Goldstein Sam - Assessing impairment from theory to practice

In Western medicine, the medical model guides diagnosis and treatment in all aspects of medicine and mental health. The purpose is to identify treatments for diagnoses based on evidence of specific symptoms assumed to suggest problems inherent within one or more organs of the human body. The medical model has driven research and theory about physical and mental health problems on the basis of causation, symptom relief, and cure and in some cases has been quite successful (e.g., tuberculosis, measles, etc.). As the fields of medicine and psychology have evolved, interest in the degree of impairment, regardless of the diagnosis, has increased.

Until very recently, functional impairment has not been a major focus in diagnosis or treatment in either physical or mental health problems. This interest has been sparked by an emerging body of literature that has suggested that symptoms and functional impairment need to be considered separately in making diagnostic decisions and evaluating treatment response (Bird et al., ), it is not unexpected that there is an increasing need to demonstrate functional impairment as part of the diagnostic process. In addition, in this volume a foundation is given to further appreciate why understanding impairment is by far the most important and greatest challenge facing medical, educational, and mental health care providers today. This assumes, of course, that impairment can be defined.

We can take a simple example of a child's activity level to illustrate these differences. A parent is asked to evaluate whether he or she believes his or her child is overactive. The parent endorses a high level of activity. This represents a symptom. In and of itself, it does not necessarily speak to any level of impairment. The parent is then asked whether the child's excessive activity level causes problems and, if so, in what situations? The parent endorses the dinner table as a source of problems. At this point, we know that the symptom presents in a specific situation to a significant degree. The level of impairment is still unknown. The parent is then asked whether the child is capable in any situation of sitting still, and the parent responds affirmatively. The parent notes, however, that at the dinner table the child does not sit still. The parent is further asked if the child knows how to properly use dinner utensils and feed him- or herself. The parent again responds affirmatively. At this point, it is clear that the child possesses adaptive skills. That is, the child knows what to do but, as the parent describes, is not doing what he or she knows. This represents a failure to exhibit adaptive behavior but in and of itself is still short of providing the needed information about functional impairment. The parent is then asked to describe what takes place during dinner. Because of the child's symptom severity, an insufficient number of calories is consumed, and food is spilled. This phenomenon represents the impairment caused by this child's hyperactive behavior.