Types of

UNIT 3 TYPES OF DISABILITIES – NATURE, Disabilities – Nature,

Characteristics, Causes
CHARACTERISTICS, CAUSES AND and Prevention: Part-1

PREVENTION: PART-1

Structure
3.1 Introduction
3.2 Types of Disabilities
3.3 Intellectual Disability
3.3.1 Definitions of Intellectual Disability
3.3.2 Intellectual Disability and Developmental Delay
3.3.3 Characteristics and Early Identification
3.4 Hearing Impairment
3. 4.1 Definitions of Hearing Impairment
3.4.2 Characteristics and Early Identification
3.5 Visual Impairment (Blindness and Low Vision)
3.5.1 Definition of Visual Impairment as per RPwD Act, 2016
3.5.2 Characteristics and Early Identification
3.6 Summing Up
3.7 Answers to Check Your Progress Exercises

3.1 INTRODUCTION
In Unit 1 and Unit 2, you have read about the meaning of disability, the
changing approaches towards disability and its definitions. The earlier
medical approach where the difficulty was seen to lie in the person with
disability has given way to the social model where the person’s disability is
seen in context of her interactions with the environment. The impairment
limits the person’s activity (activity limitation), and this may come in the way
of her participating in community activities (participation restriction). In this
Unit, you will learn about some types of disabilities, their causes and the
measures for prevention.

Objectives
After studying this Unit, you will be able to:
• demonstrate understanding of the nature of the following disabilities-
intellectual disability, visual impairment and hearing impairment;
• state the definitions of each of the above disabilities; and
• list the characteristics shown by children who have these disabilities.

3.2 TYPES OF DISABILITIES

In Section 2.3 of Unit 2, you have read about the Rights of Persons with
Disabilities (RPwD) Act 2016, the National Trust for Welfare of persons
with Autism, Cerebral Palsy, Intellectual disability and Multiple
41
Accepting and
Understanding Disability Act 1999 and the list of disabilities covered under both Acts. In
Disability this Unit, we will describe the nature and characteristics of some of the
disabilities listed in these Acts. We will also learn about causes and
prevention of these disabilities. The disabilities discussed in this Unit are:
• Intellectual Disability
• Hearing Impairment
• Visual Impairment (Blindness and Low Vision)

As you have noted in the earlier Unit, there are 21 disabilities covered by
RPwD (2016). However, the disabilities covered in this and the subsequent
Unit are those having implications in your curriculum planning and
instructions and the strategies are already planned. Since the other disabilities
are recently added in 2016, guidelines for certification and education of such
children are under process by the government.

Let us now understand the above listed disabilities in greater detail.

3.3 INTELLECTUAL DISABILITY

Example 1

Mamta is 14 years old and lives with her parents and two younger brothers.
Mamta began to walk when she was two and a half years old and began to
speak at 5 years of age. Mamta started going to school when she was seven
years old. She goes to a special school where she presently studies at the
level of class II. Her mother says that she had to be helped till she was 12
years old for eating, washing hands, dressing and putting on shoes. Mamta
has become independent to some extent now and can now carry out many
of the activities of daily living as a 6 to 7 year old child would do.
It is quite clear that Mamta’s mental abilities are not in accordance with her
age. Cognitively (mentally), she performs at a much lower level than other
children of her age. Mamta has Intellectual Disability. In India, this
condition was earlier called as ‘mental retardation’. Currently, RPwD (2016)
recognizes this condition with the name ‘Intellectual disability’ (ID)
replacing the term mental retardation. The reason for the change of name is
discussed below.

3. 3.1 Definitions of Intellectual Disability

Intellectual Disability is a term that describes an extremely diverse group of
people. They range from children with severe cognitive disabilities who need
constant care to those with only mild delays who are usually indistinguish-
able from others.

• According to THE RIGHTS OF PERSONS WITH DISABILITIES

ACT (RPwD) 2016-
Intellectual disability is a condition characterized by significant
limitation both in mental functioning (reasoning, learning, problem
solving) and in adaptive behaviour which covers a range of every day,
42 social and practical skills, including —
 a) specific learning disabilities and Types of
Disabilities – Nature,
b) autism spectrum disorder Characteristics, Causes
and Prevention: Part-1
• According to the Diagnostic and Statistical Manual of Mental
Disorders DSM-5, Intellectual Disability was called “Mental
Retardation” in previous editions of the Diagnostic and Statistical
Manual (DSM) which is an authentic publication on diagnosis and is
updated and revised periodically. The term Mental Retardation is no
longer used because of its negative connotation. According to the DSM-5
Intellectual Disability is characterized by significant limitations in
general mental abilities and adaptive functioning that emerge during the
course of children’s development. Limitations must be evident in
comparison to other people of the same age, gender, and social-cultural
background.

• American Association on Intellectual and Developmental Disabilities

(AAIDD) is an internationally recognized body that focuses on
intellectual and developmental disabilities and updates information based
on the developments, trends and needs in the field. It was earlier called
AAMR –American Association for Mental Retardation. In keeping with
the growing understanding regarding disabilities, the AAIDD also
revises its definitions periodically. The latest definition of Intellectual
Disability has been given by AAIDD in 2010. This definition states:

“Intellectual Disability is a disability characterized by significant limitations

both in intellectual functioning and in adaptive behaviour as expressed in
conceptual, social and practical adaptive skills. The disability originates
before the age of 18 years.

The condition is diagnosed through the use of standardized tests of

intelligence and adaptive behaviour. Only when there are limitations in
intellectual functioning and adaptive behaviour together, is a person said to
have the condition intellectual disability. With regular individualized
supports, both functioning and adaptive behaviour can be enhanced.”

It is important to keep in mind the common factors about Intellectual

Disability after reading the three definitions. Intellectual Disability is
characterized by:
1) low intellectual functioning,
2) deficits in adaptive behaviour and
3) onset is during the developmental period (before the age of 18 years).
The general belief that Intellectual Disability is determined solely by IQ
is not considered to be correct any more; concurrent deficits in adaptive
functioning and age of onset are equally necessary for the diagnosis.

Let us understand the various aspects of this definition:

1) What is meant by intellectual functioning?

Intellectual functioning—also called intelligence—refers to general

mental capacity, such as learning, reasoning and problem solving.
43
Accepting and
Understanding One way to measure intellectual functioning is through the Intelligence
Disability Quotient obtained from Intelligence Tests. Generally, an IQ score of
below 70 indicates a limitation in intellectual functioning. IQ scores
between 65 and 75 are recommended as cutoffs in determining intel-
lectual deficits (American Psychiatric Association, 2013). The tests to
determine IQ is generally carried by qualified psychologists using
standardized IQ tests that are culturally appropriate.

Let us understand the concept of IQ in detail.

Just as the child’s body grows and develops in a manner appropriate to

her age, the mental abilities also expand in accordance with age.
Generally, we calculate the age of a child/ individual in terms of number
of years. This is called chronological age. The level of development of
the mental abilities of a child/ individual is called ‘mental age’. In case
of children without disability, the mental age is equal to their age in
years i.e. chronological age. Thus mental age and chronological age
move together. Such a child is described as having “age appropriate”
mental development or average intelligence. This also means that she has
the same level of mental abilities as majority of children without
disability of her age group. But in a child with Intellectual Disability,
there is a slowing down in the development of mental abilities and
the mental age is lower than the chronological age. For example, a
child who is 6 years old may have the mental abilities at the level of a 3
year old. The mental age of a child is found out by using certain
standardized Intelligence tests and is expressed in terms of
Intelligence Quotient or IQ.
In the past, children with Intellectual Disability were classified based on
their IQ. This practice was abandoned in DSM-5 for three reasons —

• First, to give equal importance to IQ and adaptive functioning in

describing children with Intellectual Disability, rather than focus
exclusively on IQ alone.
• Second, children’s IQ scores are less helpful than their level of
adaptive behaviour in determining their need for support and
assistance at home, at school, and in the community.
• Third, IQ scores tend to be less valid toward the lower end of the IQ
range.

Consequently, in DSM-5, clinicians specify the severity of Intellectual

Disability based on the person’s level of adaptive functioning.

2) What is meant by adaptive behaviour?

Adaptive behaviour refers to the abilities/skills needed by people in

order to cope in their everyday lives and to adapt with one’s
environment. When a person is said to be adapting appropriately, it
means that her activities or behaviour are suitable for her age, time and
place. All of us adapt to our environment (home, neighbourhood,
community) using our abilities such as communication, problem solving,
44 following and obeying rules, moving from one place to another, using
 money efficiently, reading and writing and other similar skills. Types of
Disabilities – Nature,
Significant limitations in activities and behaviour affect the person’s Characteristics, Causes
daily life and the ability to respond to a particular situation or to the and Prevention: Part-1
environment.

Our various adaptive abilities can be classified in the following manner:

a) Conceptual skills – these include
• language – spoken (expressive language) and understood (receptive
language or comprehension)
• literacy – reading and writing
• money – understanding value of money
• time – day, date, months, before and after, early and late
• number concepts – more and less, counting, arithmetic
• self-direction – ability to manage one’s behaviour as per time and
situation, according to one’s goals.
b) Social skills – these include
• interpersonal skills – skills of dealing with people
• social responsibility — realizing that one is part of the society and
carrying out one’s responsibilities
• self-esteem – the positive and negative opinions we have about
ourselves, the way we value ourselves
• gullibility, naïveté (i.e., wariness) – the extent to which one is aware
of things happening around in the environment and the reasons
behind it
• social problem solving
• the ability to follow rules/obey laws
• avoiding being victimized.
c) Practical skills – these include
• personal activities of daily living such as eating, dressing and
mobility and toileting
• occupational skills
• healthcare
• travel/transportation
• schedules/routines (preparing meals, taking medication, house keeping
activities)
• safety
• use of money
• use of the telephone.

A person is said to have significant limitations in adaptive behaviours if the

person has a major difficulty in one or more of the above three areas as
relating to adaptive behaviour.
45
Accepting and
Understanding Adaptive functioning can be assessed using standardized rating scales,
Disability clinical interviews, and observations at home and school. Children with mild
deficits in adaptive functioning (i.e., standard scores 55–70) in only one
domain would presumably need less support from caregivers than children
with profound deficits in adaptive functioning (i.e., standard scores <25)
across multiple domains. Furthermore, by specifying the domains most in
need of support, clinicians can begin to plan interventions to improve
children’s adaptive functioning or compensate for deficits that might be less
responsive to treatment. Table 3.1 provides a general overview of children’s
adaptive functioning at each level of severity.

Table 3.1: Adaptive Functioning of Children at Different Levels of

Severity of Intellectual Disability
Level of Adaptive functioning
Severity Conceptual Social Domain Practical
Domain Domain
Mild • Preschoolers • Communication, • The child may
may show no conversation, and function in an
obvious language are more age-expected
conceptual concrete or manner with
differences. immature than the regard to
• School-aged skills of peers. personal care.
children show • The child may have • In adolescence,
difficulties in difficulty in assistance may
acquiring accurately be needed to
academic skills understanding the perform more
(e.g., reading, social cues of complex daily
writing, others. living tasks like
arithmetic, • There may be shopping,
telling time, difficulties in cooking, and
using money). regulating emotion managing
• Abstract and behaviour money.
thinking and compared to peers.
planning may be
impaired;
thinking tends to
be concrete.
Moderate • Preschoolers’ • The child shows • The child needs
language and marked differences more time and
early-academic in social and practice
skills develop communicative learning self-
slowly. skills compared to care skills, such
• School-age peers. as eating,
children show • Spoken language is dressing,
slow progress in simplistic and toileting, and
academic skills. concrete. hygiene, than
• Academic skill • Social judgment and peers.
development is decision making are • Household
usually at the limited. skills can be
elementary acquired by
school level. adolescent with
46
 • Friendships with ample practice. Types of
Disabilities – Nature,
peers are often Characteristics, Causes
affected by social or and Prevention: Part-1
communicative
deficits.

Severe • The child • There are limited • The child needs

generally has spoken language ongoing
little skills with support for all
understanding of simplistic activities of
written language vocabulary and daily living:
or numbers. grammar. eating,
• Caretakers must • Speech may be dressing,
provide single bathing,
extensive words/phrases. elimination.
support for • The child • Caregivers
problem solving understands simple must supervise
throughout life. speech and gestures. at all times.
• Relationships are • Some youths
with family show
members and other challenging
familiar people. behaviours,
such as self-
injury.
Profound • Conceptual • The child has • The child is
skills generally limited dependent on
involve the understanding of others for all
physical world symbolic aspects of
rather than communication. physical care,
symbols (e.g., • The child may health, and
letters, understand some safety,
numbers). simple instructions although he or
• Some visual— and gestures. she may
spatial skills, • Communication is participate in
such as usually through some aspects of
matching and nonverbal, non- self-care.
sorting, may be symbolic means. • Some youths
acquired with • Relationships are show
practice. usually with family challenging
• Co-occurring members and other behaviours,
physical familiar people. such as self-
problems may injury.
• Co-occurring
greatly limit physical problems • Co-occurring
functioning. may greatly limit physical
functioning. problems may
greatly limit
functioning.
Source: Based on DSM-5, 2013.
47
Accepting and
Understanding Limitations in adaptive functioning in specific skill areas are a necessary
Disability criterion for diagnosis under the AAIDD and DSM -5 definitions. The World
Health Organizations (WHO, 2001), International Classification of
Functioning, Disability and Health (ICF) and the ICF Children and Youth
Version (WHO, 2007) recognize activity and participation limitation in
addition to impairments in body functions and structures (discussed in
Section 1.5 of Unit 1)

In years past, the DSM and AAIDD definitions of Intellectual Disability had
differed considerably. Currently, however, the DSM-5 and AAIDD
definitions overlap considerably, which will likely improve communication
between members of these two professional organizations. One difference in
the AAIDD conceptualization of Intellectual Disability is its emphasis on
needed supports.

As teachers, our focus should be on the abilities/potentials and the needs of

the child. Irrespective of the label based on the classification, we as teachers
should aim at polishing their potentials and provide support to meet the needs
to lead towards independent living.

3) What is meant by supports?

A person’s level of functioning and adaptive behaviour can be enhanced by
providing individualized support. Support refers to resources and
strategies that can be used to enhance the individual’s well-being and
functioning. Well-being means a feeling of satisfaction that comes from
experiencing good physical, mental and emotional health.

Supports can come from family (parents, siblings, aunt, uncle), friends,
teacher and community or from an organization providing services. Supports
can be provided in many settings such as at home and school.

The AAIDD designates four possible levels of supports, based on how much
and how long assistance is needed: intermittent (i.e., occasional, in time of
crisis), limited (i.e., short-term), extensive (i.e., long-term), and pervasive
(i.e., constant).

Rather than categorize people into mild, moderate, severe, and profound
impairment, the AAIDD recommends that professionals describe individuals’
need for supports across various areas of functioning. For example, a child
with Intellectual Disability might be described as needing “extensive”
educational support, such as a full-time classroom aide, for all academic
activities, but only “intermittent” support in areas of social functioning, such
as one-time training to help her learn to make friends.
The AAIDD’s approach to classifying individuals with Intellectual Disability
in terms of needed supports has two main advantages. First, this approach
conveys more information about the persons with Intellectual Disability than
simply classifying them with Intellectual Disability alone. Second, it focuses
on the person’s abilities rather than on their impairments. The four levels of
supports identified are presented in Table 3.2.

48
 Table 3.2: Degrees of Intellectual Disability on the Basis of Level of Types of
Disabilities – Nature,
Supports Required Characteristics, Causes
and Prevention: Part-1
Intermittent Support is not always needed. It is provided on an “as
needed” basis and is most likely to be required at times
when there is a change in the person’s life circumstances
(e.g. moving from home to school, birth of a sibling).
Limited Consistent support is required, though not on a daily basis.
The support needed is of a non-intensive nature (e.g.
escorting to places like school, shops, playground). In
other words, high level of support is not required.
Extensive Regular, daily support is required in at least some
situations (e.g. daily support to carry out some of the
activities of daily living).
Pervasive Extensive support and care is needed across many
situations to sustain the person’s life (e. g. total
dependence for all needs including feeding, washing after
toileting and so on).

In a nutshell, we can say that the approach of the latest definitions goes
beyond simply identifying the degree to which a person has intellectual
disability on the basis of IQ Score. The objective, finally, is to identify the
degree of support the person needs so as to function most effectively, with a
sense of well-being.

3.3.2 Intellectual Disability and Developmental Delay

You may have heard the words slow to reach milestones, delayed
development, slow to catch, learning and developing slowly. Are they similar
or different; can they be used interchangeably?

If a child below the age of 6 years show delay in various areas of

development, the term used to refer to such delay is ‘developmental delay’.
Another expression used to refer to them is ‘children at risk for ID. Let us
understand why we do not use the word ID for children below 6 years of age.
a) The development of the brain takes place at a very rapid pace up to the
age of 5 years. Hence, development at this stage will depend on
stimulation/inputs received. Change in stimulation/inputs can increase or
reduce cognitive abilities at any time before 5 years of age. Therefore,
we cannot say with certainty that the child has Intellectual Disability and
to what degree.
b) Due to rapid development before 5 years of age, there are no standard
assessment which can be carried out to confirm the IQ of young children.
And technically, IQ less than 70 is one of the criteria for labeling an
individual as person with Intellectual Disability.

49
Accepting and
Understanding
Disability

A child with intellectual disability engaged in an activity

3.3.3 Characteristics and Early Identification

Many children with Intellectual Disability may look like any other children
without disabilities. Yet, there are certain characteristics that help us to
identify developmental delay/risk factors for Intellectual
ntellectual Disability in
children. These are as follows:

• Delayed Development: Early milestones of development like sucking,

holding the hea
head,
d, responding to sound, smiling, babbling, sitting,
standing, uttering first words, walking, may be delayed beyond the
average age range in which they should be achieved. In Block 1 of
Course 1, you have read about milestones of development.

• Child’s Behavi
Behaviour:
our: Generally, a child in the preschool age who is
developmentally delayed may show some of the following
characteristics. It must be remembered that the extent to which these
characteristics are shown by a particular child, will depend on the extent
of ddelay.
- The child may have difficulty in communicating with others through
verbal and non-verbal
verbal means. The child may have limited speech.
The speech may be unclear and the listener may find it difficult to
understand the child.
- The child may have difficulty
ficulty in understanding instructions.
- The child will have difficulty in paying attention to the task they are
doing.
- The child takes longer to learn to look after her own daily needs and
carrying out self care activities such as eating, bathing, dressing
dre and
going to the toilet.
50
 - The child may have difficulty in interacting with people. She may Types of
Disabilities – Nature,
not play actively with other children, unless helped to do so. Characteristics, Causes
and Prevention: Part-1
- The child may not show initiative and imagination when playing.
- The gross and fine motor development may be poor and there may
be difficulty in coordinating body movements.
- The child may show difficult behaviours such as aggression, temper
tantrums, stubbornness, withdrawn behaviour or resistance to new
situations.
- The child may have difficulty in understanding (comprehension) and
in remembering (retention). This will cause difficulties in learning.
- The child may require help in looking after her health and safety.
- The child will require extra support in academic work.

• Child’s Appearance: Some children may look very different from

other children of their age. For example, the child’s head may look too
small or too large for her age. Some children will have slanting eyes, a
narrow forehead and a protruding tongue. Some children do not appear
to be very alert.

It is important to understand that Intellectual Disability is not the same

as mental illness. Mental illness is a broad term used to denote a disorder of
one or more functions of the mind such as emotion, perception, memory, or
thought, and treated with medical and therapeutic support. Intellectual
Disability, on the other hand, is the slow and incomplete development of the
brain and is not an illness. It cannot be cured. It is a developmental disability
which needs early and holistic management strategies.

Check Your Progress Exercise 1

1) Fill in the blanks
a) A person is said to have intellectual disability only when there are
limitations in both ……………………..and ……………occurring
together.
b) ……………………. refers to the abilities needed by people in order
to cope in their everyday lives and to adapt with one’s environment.
c) A person’s level of functioning and adaptive behaviour can be
increased by providing individualized ……………………. .
d) Children with intellectual disability show a ………………………
in achieving their developmental milestones.
2) Define Intellectual Disability.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
51
Accepting and
Understanding 3) Explain what do you understand by ‘individualized supports’?
Disability
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
4) Explain the following statements
a) A person is said to have intellectual disability only when there are
limitations in both intellectual functioning and adaptive behaviour
occurring together.
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
b) A person’s level of functioning and adaptive behaviour can be
enhanced by providing individualized support.
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………

3.4 HEARING IMPAIRMENT

Example 2
Sujeet is four years old. He has many friends, but whenever he wants to say
something to his friends, or to his family members, he uses gestures or points.
He has difficulty in speaking and does not respond when others speak to him
or call out his name.

Example 3
Shaano is a five year old girl studying in class 1. She is not performing as her
peers in the class. She likes to play. She likes to watch TV on high volume;
and enjoys watching advertisements. Her speech is different from others.
Only her family members can understand her. She does not like to take a
dictation, but enjoys doing sums and drawings. Shaano does not respond to
soft low pitched sounds. It seems she cannot hear them. Her teacher says that
she has difficulty in following the instructions in class.

52
What is common between the two children? Yes. They have difficulty in Types of
Disabilities – Nature,
hearing. These children could have hearing impairment (hearing loss). Characteristics, Causes
and Prevention: Part-1
We often use the terms ‘hearing loss’, ‘hearing impairment’, ‘hard of
hearing’ and ‘deafness’ to refer to people who have difficulties in hearing.
Let us understand what these terms mean. Any decrease in the ability to hear
sounds is referred to as hearing impairment or hearing loss. Hearing
impairment, thus, is the inability of an individual to hear sounds
adequately. Some people with hearing impairment can hear loud sounds, like
the bursting of fire crackers while others may not be able to hear even these.
Thus, hearing loss may range from mild to severe. The term ‘hard of
hearing’ is used for a person who can hear some sounds. Hearing aids assists
such a person to hear fairly well and communicate with others. The term
‘deaf’ is used for a person whose hearing loss is very severe. Typically, such
a person may not be benefitted from a hearing aid.

Hearing impairment is an invisible disability and we may not come to know

that a person has hearing impairment unless the person is using a hearing aid.
Because a child with hearing impairment may respond to some sounds
and not to others, it may take a long time to detect that she has hearing
impairment. Not being able to hear everything that is spoken around her
may affect the child’s language, communication and cognitive development.
In this way, valuable time gets lost during which the child could have
received appropriate support, hearing aid and training to develop
communication and speech. When a child has a severe hearing loss, she may
experience a sense of isolation and neglect because she is not able to
participate spontaneously in the conversations and activities taking place
around her. If people around her do not make attempts to communicate with
her and involve her in different activities, this feeling will increase.

3.4.1 Definitions of Hearing Impairment

The RPwD Act (2016) defines Hearing Impairment (HI) on the basis of the
intensity of the sound the person is able to hear. Hearing impairment has
been categorized in two forms — being deaf or hard of hearing.

a) “deaf” means persons having 70 dB hearing loss in speech frequencies in

both ears;
b) “hard of hearing” means person having 60 dB to 70 dB hearing loss in
speech frequencies in both ears.

According to World Health Organisation (WHO), a person who is not

able to hear as well as someone with normal hearing – a hearing thresholds of
25 dB or better in both ears – is said to have hearing loss. Hearing loss may
be mild, moderate, severe, or profound. It can affect one ear or both ears, and
leads to difficulty in hearing conversational speech or loud sounds.

‘Hard of hearing’ refers to people with hearing loss ranging from mild to
severe. People who are hard of hearing usually communicate through spoken
language and can benefit from hearing aids, cochlear implants, and other
assistive devices as well as captioning. People with more significant hearing
losses may benefit from cochlear implants.
53
Accepting and
Understanding ‘Deaf’ people mostly have profound hearing loss, which implies very little or
Disability no hearing. They often use sign language for communication. Table 3.3
summarizes the different degrees of hearing loss.

Table 3.3: Characteristics of the different Levels of Hearing Loss

Degree of Hearing Loss Functional Characteristics

Hearing Loss in Decibels
(dB)
Slight/Mild 26–40 The person has trouble hearing and
understanding soft speech, speech from a
distance or speech in a background of
noise.
Moderate Children: 31–60 The person has difficulty hearing regular
Adults: 41–60 speech, even at close distances. This may
affect language development, interaction
with peers and self-esteem.
Severe 61–80 The person may hear only very loud
speech or loud environmental sounds,
such as a siren or a door slamming. Most
conversational speech is not heard.
Profound Over 81 The person may perceive loud sounds as
vibrations. Speech and language may
deteriorate.

If you look closely you will notice that the definition of ‘hard of hearing’
category is different in RPwD and WHO definitions.

Let us understand what is meant by decibles (dB) in the above definition:

Loudness of sound is measured in decibels (dB). When we whisper, it is 30 to
40 dB level. We normally speak and have conversation at 40- 60 dB level.
The softest sound that a human being can hear normally is between 0 dB to
20 dB. A moving bus produces sound of about 80 dB and a jet, when taking
off, produces sound around 120 dB. On the other hand, sounds louder than
120 dB cause pain to our ears, like that of firecrackers. 120dB – 140 dB is the
threshold of pain.

People with normal hearing can hear sounds with intensity as low as 0-25 dB
— in other words, a person who can hear sounds of intensity 25 dB or less is
considered to have normal hearing. However, individuals who can only hear
sounds that are louder than 25 dB — in other words, persons who have a
hearing loss of more than 25 dB — are said to have hearing impairment. This
may be categorized as mild, moderate, severe and profound, depending
on the degree of hearing loss.

There are other ways, as well, of classifying hearing impairment:

• On the basis of where the defect is in the hearing mechanism – in the
outer ear, middle ear, inner ear. It may be conductive or sensorineural in
nature. Conductive hearing loss is due to problems with the ear canal,
54
 ear drum, or middle ear and its little bones (the malleus, incus, and Types of
Disabilities – Nature,
stapes). Sensorineural hearing loss (SNHL) is due to problems of the Characteristics, Causes
inner ear, also known as nerve--related hearing loss. and Prevention: Part-1

• On the basis of age of onset

set of hearing loss — whether the hearing
impairment occurred before or after language/ speech had been acquired.

Fig. 3.1: Structure and Functioning of Human Ear

3.4.2 Characteristics and Early Identification

Hearing loss can be in one ear or in both the ears, and it can range from mild
to profound. Further, we need to have a tool to assess the extent and type of
the hearing loss. A hearing test is this tool.
Broadly speaking, hearing tests may be classifi
classified as (i) informal hearing
tests, and (ii) formal hearing tests. An informal hearing test is more popularly
known as a “screening test”.
Screening tests are very quick and easy to perform. When we perform a
screening test, we observe if the child responds to all the sounds presented to
him, or if she fails to respond. If the child fails to respond, it indicates the
possibility of hearing loss.
ertain signs and checks parents
Here are certain parents/ECCE workers and educators
can look for to identify hearing loss to become alert and seek
professional help. However, do not panic that the child has hearing loss
based on a single instance of lack of response. At any age, if the child fails to
respond too the sounds on a regular basis, then she should be taken to an
expert for further evaluation.
• If a newborn baby does not get startled by a sudden loud noise and she
does not blink or open her eyes widely to such sounds.
• At one month, the baby does not bec
become still if you make a sudden
prolonged sound.
• Between birth and three months of age, the child is not aroused from
sleep when there is a loud sound.
• At 3 months of age, the baby does not quieten or smile to the sound of
your voice even when she cannot ssee you.
55
Accepting and
Understanding • The child begins to babble between 4 – 7 months of age, but gradually,
Disability the frequency of babbling decrease.
• By 6 months of age, she does not turn immediately to your voice across
the room.
• By 9-10 months of age, she does not look towards the named object. If
asked, “where is the car?”, she does not look for it.
• By 9-10 months of age, she does not respond to unseen sounds such as
music, doorbell, telephone ring, whistle of pressure cooker.
• By the age of one year, she does not show some response to her own
name and to other familiar words like ‘no’ and ‘bye- bye’.
• Also by the age of one year, the child does not respond to being called
from the other room and is also not able to say a word or two.
• At 1½ years of age, the child does not follow simple directions like:
‘come here’; ‘take this’.
• Even at 1½ or 2 years of age, the child does not speak meaningfully. She
speaks words with distortion that are difficult to understand. Also her
speech development is slow.
• Between 13-24 months of age, she imitates adult speech, in particular
intonation pattern.

The other signs when parent and the ECCE worker/teacher should
become alert and seek professional help are when
• The child has frequent colds and sore throats or fluids runs from the ears.
• The child understands your speech only after you repeat a few times.
• The child uses too many gestures and signs to communicate.
• The child tunes the TV/ radio abnormally loud all the time.
• The child’s attention wanders in class or during play. This happens
because the child loses interest more easily because she misses out on
spoken information.
• Turning of head by the child when she needs to hear the speaker. This
may happen because she is trying to hear with her better ear.
• A hearing impaired child shows fluctuations in her listening behaviour.
This may be because of blockage or discomfort in the ear which may be
sometimes released when she yawns or swallows. During blockage, she
experiences difficulty in listening. This behaviour that the child
understands a spoken message at one time and not at another may be
wrongly considered as stubbornness.
• Difficulty in following oral directions. In our ignorance we may label
such a child as lazy or shy. The child may not show difficulty in
following written directions.
• The child looks at other people in the group before she starts work.
• The child does not seem to be performing as well as is expected of her.
Slow progress in learning can be due to hearing impairment.
56
 Types of
Disabilities – Nature,
Characteristics, Causes
and Prevention: Part-1

Total Communication: Using a hearing aid and sign language helps us to communicate
with each other

Check Your Progress Exercise 2

1) Fill in the banks
a) A category of Hearing Impairment, Deaf means persons having
………………………… hearing loss in speech frequencies in both
ears.
b) Loudness of sound is measured in ………………………………… .
c) People with normal hearing can hear sounds with intensity as low as
………………………………. .
d) Hearing impairment is also classified on the basis of
…………………… of defect and ……………………. .
e) Not being able to hear everything that is spoken may affect a child’s
…………….. , …………………. and ………………….. .
2) What challenges does a child born with hearing impairment face?
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
57
Accepting and
Understanding 3) How is hearing impairment classified on the basis of degrees of loss?
Disability
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
4) How will you detect a possible hearing impairment in a child?
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….

3.5 VISUAL IMPAIRMENT

Example 4
Sharada is a nine-month-old girl. Her mother noticed that she did not reach
out for toys or people. But her eyes seemed to be normal. Her parents took
her to an eye hospital. To their shock, they came to know that their child had
visual impairment. The eye doctor explained that she had visual impairment
at the time of her birth itself. The doctor further explained the child had to be
taught non-visual techniques using other senses such as touch, hearing,
smell, taste and kinesthetic (leaning through feeling and body movement).
Who is a visually impaired person? Let us learn the concept and definition of
visual impairment.

3.5.1 Definition of Visual Impairment as per RPwD Act, 2016

In the RPwD Act 2016, the term ‘Visual Impairment’ is used for those
who are totally blind, and those who have ‘low vision’. What is the
difference between these terms? Let us understand these terms.
But before we do that, it is important to clarify the following:
Most of us would say that a blind person is one who cannot see. But the fact
is that the majority of blind people can actually see something. Most blind
people can make out shades of dark and light, though they may not be able to
perceive the exact colour; they can make out the intensity of sunlight – how
bright the sun is; some can read if the print is very large and bold. This means
that they have some vision that helps them in the day-to-day tasks: they are
not completely blind. Only a minority of visually impaired people are totally
blind. Totally blind persons cannot see light.
Definitions of visual impairment are based on legal and educational aspects.
Let us first discuss the definition of Blindness and Low vision from the legal
58 point of view.
I) Definition of Blindness Types of
Disabilities – Nature,
1. “Blindness” Characteristics, Causes
and Prevention: Part-1
To define ‘blindness’ we use three conditions as per the RPwD Act.
a. The first condition is the ‘total absence of sight’ – This means the
person cannot even see the light. The person cannot perceive light.
b. The second condition is that the ‘visual acuity is less than 3/60 (metre)
or less than 10/200 (feet) in Snellen chart in the better eye with best
possible correction’

E
Let us understand this definition in detail.
Here the term visual acuity is a number that
indicates the sharpness or clarity of vision or 6/60
the amount of vision. A visual acuity
measurement of 3/60 means that a person
with 3/60 vision is one who can see an eye
chart (Snellen chart) from 3 metre which a
person with unimpaired or standard vision
L T 6/36

can see at 60 metre. Visual acuity is

represented as a fraction. The numerator
F P H 6/24

indicates the distance from the chart at O L C F 6/18

which the test is conducted. The D H J B S 6/12
denominator means the smallest line of E P T Z O 6/9
letters that the child/ person can read from CF D H J 6/6
LTIPH
the testing distance. See the Snellen chart
(India) and the corresponding acuities.
In cases where the child is unable to read the uppermost letter on the
chart, she should walk one metre forward to the chart. The child/ person
moves one metre forward until she can see the top line or symbol. The
distance between child and chart becomes the numerator and vision is
recorded as such: 5/60, 4/60, 3/60. Here, if the visual acuity is less than
3/60, the condition is considered as ‘blindness’. It means that the
child/person cannot see the letter at a closer distance of 3 metre.

c. The next condition is the ‘limitation of the field of vision subtending

an angle of less than 10 degree’
While defining visual impairment, the eye doctors use a combination of
both visual acuity and field of vision or visual field to judge whether
someone is eligible to be registered as blind or low vision. We learnt the
term visual acuity. What does the term field of vision mean? The field of
vision is the whole area seen when looking straight ahead without
moving head or eye. In other words how much can be seen around the
edge of vision, on the sides, above or below the eye level while looking
straight ahead. The visual field is 90 degree in one eye and thus 180
degree in both eyes in an unimpaired or standard vision. Here if the field
of vision is less than 10 degree at the point of fixation, the condition is
said to be ‘blindness.’

59
Accepting and
Understanding II. Definition of Low Vision
Disability
“Low-vision” as per RPwD Act 2016 means a condition where a person has
any of the following conditions, namely:

a. Visual acuity not exceeding 6/18 or less than 20/60 upto 3/60 or upto
10/200 (Snellen) in the better eye with best possible corrections; or
b. Limitation of the field of vision subtending an angle of less than 40
degree upto 10 degree
Low vision is not blindness, which is the absence of useful vision. Persons
with low vision may see light, colour, movement, dimension, shape and size.
However, things can appear blurred, faded or distorted.

For a person with low vision, visual acuity (the ability to see fine details) can
get worse. There is possibility of narrowing or loss of parts of the visual field
i.e., the area of sight. A person with low vision may be less sensitive to
differences and changes in brightness, contrast and colour; adaptation to high
or low levels of light may also be slowed or impossible. Hence various
combinations of these changes in vision can occur leading to low vision.

Most students with low vision can use print for learning. Some may need
visual aids such as glasses and other magnifying devices. Depending on the
eye condition and the task, each child will have different needs. For example,
one child may have sufficient vision to move around freely but be unable to
distinguish small print or facial features; another may be able to read small
print but not able to see detail beyond a relatively short distance; another may
have such reduced vision that parts of objects or words are visible. Most
children with low vision will have difficulty reading on the black board
without the help of a low vision aid. Some of these children may wear glasses
which help improve their vision, but cannot be corrected to normal levels.

Classification of Low Vision

Low vision can be classified into:
1) severe ability loss,
2) moderate ability loss, and
3) mild ability loss, depending on the visual function.
See the diagram below for better understanding.
1) Severe ability loss
Objects visible to children with normal vision at or beyond 120 metres can
only be seen by children with severe low vision at 6 metres, or their visual
field is 20 degrees or less.

120 metre 6 metre

60
2) Moderate ability loss Types of
Disabilities – Nature,
Characteristics, Causes
Objects visible to children with normal vision within 60 to 120 metres and Prevention: Part-1
can only be seen by children with moderate low vision at 6 metres.

60 metre 6 metre

3) Mild ability loss

Objects visible to children with normal vision within 18 to 60 metres can
only be seen by children with mild low vision at 6 metres.

18 metre 6 metre
Categories of Low Vision
There are three categories of vision loss based on the similarity of functional
symptoms. Any eye disease that cause visual impairment can be placed in
one or more of these three categories. These categories are:
1) Blurred vision – over all blurred or hazy vision
2) Peripheral field loss – vision loss at the sides
3) Central field loss – vision loss of the central part

The following image demonstrates what type of vision loss, the low vision
persons experience based on the functional symptom.

The term blindness and Low vision are considered as legal definition of
blindness. The other term is ‘Educational blindness’. 61
Accepting and
Understanding Definition of Blindness from Educational Perspective
Disability
In the educational setting blind is defined as totally without sight or with light
perception only. Light perception is the ability to distinguish the absence of
light. The perception of llight ight would be useful in moving through the
environment. Educationally blind individuals would be primarily tactile
learners and would read with Braille or auditory media. However, students
with low vision exhibit a wide range of visual impairments. Teachers
Teacher should
be aware that no two students with low vision have the same functional
vision even if they are diagnosed as having the same eye condition and
similar vision acuity. Vision may fluctuate and be influenced by such factors
as fatigue, light glare, li
lighting
ghting conditions and time of day. Therefore, special
attention must be given in assessing the needs of the student with low vision.
Accommodations can be incorporated into her program plan.
Low vision individuals are defined by educationists as those who can read
print, though they may need to use magnifying devices to read or books with
large prints or some may need Braille for their education.
Though persons with low vision have significantly reduced vision, which
performance, they still have vision that can be used.
affects their visual performa
This is called ‘residual vision’. The important aspect here is that these
people can be trained to use this residual vision. Moreover, these persons
are not labeled as blind.
These definitions enable educators to decide how the child has to be taught
and are more useful functionally rather than legal definitions.

On a shopping trip with friends to buy material for the pre

pre-vocational centre.
Learning as well as fun!

3.5.2 Characteristics and Early Identification

Identificatio

If any of the following signs are noticed, it indicates a problem in the eye.
62 The child must be referred to a doctor. The presence of one or more of these
signs does not always mean that the child has visual impairment; but the Types of
Disabilities – Nature,
child has to be referred for further evaluation before one can say so. Do not Characteristics, Causes
ignore any problem in the eye. Seek help if you see the following signs: and Prevention: Part-1

Appearance
• Crossed eyes, eyes turning in or out, eyes do not appear straight
• Frequent blinking
• Watery eyes
• Red eyes or lids
• Excessive eye movements
• Frequent styes
• Clouding of the pupil
• Pupils are of uneven size.
Behaviour
• Rubbing eyes excessively
• Holding books very close to the eye
• Tilting head while looking
• Avoiding close work
• Making errors when reading or copying
• Frowning while seeing blackboard
• Clumsiness and trouble walking in the environment
• Stumbling over objects
• Confusion in letters of a similar shape
• Poor spacing in writing
• Difficulty staying in the line in the notebook while writing
• Difficulty to see distant things clearly.
Complaints
• Headaches
• Seeing double
• Pain in the eyes
• Blurring of vision while reading and writing.

63
Accepting and
Understanding
Disability

Low vision does not stop me from painting!

Check Your Progress Exercise 3

1) Complete the following:
a) According to the RPwD Act, blindness is
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
b) According to the RPwD Act, low vision refers to
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
c) Visual acuity means
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
2) List five behaviours of the child that the teacher in a school can use to
determine if the child has visual impairment.
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
64
3) Who are persons with low vision and how are they different from those Types of
Disabilities – Nature,
who are blind? Characteristics, Causes
and Prevention: Part-1
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………

3.6 SUMMING UP
The RPwD Act 2016 recognizes many disabilities.

• The two important features of the AAIDD definition of Intellectual

Disability are: Intellectual Disability is identified on the basis significant
limitations in intellectual functioning and in adaptive behaviour
occurring together, and with regular support there is an increase in the
functioning of the person with Intellectual Disability.
• Persons with Intellectual Disability can be classified on the basis of their
IQ or on the basis of the level of supports required by them.
• The needs of a child with hearing impairment are determined by the age
in which the child acquired the condition.
• Majority of children with visual impairment are not totally blind. They
have some residual vision or can see light. This ability can be used, with
the help of appropriate aids and appliances, to help them to learn about
the world around them.

3.7 ANSWERS TO CHECK YOUR PROGRESS

EXERCISES
Check Your Progress Exercise 1
1) a) intellectual functioning; adaptive behaviour

b) adaptive behaviour

c) support

d) delay

2) “Intellectual disability is a disability characterized by significant

limitations both in intellectual functioning and in adaptive behaviour as
expressed in conceptual, social and practical adaptive skills. The
disability originates before age 18. Refer Section 3.3.
4. a) It means that a person has an IQ of 70 or less. This means that the
person has difficulties in doing tasks that require mental functions
such as learning, reasoning and problem solving. At the same
time, this person will also have difficulties in adapting to her
65
Accepting and
Understanding environment using abilities such as communication, problem
Disability solving, following and obeying rules, moving from one place to
another, using money efficiently, reading and writing and other
similar skills. When difficulties are seen both in mental functions
and in adaptive behaviour skills, the person is said to have
Intellectual Disability.

b) With individualized supports over a period of time, the limitation

will decrease and the functioning of the person with Intellectual
Disability will increase and the person can participate better in
community activities.

Check Your Progress Exercise 2

1) a) 70 decibles
b) decibels (dB)
c) 0-20 dB
d) location of defect and age of onset
e) language, communication and cognitive development.
2) The child’s language, communication and cognitive development is
affected because she is not able to hear everything that is spoken around
her. She may experience a sense of isolation and neglect because she is
not able to participate spontaneously in the conversations and activities
taking place around her. If people around her do not make attempts to
communicate with her and involve her in different activities, this feeling
will increase.
3) Hearing impairment is classified based on the degrees of loss as
mentioned in Table 3.3 of this Unit.
4) We can detect if a child has hearing impairment by observing the
following behaviour:
• by 3 – 4 months of age: the child does not respond to loud sounds;
does not recognize mother’s voice
• by 6 – 8 months — the childstops babbling
• by 9 – 10 months — the childdoes not respond to simple commands
or questions
• by one and half years — the childdoes not speak in single words
• by 2 years of age — the childhas unclear speech or prefers to use
gestures to say something.
Check Your Progress 3
1. a) According to the RPwD Act, “blindness” means a condition where a
person has any of the three conditions, after best correction — total
absence of sight; or visual acuity less than 3/60 or less than 10/200
(Snellen) in the better eye with best possible correction; or limitation
of the field of vision subtending an angle of less than 10 degree.
b) According to the RPwD Act, “Person with low vision” means a
66 condition where a person has a visual acuity not exceeding 6/18 or
 less than 20/60 upto 3/60 or upto 10/200 (Snellen) in the better eye Types of
Disabilities – Nature,
with best possible corrections; or limitation of the field of vision Characteristics, Causes
subtending an angle of less than 40 degree up to 10 degree. and Prevention: Part-1

c) Visual acuity means the ability to see clearly from a specified

distance.
2) a) The child experiences difficulty in reading or in other work
requiring close use of the eyes.
• The child holds things close to the eye.
• The child finds it difficult to see distant things clearly.
• The child tends to confuse letters of a similar shape.
• There is poor spacing in writing and difficulty in staying in the line.
3) Persons with low vision have vision that can be used (visual acuity upto
10/200 in the better eye.). This is called ‘residual vision’. They can be
trained to use this residual vision. But blind persons have a visual acuity
less than 10/200 in the better eye and total absence of light. Thus even
with the glasses and other aids, they will not be able to see.

67