clearly linked to the development of chronic disease and to multiple causes of early death in adulthood (Felitti et al., 1998).
It is also critical for us to be aware, as we also mentioned for the social determinants of health, that the ACEs interact with culture and identity in ways that are not obligatory from the model or objectively necessary but that are nevertheless known to be true in the U.S. There is no inherent reason, for example, that children from any particular racial or ethnic group should necessarily experience any more imprisonment of parents, alcoholism in the home, or negative interactions with community members than children from any other racial or ethnic group experience. In the U.S., however, many types of data show us conclusively that children from those racial, ethnic, religious, or other culturally identifiable groups that we might call “traditionally marginalized,” and children and adolescents with some individual identities (including having mental illness, being gay or transgender, or having a physical disability) are disproportionately affected by multiple ACEs, usually for complex historical, sociological, and systemic reasons. Within these groups, existing social and economic conditions also tend to compound the combined effects of the multiple ACEs that children live with (see Singh et al., 2017, for one comprehensive review).
Thus, while we are aware that ACEs can influence all children’s or any child’s physical and mental health and educational achievement in many ways, we are also aware that, in practice in the U.S., ACEs tend to affect some children more severely and tend to interact with children’s other cultural, identity-based, linguistic, and other background variables. We as speech-language pathologists must take these multiple overlapping and mutually dynamic influences into account, if we seek to recognize, respect, and respond to the needs of our clients, colleagues, and communities.
Your Turn
Many of the social determinants of health are phrased neutrally or positively, using such terms as economic stability and educational access. Lists of adverse child experiences (ACEs), in contrast, are distinctly negative, referring to illness, neglect, suicide, bullying, and other problems. To compare the two sets of constructs and their larger implications for children’s lives, try mapping several negative ACEs (from Box 10.4) onto one or more of the social determinants of health (from Box 10.3), thinking broadly about all the ways that any given ACE or combination of ACEs would influence a child. Imprisonment of a parent, for example, from the ACE list, maps onto the social determinant social and community context (relationships) and also onto economic stability, because the parent cannot work while incarcerated; the result is often that the family needs to move to less expensive housing or even loses their housing (reducing the quality of the child’s neighborhood and built environment and potentially affecting their access to quality education). Notice how the ACEs can affect more than one – or even all – of the child’s social determinants of health.
The U.S. Centers for Disease Control and Prevention addresses ACEs under the umbrella of violence prevention. Consider that classification. What is your definition of “violence” against a child? Why does it make sense to classify preventing all of the ACEs as preventing violence?
Combine the definitions of prejudices and discrimination (from Module 9) with the constructs we are discussing here in Module 10: the structural determinants of health equity for groups, the social determinants of health, and the available data about health equity for groups in the U.S. that we might described as “traditionally marginalized.” How do you think these constructs and outcomes have influenced each other through time?
Abilities, Diverse Abilities, and Disability
One final group of people deserves our attention, as we think about the systemic and social factors that can affect people’s health, healthcare, health-related quality of life, and overall quality of life: those who live with physical, mental, cognitive, emotional, or other abilities or needs that have variously been termed disabilities, handicaps, challenges, special needs, divergent abilities, or different abilities, among other terms.
What do these words mean, and how can an individual trait like a physical or neurocognitive difference from many other people somehow become a systemically or socially limiting factor for an entire group of people?
Three approaches to defining “disability” are directly relevant here, starting with the World Health Organization’s “biopsychosocial” approach.
The WHO’s International Classification of Functioning, Disability, and Health
The World Health Organization’s International Classification of Functioning, Disability, and Health (ICF; WHO, 2001) addresses differences among individuals and groups by beginning with the idea of a physical and/or mental impairment, defined as a problem with the structure or function of the human body. If I had broken my hand, was dealing with an acute stomach virus, or was too anxious to focus on preparing my dinner, the ICF would describe those physical or mental states as impairments.
If my impairment led to my being unable to do something I used to do, wanted to do, and/or needed to do, then the ICF would describe me as having one or both of two types of functional limitations: activity restrictions, defined as inabilities in or problems with “functioning at the level of the individual,” and participation restrictions, defined as related to “functioning...as a member of society.”
Impairments, activity restrictions, and participation restrictions can be short term or long term; I will hope for myself in my hypothetical examples that my broken hand and my stomach virus are short term. If my impairments, activity restrictions, and/or participation restrictions are longer-term, however (perhaps chronic arthritis such that I could not hold pan handles or spatulas, ongoing digestive tract complications, or a neurocognitive or emotional characteristic that made it difficult for me to cooperate with too many other people in the kitchen or to shop in a busy grocery store), then the ICF would describe me as having a disability, which is the ICF’s umbrella term for the “negative aspects” of the dynamic interactions that occur between and among a person’s health, the personal factors of their life, and the environmental factors of their life.
The ICF model, in other words, is a bio - psycho - social model of functioning, created and intended to combine the biological, the psychological, and the sociological elements of any one person’s life. The tripartite emphasis of the model, and its focus on function in context, are both important: arthritis would be problematic because my fingers would not move through their entire range of motion and because they would hurt (biological), but arthritis would also annoy me, prevent me from holding pans, prevent me from cooking for myself, interfere with my ability to enjoy my husband’s company as we cook dinner together, and interfere with my ability to drive myself to my job and then complete my assigned tasks at work (activity restrictions and participation restrictions, and problems in the psychological, social, and vocational realms).
The ICF’s biopsychosocial model is almost universally used in all aspects of healthcare, and ASHA’s (2016) Scope of Practice for Speech-Language Pathology includes it and refers to it as part of how we practice speech-language pathology. Indeed, you are probably familiar with its emphasis that we must address not only our clients’ anatomical structures and basic physiological functioning but also their desires and abilities in the contexts created by their unique personal and environmental circumstances. It is a well-respected and at least reasonable framework for healthcare practice – but let’s also spend a moment questioning some of its assumptions, as part of our attempts to think about groups, cultures, differences, and client-centered care.
Social Models of Disability
Think about an adolescent who had a leg amputated as a child, uses a prosthetic leg, takes the bus to school, works at a fast-food restaurant on the weekends, has friends, and describes his life as basically pretty good.
Or think about a professor who was born with cerebral palsy, uses a wheelchair, goes to her job at a college campus, cooks meals with her partner, and finds her life happy and fulfilling.
Or imagine a successful accountant who is aware that she is good at focusing on details, can keep herself occupied for long periods of time with the repetitive tasks that define her job, and is good at avoiding unproductive conversations. She has been told by various professionals that she has autism, should learn to engage in small talk, and should learn to be more flexible in her thinking, but she is genuinely fine with herself and with her life. She might even embrace the descriptor “neurodivergent” as pride language for herself, or she might take pleasure in being part of what she would describe as a “neurodiverse” community.
Do any of these three people have “disabilities”?
It is important to recognize that in many ways they do not. The structure and function of their bodies, including the third person’s neurocognitive or neuropsychological functioning, differ from the structure and function of many other bodies, but their characteristics of structure and function are not negative or problematic for them. All human bodies, including human brains, differ from each other, in infinite ways, along many continua (as we emphasized in Module 2). We notice some of our differences, but we are not aware of many other differences (as we discussed for the unnoticed dialectal differences that surround us constantly; see Module 7). The fact that your body and your brain differ from mine does not give either of us a disability, just as the fact that your dialect differs from mine does not give either of us a language disorder.
How and why, then, would any “negative aspects” arise in the interactions among the structure and function of a person’s body, the personal factors of their life, and the environmental factors of their life? The ICF model starts with the structure or function of the body, and then secondarily recognizes the influence of other factors, but a different view of disability might actually start with society itself.
What does that mean? How can society create disability?
Imagine that I with my two biological legs and no complaints was happily going about my day but then could not get into my workplace’s building because the door was blocked. I would be unable to enter my workplace. Why? Would we say that the problem started with my body, because I have structural and functional limitations that prevent me from flying up to the second floor or scaling the brick wall to enter through a window?
No.
We would say that the precipitating factor here, the cause of the problem I am now facing, and the only cause of my inability, lack of ability, non-ability, or dis-ability to enter the building, is that some persons, policies, or procedures at my workplace had allowed a situation to occur in which the building interferes with my otherwise perfectly intact, reasonable, complete, and functional ability to enter buildings.
The social model of disability applies the same reasoning to all people trying to complete all personal, interpersonal, and community activities. If a person with one biological leg, a wheelchair, and no complaints was happily going about her day but then could not get into her workplace’s building because the ramp had been removed or blocked, or could get inside but not up to her office because the building had stairs but no elevators, the problem would not be that her body differs physically from bodies that have two legs. Her only problem would be that some persons, policies, or procedures at her workplace had allowed a situation to arise in which the building interfered with her otherwise perfectly intact, reasonable, complete, and functional ability to enter buildings.
A social model of disability differs from the ICF’s emphasis on the body as the ultimate source of the problem, in other words, and also builds from the constructs we have been emphasizing throughout this website. We are each defined by our unique combination of placements on a range of descriptive continua, and we each belong to many groups, sub-groups, and intersecting groups (again, see Module 2). One of the primary tenets of client-centered, culturally and individually appropriate speech-language pathology is that all of the many places along those many continua, including continua about human bodies and about human neurocognitive or neuroemotional functioning, are to be equally valued.
But human societies also include many assumptions, stereotypes, and prejudices about bodies; about people’s physical, neurocognitive, or neuropsychological functioning; about what is “normal”; and about what is “necessary” or “desirable” for whom. Some of these assumptions constitute ableism: the stereotypes, behaviors, and social policies that create or allow discrimination against some people on the basis of their physical, mental, neurocognitive, or neuropsychological characteristics or identities (as we described in Module 9; discrimination refers to living with an unfair, unearned, and unnecessary disadvantage).
The parallels between the word “ableism” and older words including “racism” and “sexism” were intentional. The word ableism was coined in approximately 1980 (Oxford English Dictionary, 2024) specifically to draw attention to the similarities. Moreover, one of the more influential versions of a social model of disability was developed by a group that used explicitly political arguments and terminology: they called themselves the Union of Physically Impaired Against Segregation (UPIAS; see Shakespeare, 2013) to emphasize that the structure of society causes “segregation” (i.e., separation; see Module 1) and its attendant discrimination for some people.
Have you noticed that social models of disability reflect several of the issues raised by the structural and social determinants of health and health equity, by our consideration of civil rights in Module 3, and by our main themes of attempting to envisage and to practice culturally and individually appropriate speech-language pathology? As we think about how we will choose to practice, thinking about abilities and ableism leads us to think about how we can recognize, respect, and respond to the wide range that exists among human bodies (including brains); to think about the many ways in which most human activities can be completed; to remember that most of those ways are perfectly acceptable alternatives to each other; and, in the social contexts emphasized in this module, to do our best to think clearly about the societal and systemic factors that create, influence, define, and often limit an individual’s abilities, opportunities, and successes.
A Person-Centered View of Ability, Disability, and Diverse Abilities
A third and critically important view of human abilities, finally, asks a question that medically focused, biopsychosocial, and even social models of disability are often accused of forgetting to consider: What is the person feeling?
Social models of disability, in particular, emphasize that the physical difference is not, in itself, the source of the problems or limitations the person faces. In other situations, however, some structural and functional traits of human bodies actually are, in and of themselves, physically and emotionally painful in ways that are not related to society and that do directly cause in-abilities or dis-abilities. Communities of people with chronic physical pain or physiological limitations, for example (now including large and increasing numbers of people living with Long COVID), have actually been among the most vocal in arguing against an overly narrow focus on social or systemic causes of disability, because such a focus can easily become a prejudice and then discrimination against persons who are, in fact, limited and/or bothered by the structures or functions of their bodies (again, recall the definitions of discrimination, in terms of unwarranted group-level disadvantage, from Module 9). Their point is that we cannot allow the truth that some people are dis-abled by societal structures to overwrite the co-existing truth that some people are dis-abled by the current structure or function of their bodies.
How to reconcile these competing medical, physical, psychological, social, societal, and political views is an almost unanswerable question, for many of us, because for many of us the answer is “it depends.” A third and useful view of abilities, diverse abilities, inabilities, and disabilities, therefore, might help us find an answer by returning us to the individual at the center of the conversation, and upon whom it depends: How are you doing in your world? Do you need anything? (And if so: Can I help?)
Disabilities rights activists and many other groups have long used “Nothing about us without us” as a memorable and meaningful slogan (Charlton, 2000; see Module 4) that is usually invoked at the level of groups or policy. The idea also applies in many ways as we think about the personal and societal abilities, and the personal and societal limitations, that individual people live with. Many of the frameworks addressed throughout this website seek to balance our professional responsibilities and actions with the many ways that we might view the importance, perceptions, conditions, characteristics, and needs of other people. The answers for the groups, cultures, identities, and individuals created by the wide range of human bodies, human neuropsychological states, and human neurocognitive traits might therefore be the same as the answers we are emphasizing for all other groups, cultures, identities, and individuals:
Be aware that characteristics and conditions exist along continua;
Be aware of the distinctions among your assumptions, the facts in front of you, and your interpretations of those facts;
Ask people how they are doing in their world;
Believe and respect their answers;
Respond in appropriate ways that fit our clients’ and our colleagues’ worlds, lives, needs, and requests, not in ways that stem only from our own journeys, assumptions, or even prejudices.
Once again: It’s a lot to think about. You are doing some good work, here.
Your Turn
Try going back to the examples from the beginning of this module about living under political, environmental, or social circumstances that limited you, while the people around you were not bothered by the fact that you were limited. Can you draw parallels in your mind to the experiences of people with a range of physical, mental, neurocognitive, neuropsychological, or emotional traits, characteristics, or abilities? Is it ever reasonable or not reasonable for any group or subgroup of people to be treated as “able” or “unable” to live in a certain way, as a group or as individuals? Have you become familiar with the recent emphases on such terms as “neurodiversity” and the implication of those terms for the changes we seek to make with clients? How do your answers to these questions influence the way you practice speech-language pathology?
Speech-language pathology has a long history of accepting some abilities in the realms of speech, language, and hearing while defining other abilities as disorders (as we will address in Section Four). How did your original undergraduate or graduate school courses describe the abilities or needs of people who are native users of American Sign Language in the Deaf community, people with autism, people with dysarthria, or people who stutter? Can you accept a social-model description that differences in hearing status, neuropsychological or neurocognitive differences, voice and articulation differences, or differences in speech fluency abilities are not disorders but simply represent a neutral descriptive continuum of abilities, or even represent a positive diversity in human abilities, that are judged to be problematic only because of society’s assumptions and prejudices? Why or why not? How might the ICF’s biopsychosocial model, a social model of disability, or a person-centered view that asks “How are you doing in your world?” help you to answer this question?
Many of the issues described in this module relate to one version of trauma, which can be defined as the ongoing adverse effects on any individual’s physical, mental, social, emotional, or spiritual functioning and well-being that occur because of one or more events or circumstances that were experienced by the individual as physically or emotionally harmful, life threatening, and/or out of the individual’s control (see SAMHSA, 2014). We will address the related notion of trauma-informed care as a potential contribution that speech-language pathologists can make to individuals’ lives in Section Five; skip up and read it now if you are interested.
Highlight Questions for Module 10
Use at least two different verbal or visual representations to summarize each of the following models or constructs (try sentences, Venn diagrams, old-fashioned outlines with Roman numerals, drawings of umbrellas or neighborhoods, etc.).
the World Health Organization’s model of structural determinants of health equity for groups (Boxes 10.1 and 10.2)
the U.S. Department of Health and Human Services’ five domains of social determinants of health for individuals (Box 10.3)
the U.S. Centers for Disease Control and Prevention’s model of Adverse Childhood Experiences (ACEs; Box 10.4)
the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) as a model of a person’s or a group’s ability or inability to complete life activities
social models of disability
a person-centered view of ability and abilities
ableism
For each of the models or constructs listed above, provide one example that you find relatively noncontroversial or easy to accept and one example that you find more controversial or harder to accept. What differentiates the examples that you find easier or harder to accept? (Use our basic metaphors and models to help your reflections here. Is your thinking influenced by your journeys so far in your life or by some issues you might recognize using a 16 Questions matrix?)
Social models of disability are currently presented in many ASHA publications as the best and most up-to-date approach, often described as the correct alternative to a “medical” model (see, e.g., Murza, 2025). Try thinking in more complex ways about all three models of disability described in this segment. Which aspects of which models strike you as true or necessary? How can our general notions of dimensions and continua help your thinking here?
This module addressed the influences on ourselves, our clients, and our colleagues of political and economic structures, social determinants of health, adverse experiences, and individuals’ physical, neurocognitive, and other abilities. How can your work in the domains of clinical service delivery address these intertwined personal and societal needs for individual clients, given your unique personal experiences with these issues? Which of the domains of professional practice (including advocacy, education, research, and leadership; ASHA, 2021) will be more relevant to you, given your experiences and your interests, and how will you use those domains to improve social and structural issues related to speech-language pathology? (The question here is not how SLPs generally might address these issues in generic ways; it’s about you specifically. How can you, with your experiences, your skills, your circumstances, and maybe even your needs, address the kinds of issues this module discussed in your practice?)
Module 10: Copyright 2025 by Compass Communications LLC. Reviewed May 2025.