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Abnormal-Becoming- Normal: Conceptualizations of Childhood Disability in Children’s Rehabilitation Textbooks

Authors:

Donya Mosleh ,

University of Toronto, CA
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Barbara E. Gibson

University of Toronto, CA
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Abstract

Despite advancements to theory and practice, children’s rehabilitation is dominated by taken-for-granted assumptions about disability and childhood. In order to address a pressing need for scholarship in this area, this paper draws on post-structuralism, critical disability studies, and disabled children’s childhood studies to interrogate the underlying logics and central assumptions of eight North American children’s rehabilitation textbooks. Using discourse analysis, we highlight how the discourse of normal/abnormal is pervasive and underpins the understandings and logics deployed throughout the texts. We argue that the texts construct disabled children as abnormal-becoming-normal, and thus reinforce a moral imperative whereby disabled children are understood as requiring motivation and self-efficacy to lead a ‘good’/normal life. In drawing on these reductive understandings, children’s rehabilitation relies on a disempowering conception of disabled children as lacking, and thus fails to acknowledge and appreciate the many ways in which disabled children can be and become.

How to Cite: Mosleh, D. and Gibson, B.E., 2022. Abnormal-Becoming- Normal: Conceptualizations of Childhood Disability in Children’s Rehabilitation Textbooks. Scandinavian Journal of Disability Research, 24(1), pp.122–135. DOI: http://doi.org/10.16993/sjdr.877
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  Published on 08 Apr 2022
 Accepted on 15 Mar 2022            Submitted on 10 Nov 2021

Introduction

Despite advancements to theory and practice, children’s rehabilitation is dominated by taken-for-granted assumptions and unexamined beliefs about disability and childhood. These understandings hold problematic implications for disabled children and their families. Within North America (NA), children’s rehabilitation remains rooted in biomedical thinking, which largely ignores the broader social and cultural contexts in which disability and disabled children are embedded. This paper draws on post-structuralism and critical disability studies to interrogate the underlying ‘logics’ and central assumptions of children’s rehabilitation textbooks. We highlight how the discourse of normal/abnormal pervasively underpins the understandings and logics deployed throughout the texts. We argue that the texts construct disabled children as abnormal-becoming-normal, and reinforce a moral imperative whereby disabled children are understood as requiring motivation and self-efficacy to lead a ‘good’/normal life. In drawing on these reductive understandings, children’s rehabilitation relies on a disempowering conception of disabled children and fails to acknowledge and appreciate the many ways in which disabled children can be and become. Before describing our methodology and methods, we begin by elaborating the conceptual framework.

Conceptual Framework

This paper draws on post-structuralism, critical disability studies and disabled children’s childhood studies to interrogate underlying logics and assumptions of children’s rehabilitation. By logics we are referring to the unstated or implicit rationales underlying particular ways of thinking and ‘doing’ in rehabilitation (Mol 2008: 8). As a meta-theory, post-structuralism challenges the idea that language and knowledge are value-free and neutral conveyers of ‘reality’ (Cheek 2000). A post-structural analysis aims to expose the many ways in which language itself is constitutive of the reality it seeks to represent. Thus, the way a text represents an aspect of ‘reality, that is, the conventionalized practices and assumptions that underpin the shaping of the text itself, is as of much interest as what the text actually describes’ (Cheek 2000: 40). ‘Texts’ refer to any cultural or literary representation of reality. As explained further below, discourse refers to patterned ways of thinking and speaking about reality that define what can and cannot be known (Lupton 1998: 8). Discourses thus consist of taken-for-granted assumptions and logics which provide the basis for ways of understanding and thinking about the world (Kress 1985).

The post-structural position advanced throughout this paper focuses on the discursive construction of disabled bodies as atypical and problematic. Given that ‘reality’ is always structured by language and meaning, this paper maintains that bodies, like other phenomena, cannot be understood except through language (Lupton 1997: 99). Grounded in post-structuralism, this paper aims to highlight the ways in which the discursive construction of childhood disability as a problem to be fixed, is indicative of wider knowledges, beliefs, and value systems concerning the ‘nature’ of the human body, and what it means to live a ‘good’ life.

While the focus of this paper is to interrogate discourses, it is important to note that such a focus does not deny the way in which discourses produce material consequences for disabled people. Importantly, what counts as ‘being disabled’ varies from person to person; however, the point we wish to emphasize here is that language and discursive constructions of normal/abnormal produce understandings of disability as inherently negative which orders and orients human thought and practice in particular ways. Thus, in conjunction with Shildrick (2009) and other disability studies scholars (Goodley 2011; Titchkosky 2007; Slater 2015), being disabled does have consequences, however, as we explore in our analysis, these consequences are inherently produced by discursive constructions of disability and what constitutes a ‘good’ life.

Building on these understandings, we draw on post-structural variants of critical disability studies (CDS) and its application to rehabilitation. Post-structural CDS maintains that disability is constituted by language and particular ways of knowing. This perspective does not deny that experiences of disability are ‘real,’ nor does it discount the materiality of impairments. Rather, it suggests that impairments are not the sole mediators of disabled lives. As relational concepts, disability and impairments are mediated by a variety of different forces which intersect and influence one-another. These forces—social, political, economic, cultural and historical—vary across time and space. Thus, disability is a concept which changes meaning over time and sociomaterial locations. As a central tenet of this paper, we will argue that ability/disability and consequently, normal/abnormal are oppositional categories which reflect dominant ideas about a ‘good’/normal life in ways that disavow a positive disabled sensibility. Categorizations create and sustain particular bodies and ways of being, which pose a range of effects (Hacking 2002). For example, autism spectrum disorder is a relatively new way of labeling differences, and this categorization has implications for how children with this label are diagnosed, treated, and educated. Categories are never neutral; they have effects, whether intended or not, obvious or hidden (Gibson 2019). This paper explores the hidden effects of discourses and categorizations employed throughout children’s rehabilitation textbooks.

Informed by post-structural CDS, this paper aims to interrogate and disrupt commonly held beliefs about disability within NA children’s rehabilitation. While Canada and the US have different healthcare systems, they share a medicalized understanding of disability that dominates rehabilitation practices (Bezmez, Shakespeare & Lee 2021; Hammell 2006; Magasi 2008). As we demonstrate, children’s rehabilitation draws on particular discourses to construct disability as inherently abnormal and in need of intervention and therapies. Such value judgements of what constitutes normal/abnormal, healthy/unhealthy and good/bad bodies and lives requires a thoughtful and critical analysis in order to examine the ways in which these understandings impact the lives of disabled young people.

Childhoods and children

Within the field of psychology, children have been traditionally conceptualized as irrational, immature, dependent, and in the process of becoming adult (Burman 2012). Common notions of ‘childhood’ refer to a social category predicated by developmental thinking (James & James 2004; Burman 2008, 2012). The notion of child development emerged in the early twentieth centuries (Rose 1999) as a means to observe and measure children’s bodies and abilities, including their physical, cognitive and social performance. This growing interest in the routinized observation of children solidified a science dedicated to the establishment of the ‘normal’ child (Gibson 2016: 76). These efforts were oriented to identifying and intervening with those children who deviated from established developmental norms in order to ‘correct’ their bodies and behaviors. To-date developmentalism continues to dominate Western approaches to childhood, and the term ‘atypical’ often replaces ‘abnormal.’

Supported by developmentalist discourses, childhood and adolescence are often described as periods of transition to adulthood. Childhood, as a universal stage of development, is positioned as a stepping-stone to a normative ideal of adulthood, which in Western societies aligns with notions of the independent and productive neoliberal citizen (see page 11). These representations uphold a binary of adult/child that supports the regulation and governance of children as potential-citizens in Western societies. Those children who fail to meet normative milestones and developmental trajectories, such as disabled children, are pathologized and deemed at risk of failing to develop into ‘normal’ adults (Gibson 2016; Slater 2015, 2016; Burman 2008; Priestley 1998, 2003). Within children’s rehabilitation, normal development is a primary organizing concept which mediates theory and practice (Gibson 2016).

As a consequence of being labeled as both disabled and a child, disabled children occupy a precarious intersectional position whereby their bodies and experiences are often made subject to intense medical and psychological scrutiny (e.g., through biomedicine and developmentalism, to name a few) (Priestly 2003; Slater 2015). Situated within CDS, disabled children’s childhood studies (DCCS) draw on the experiences of disabled children and youth to develop theories about their childhoods (Curran & Runswick-Cole 2013). DCCS critically interrogates the intersectionality of disability and childhood and considers disabled sensibilities. We draw on DCCS to highlight and challenge the ableist and adult-dominated discourses prevalent in children’s rehabilitation. We theorize notions of disabled childhoods and children as socio-cultural categories shaped by particular structural conditions and adult-dominated discourses. We use the term ‘childhoods’ (plural) to highlight the variability of disabled children’s experiences and the social, temporal, cultural and political contexts in which they are located.

Methodology, Aims and Objectives

Given these insight, this paper aims to analyze the construction of disabled childhoods within children’s rehabilitation textbooks. We do so using Fairclough’s (1992) critical discourse analysis (CDA) methodology. CDA approaches language as both reflecting and perpetuating power structures and ideologies. It maintains that language is always embedded in a particular discourse (Cheek 2000; Willig 2014). Thus, language is never neutral, and always reflects and perpetuates a particular understanding of the world. In conjunction with post-structuralism, CDA maintains that ‘texts,’ such as language, words, talk and visual representations, are never value-neutral and thus change meaning depending on the discourse from which they emerge. Thus, discourses do not merely reflect or represent social entities and relations, but rather, they construct or constitute them (Fairclough 1992: 3). In the context of rehabilitation, different discourses constitute normal/abnormal in different ways, and position childhood disability in different ways. Importantly, CDA focuses on these social effects of discourses (Crowe 2005). Moreover, attending to the ways in which language shapes how disability and disabled childhood is understood and addressed advances critical insight regarding how categories of difference come to matter. From a critical disability studies perspective, these insights highlight how categories and terms such as ‘disabled’ and ‘disabled childhood’ sustain particular ways of being, and of bodies, which contribute to binary divisions of people.

Drawing on CDA, our analysis aimed to interrogate contemporary children’s rehabilitation textbooks in order to uncover and explore latent assumptions and meanings within them. Specifically, our analyses addressed three overlapping objectives: (i) identify dominant discourses within children’s rehabilitation textbooks; (ii) examine how these discursive frameworks construct childhood disability; and (iii) explore how these ideas mediate what constitutes a problem to be addressed in rehabilitation. The study’s first objective required a careful reading of the texts to identify dominant discursive frameworks, and the second aim involved a critical interpretation to reveal how the discourses shape particular understandings of disabled children and childhoods and their effects. In this sense, the key task, as elaborated in the third aim, was to explore how these ideas mediate children’s rehabilitation practices.

Methods

To address the study objectives, we conducted a CDA of contemporary children’s rehabilitation textbooks. Our focus was on how the texts constituted cultural representations of prevailing ideas regarding disabled children that underpin current ‘best’ practices in NA. To be included, textbooks had to be in print, have a primary focus on children’s rehabilitation, and have been published in NA in English within the last eight years. Consistent with our CDA methodology, the intent was not to identify an exhaustive list of international textbooks for inclusion. Rather, the purpose was to conduct an in-depth interrogation of representative texts that exemplify the state of the current field within a bounded context (NA).

The identification of texts for inclusion in the analysis was conducted in four stages. In stage one, potential textbooks were identified through a broad-based online search using a combination of the following keywords: ‘disability,’ ‘children,’ ‘pediatric,’ ‘disabled children,’ ‘children’s rehabilitation,’ ‘occupational therapy’ and/or ‘physical/physiotherapy.’ With the help of a librarian, DM searched electronic databases and online bookstores/sources to identify an initial set of contemporary texts (n = 17). In the second stage, DM conducted an additional online search for NA rehabilitation course syllabi using the key terms. DM then hand searched these syllabi and identified 13 additional textbooks for a total of 30 texts.

In stage three, DM ensured the texts focused on disabled children’s rehabilitation by reading the preface, table of contents and introduction of each textbook. Texts were omitted if they: 1) were not from within rehabilitation sciences and/or were not within the areas of physiotherapy, occupational therapy or general rehabilitation; 2) did not discuss childhood disability; 3) focused exclusively on a particular diagnosis (e.g., autism); 4) focused exclusively on empirical case studies; and/or 5) were not published in NA (n = 10).

In stage four, further inclusion/exclusion criteria were applied to ensure the remaining 20 textbooks explicitly discussed the theoretical grounding of the book. DM read one to four relevant chapters of each textbook which outlined the theoretical framework. Textbooks that did not explicate their theoretical grounding, or did so very briefly, were omitted (n = 6).

A total of eight textbooks remained for inclusion in analysis; two in general children’s rehabilitation, three oriented to occupational therapy, and three oriented to physiotherapy (see Table 1).

Table 1

Analyzed Textbooks.


TEXTBOOK PROFESSIONAL DISCIPLINE NAME USED IN THE PAPER

Pediatric Rehabilitation: Principles and Practice (Alexander & Matthews 2015) General Rehabilitation Rehab1

Pediatrics (Nelson 2011) General Rehabilitation Rehab2

Occupational Therapy for Children and Adolescents (Case-Smith & O’Brien 2014) Occupational therapy OT1

Occupational Therapy Evaluation for Children: A Pocket Guide (Mulligan S. 2014) Occupational therapy OT2

Best Practices Occupational Therapy for Children and Families in Community Setting (Dunn 2011) Occupational therapy OT3

Meeting the Physical Therapy Needs of Children (Effgen 2013) Physiotherapy PT1

Pediatric Physical Therapy (Tecklin 2015) Physiotherapy PT2

Campbell’s Physical Therapy for Children: Expert Consult (Palisano, Orlin & Schreiber 2018) Physiotherapy PT3

Analytic approach

As an interpretive process, CDA focuses on any combination of words, texts, or symbolic meanings (Fairclough 1992). Analysis involves (re)examining texts to uncover how they structure reality and produce hidden meanings. To conduct our CDA, we adapted Crowe’s (2005) analytical approach to ask the following questions of the data:

  1. Why, how, when, and where was the text developed and for what purpose?
  2. How is authority to speak about disabled children established?
  3. What key concepts are developed? How is value attributed to some ideas but not others?
  4. How are ways of being in the world (i.e., disabled childhoods), and social relations constructed and constrained by the understandings of disability and childhood put forward?
  5. How are the available ways of thinking and speaking about disabled children promoting some understandings of disability and childhood whilst denying others?
  6. What truths are being privileged, why these truths and not others, and why now?

Questions were used as sensitizing strategies to guide our interpretations. DM led the analysis as follows. All textbooks were read individually, and analytical notes were organized using an extensive process of memo-ing for individual texts and across texts (Birks, Chapman, and Francis 2008). Once all the textbooks were read, DM met with BG to share and discuss initial impressions and develop a plan for further analyses. DM then analyzed the memos for insights and discursive patterns by iteratively reading within and across the memos and the texts to identify and interpret the linguistic strategies used to construct disabled childhoods. This included interrogating details about the texts such as: what types of discourses were incorporated; what sources were cited to support its claims; what particular understandings of ‘reality’ were produced; and whose voices were included/excluded from these discursive ‘realities.’ DM then generated a list of regularities, key concepts, and prevailing discourses which were further refined with BG. Both authors drew on our positionalities as non-disabled researchers whose work focuses on integrating disability studies into rehabilitation. One of us (BG) is a physiotherapist.

Analysis: The Pervasiveness of the Discourse of Normal/Abnormal

The texts drew from a variety of discourses to conceptualize disabled children and ‘childhood’ which we explore further below, but what was most striking was how all the textbooks claimed to be oriented to understanding disability through the World Health Organization’s (WHO) International Classification of Functioning Health and Disability (ICF) framing. Although the ICF arguably advances a ‘holistic’ approach to disability and impairments, our analysis suggests that the discourse of normal/abnormal insidiously underpins the theoretical foundation of the ICF, which is reflected in the textbooks. In what follows, we organize our analysis to explicate how the discourse of normal/abnormal is reproduced in the ICF and pervasively reiterated through other discourses, logics and approaches to disability identified across the textbooks. To ground this discussion and provide context, we begin by briefly describing the ICF and its development. Next, we provide our analysis of how the ICF and related discourses are presented and applied to children’s rehabilitation within the texts. Finally, we critique the ways in which the textbooks conceptualize disabled children as ‘abnormal-becoming-normal,’ which impacts how disabled childhoods are understood and the types of therapies and interventions deemed most appropriate.

The International Classification of Functioning Health and Disability (ICF)

The precursor to the ICF was the International Classification of Impairments, Disabilities and Handicaps (ICIDH) (WHO 1980). The ICIDH was critiqued for the way it located the source of disability within the malfunctioning biological body and failed to acknowledge the role of the environment (Bickenbach 2001; Imrie 2004; Ravaud & Stiker 2001). As a corrective, the ICF contends that disability is multidimensional and interactive, meaning that all components of disability are important and interconnected with one another (WHO 2001: 9). The ICF asserts that the presence of impairment is not an immediate indicator of disability, and that the environment plays an influential role in mediating health and function.

The ICF divides ‘functional performance’ into three sub-categories, including ‘body functioning and structures,’ ‘activity limitations’ and ‘participation restrictions,’ and contends that ‘function’ is a direct result of the interaction between personal and environmental factors (WHO 2001). Disability and functioning are seen as outcomes of interactions between these components of ‘health conditions’ and ‘environmental factors’ (10). Each component of the ICF contains hierarchically arranged domains. These are sets of related physiological functions, anatomical structures, actions, tasks, areas of life, and external influences. Each domain has an associated code that is used to record the extent of functioning or disability, and the extent to which an environmental factor is a facilitator or a barrier.

Within rehabilitation the introduction of the ICF has helped to accelerate changes to rehabilitation philosophy, practice, education, and research (Darrah 2008; Gibson 2016; Leplège, Barral, McPherson 2015;). Most notably, the ICF addresses limitations within the medical/disease model and considers function and health in relation to personal and environmental factors. This shift in perspective allows rehabilitation professionals to consider their patients with a more holistic lens, while also considering the complexities of functioning and environments.

Discourses of normal/abnormal in children’s rehabilitation textbooks

Impairment and development as ‘scientific truths’

Across both the textbooks and the ICF, the binary of normal/abnormal is reproduced through logics that posit the world can be understood objectively. For example, the ICF defines impairment as

a deviation from certain generally accepted population standards in the biomedical status of the body and its functions […] Abnormality here is used strictly to refer to a significant variation from established statistical norms […] and should be used only in this sense (WHO 2001: 213).

In other words, what counts as biomedically ‘typical’ is a statistically generated norm and used as a standard against which the impaired body is constituted. Although the ICF acknowledges how sociomaterial factors influence the meaning and consequences of impairment, the biological body remains an indisputable fact, and impairment—as denoted in ‘body functions and structure’—is seen as a ‘pre-social’ biological difference (Imrie 2004: 35). In drawing on the ICF’s notion of impairment, the texts position disability as an objectively negative form of bodily deviance that requires careful assessment and intervention, and thus, reproduce the discourse of normal/abnormal. Rehab1 states ‘The examiner should determine whether the patient is an essentially well child with impairment or a sick child’ (Rehab1, 2). Similarly, OT 1 claims ‘When evaluating a child’s performance, the occupational therapist determines how performance is influenced by impairment, and how the environment supports or constrains performance.’ (OT1: 1). In both instances, the authors advance the notion that impairment is problematic regardless of environmental influences. Such statements uphold the dualism of normal/abnormal by advancing an understanding of impairment as inherently problematic and in need of intervention.

The discourse of normal/abnormal is also reproduced through a reliance on developmentalism as central to understanding disabled children and childhoods. This is exemplified through statements such as ‘It is helpful to consider classic development when evaluating a child in whom there are concerns about abnormalities or deficits’ (Rehab2: 1). PT1 claims ‘it is important when working with children to determine their developmental and functional status’ (11). Here, the notion of typical or ‘normal development’ is the referent upon which the ‘problem’ of ‘disabled childhood’ is conceptualized. Presumably well-intended, these approaches to disability and childhoods reinforce the discourse of normal/abnormal by positioning ‘disabled childhood’ as inherently problematic, and disability as internal to individual children.

Development, as an organizing concept, also influences the design of therapies and the goals which disabled children, as ‘abnormal,’ must pursue. For example, the texts state:

(the) motor developmental sequence offers PTs a foundation for studying and understanding not only typical development, but also aberrant or atypical development of the child. This developmental sequence may be used as a basis for evaluating, assessing, and treating motor delays and deficiencies (PT3: 18); and

When a task challenges both cognitive and motor skills, the young child becomes fully engaged, and the activity has high therapeutic potential for improving the child’s developmental level of performance (OT1: 16–17).

In both cases development functions as an objective, value-free scientific ‘truth’ that permits and requires rehabilitation professions to make normative-judgements regarding children’s best-interests. Language such as ‘deficiencies, aberrant and atypical’ reproduce the assumption that ‘evaluating and treating’ disabled children is good/necessary. This reinforces the assumption that disabled children always and necessarily need or want fixing, and that achieving/approximating developmental norms characterizes successful rehabilitation. In drawing on developmentalism, the textbooks advance therapeutic approaches which aim to ameliorate disability on the basis that ‘normal’ development is a universal and objective scientific ‘fact.’ Statements regarding the ‘therapeutic potential’ to ‘improve developmental performance’ further exemplify how rehabilitation relies on the assumption that pursuing developmental norms is always desired and/or necessarily fruitful, and indeed working with children to improve their functional abilities is often welcomed.

The ICF’s notion of impairment and developmentalism both function as scientific truths that posit the world can be understood objectively. While the ICF conceives of impairment as a negative deviation from the ‘natural’ biological body, developmentalism advances the logic that humans can grow in right/wrong ways. While the ICF promulgates a statistical interpretation of normal/abnormal bodies, developmentalism perpetuates the idea that ‘growth’ is subject to measurement and observation. Each constructs a deviation from the norm as a problem that is amenable to intervention.

Discourses can have unintended effects. In drawing totalizing conclusions about human bodies and abilities, both the ICF and developmentalism advance universal approaches to well-being which may not be feasible and/or desirable for all people. Like the ICF’s notion of impairment, ‘normal’ development operates on the assumption that approximating normal bodies and abilities translates to a ‘good’ life. In drawing on this assumption, the textbooks operate from the logic that abnormality in body structure, function, and ‘growth’ necessarily hinders an individual’s ability to have positive experiences. Surrounded by these ideas that underpin assessment and treatment, disabled children risk internalizing the idea that they are inherently ‘broken’ and in need of fixing in order to live a ‘good’ life. Such approaches disavow alternative narratives of disabled childhoods in favor of approximating a pre-conceived idea of a ‘good’ life. While the idea of development in and of itself is not necessarily ‘bad,’ its use within children’s rehabilitation textbooks risks perpetuating these harms. Addressing this risk requires further consideration in terms of how to acknowledge and appreciate diversity of children’s bodies and abilities, and whether or not ‘normalization’ of these differences is in fact always an appropriate goal.

Normal/Abnormal and disciplinary power

The discourse of normal/abnormal is also reflected in principles such as participation and performance which function as mechanisms of ‘disciplinary power’ (Foucault 1995). Disciplinary power is a form of ‘governmentality,’ whereby individuals adhere to dominant and acceptable ways of behaving through regulation and self-control (Foucault 1988). Throughout the texts, positive participation and performance—as instruments of disciplinary power—are positioned as central to living a ‘good’ life. Rehab1 states ‘Opportunities to meet and play with other children in addition to school or home contacts, visits and sleepovers with friends, and participation in various recreational activities are formative experiences that prepare all youngsters for social functioning and adulthood’ (4). Similarly, OT2 advocates a ‘focus on family and child goals, increasing participation, and motivation’ (4). Conversely, limitations in participation and performance are deemed as in need of intervention. PT1 states ‘Once the impairments in body structures and function in each of the systems are identified, along with restrictions in activities and participation, then an appropriate plan of care for intervention can be determined’ (13). The ICF defines participation as ‘involvement in a life situation’ (WHO 2001: 10), while performance is a domain that describes ‘what an individual does in his or her environment’ (11). The ICF contends that limitations or restrictions in participation are assessed according to statistical population norms:

The standard or norm against which an individual’s capacity and performance is compared to that of an individual without a similar health condition […] The limitation or restriction records the discordance between the observed and the expected performance. The expected performance is the population norm, which represents the experience of people without the specific health condition (WHO 2001: 15–16).

Here, the ICF suggests that the desired performance and level of participation for disabled children is that of a body without a ‘health condition,’ and any deviations are rendered abnormal and problematic. While the textbooks acknowledge the role of the environment in mediating participation, they subscribe to the ICF’s logic and thus operationalize participation and performance in ways that regulate how disabled children should participate and perform. Thus, the textbooks, in invoking the ICF, reproduce the dualism of normal/abnormal, and maintain the latter as problematic and amenable to intervention.

The ways in which the textbooks understand and address social interaction also rely on unnamed normative standards. OT1 describes a ‘strengths-based approach’ to enhancing a young boy’s social participation in a case presentation. The case tells the story of Victor, a 10-year-old boy with ‘high functioning autism’ and ‘significant delays’ in social skills, which impact his ability to interact with his peers.

The therapist, Amy, suggests that he video record his peers on the playground. Using these videos, Victor has examples of appropriate social interactions. He and Amy analyze the videos together […] Amy encourages him to watch some examples of positive social interaction a number of times […] (OT1: 3).

Amy’s therapeutic approach to helping Victor engage with his peers functions as an attempt to integrate Victor into the dominant social order, to fit in with nondisabled peers. Although well-intended, this preoccupation with social leveling is predicated by a desire for social homogenization—that is, a desire for immersion (Stiker 1991: 134). Victor’s behaviors are labelled as inappropriate in reference to an unnamed normative standard, that, like the ICF, valorizes the average/norm while pathologizing difference. This ‘strengths-based approach’ reproduces the understanding of disability as problematic and in need of ‘fixing.’

In holding Victor accountable to pursuing normative participation, Amy’s approach renders Victor as ‘abnormal-becoming-normal.’ Victor’s active engagement in filming his peers functions as a ‘technology-of the-self’ (Foucault 1995) whereby he learns expected and acceptable behaviors while also policing and surveilling his own. In doing so, Victor is evaluated, and also evaluates himself with reference to his ‘normal’ peers (Stiker 1991: 135). As a mechanism of governmentality’ (Foucault 1988), Victor’s use of videography teaches him to govern himself by adhering to dominant ways of behaving.

Through the discourse of abnormal-becoming-normal, the texts also portray disabled children as requiring ‘motivation’ to perform or participate in assessments, therapies, and/or in society more broadly. Statements such as ‘maintaining patient motivation is often challenging’ (PT2: 12) and ‘the child requires the motivation to perform the activity’ implies that lack of motivation is a problem inherent to the child without acknowledging the external mediators of participation, including that those therapies may be boring, frightening, uncomfortable or simply outside of the child’s interests. This is further demonstrated through the development of assessment tools, such as the ‘Pediatric Volitional Questionnaire V2’ which provides ‘An evaluation of a child’s motivation through play-based observation’ (OT2: 192). Thus, the principle of motivation, as described as integral to therapeutic evaluation and assessment, is pathologized and functions as a consequence of the larger discourse of disability as abnormal and in need of ‘fixing.’

In contrast to the understandings advanced by the ICF in the texts, the notion of sameness/normality to which Victor and other disabled children must aspire is not a universal or natural phenomenon, but a construction reflective of contemporary Western neoliberal values. Neoliberalism is a pervasive political economic theory that dominates contemporary Western societies. Drawing together liberalism and capitalism, neoliberalism involves a socio-economic weakening of the state in favor of big businesses and competition (Harvey 2007; Sothern 2007) and stresses personal and economic freedoms (Ayo 2012). Within children’s rehabilitation neoliberal values are often reproduced in notions of individual responsibility for progress and well-being, and in the construction of outcomes oriented to independence, productivity, and self-efficacy (Gibson 2016). The constructed normality to which disabled children are expected to aspire is that of an able-bodied, productive, and self-sufficient adult citizen (Slater 2015; 2016). In turn, disabled children, as deviant and abnormal, pose a direct threat to the assumption that neoliberal adulthood is universally desirable. Their differences must be subsumed under sameness to successfully transition to normative neoliberal adulthood. Thus, Victor’s subjection to disciplinary power functions as a mechanism to uphold a moral imperative—to motivate Victor to engage in self-governance which guarantees his successful development into a neoliberal adult.

OT1 makes this explicit link between disciplinary power (self-governance) and performance (participation) as it describes Amy’s ‘strengths-based approach.’

Interventions rooted in a strengths-based-approach can lead to increased self-efficacy and self-determination. When an OT acknowledges a child’s strength and competence, the child becomes more self-efficacious and motivated, and he/she may be more willing to take on performance challenges” (3).

The text promotes a ‘strengths-based-approach’ because it involves children in interventions while also acknowledging their ‘positive’ traits. However, the conditions under which these ‘positive’ traits are acknowledged are rooted in the discourse of normal/abnormal and utilized to persuade children to comply with professional advice. The child’s strengths are acknowledged not as positive in themselves, but as positive because they might lead to increased motivation for normative social participation. Victor’s use of videography (‘strength’) is employed to facilitate his motivation to want to participate in normative ways. This understanding reinforces approaches whereby ‘A behavior can be elicited and then improved and elaborated on by using shaping or chaining techniques. Shaping involves reinforcing behaviors that are increasingly closer to the desired behavior’ (OT2: 32). Chaining involves teaching behaviors through sequences of actions. While these psycho-behavioral techniques aim to address isolation from peers, this approach operates on the principle that disabled children’s differences universally require modification to meet normative ideals of participation. Whether Victor is interested in group participation or wants to use his interests in videography in these ways is not discussed.

Hansen and Tjørnhøj-Thomsen (2008) refer to the moral imperative of rehabilitation to highlight how certain principles, ideals, or goals replace the desire to cure, thereby requiring individuals to govern themselves. This method of self-regulation stems from rehabilitation professionals’ expectations for cooperation to pursue elements of normality (Røberg, Feiring, & Romsland 2017). From this perspective, disabled children are expected to comply with interventions in order to meet these pre-determined ideals of normalcy. In drawing on the ICF’s notions of impairment, participation, and performance, and their reliance on preconceived notions of normalcy, the textbooks advocate for shared moral imperatives to engage in therapy as a means to achieve normalcy and a ‘good’ life, which reproduces the discourse of normal/abnormal.

Abnormal-becoming-normal: The moral imperative to becoming-adult

As mentioned above, disabled children as ‘abnormal’ are positioned throughout the texts as always at risk of failing to progress to adulthood. In drawing on the ICF’s notions of impairment, participation, and performance, all the analyzed texts conceptualize disabled children as abnormal-becoming-normal. That is, disabled children are characterized by biological malfunctions that hinder their ability to perform desirable tasks in ways that limit participation and consequently, their development into adult citizens. Within these expectations to shift from ‘childhood’ dependence to adulthood independence, disabled children are represented as needing interventions that support their optimal development into adulthood. Statements such as ‘Children with special health care needs are a population who have been or are at risk for chronic physical, developmental, behavioral, or emotional conditions, and require health and related services of a type or amount beyond that required by children generally’ (Rehab1: 12) are plentiful and highlight the pervasive representation of disabled children as abnormal, risky, and in need of intervention. In turn, the textbooks advance the idea that ‘those individuals who remain dependent through adolescence tend to remain dependent through adulthood’ (PT2: 21). Far from neutral, the discourse of disabled children becoming-normal operates on the assumption that young people will ‘develop’/transition into normative adulthood, and as ‘abnormals,’ disabled children are inherently at risk of failing to develop into such adulthood normativity.

Relatedly, the texts consistently referred to neoliberal adulthood as the referent upon which disabled childhood is conceptualized and evaluated. Neoliberal values and beliefs do not challenge developmental discourses or independent/dependent and normal/abnormal binaries, but rather, compound with developmentalism to construct notions of what it means to be a legitimate adult living within neoliberal times. Said differently, neoliberal values that promote, for example, independence, living away from parents, work as central to life’s purpose, etc. pervade rehabilitation practices and, whether intentional or not, promote particular kinds of lives while discouraging others. Throughout the analyzed texts, disabled ‘childhood’ is frequently described as a monolithic transitional phase requiring focused interventions to develop desirable traits such as independence, productivity and self-sufficiency. Statements such as ‘Transition to independence, individuation, and self-determination are key development considerations’ (Rehab2: 8) exemplify the pervasiveness of neoliberal rhetoric and developmentalism in fashioning disabled children as becoming-neoliberal-adults. Successful interventions are described as those that ‘emphasize motivation, self-direction, and self-actualization’ (OT2: 118), that help ‘disabled children develop skills and competencies, experience socialization, and foster initiative and self-efficacy’ (OT2: 128).

This positioning of disabled children as becoming-adults leaves little room for disabled children to enjoy life in the present. For example, disabled children’s ‘free-play,’ that is, spontaneous, voluntary play oriented to pleasure (Beckett et al. 2020) is often appropriated as a means to achieve developmental goals (Goodley & Runswick-Cole 2010). As disabled children’s development is understood as atypical, their play is identified as abnormal, and thus, becomes amenable to assessment and intervention (Burman 2001). This understanding of play as instrumental, as opposed to play for enjoyment, is made explicit within the textbooks through claims such as: ‘For young children, play occupations serve as the means and the end for intervention, and playfulness is part of interventions’(OT1: 15), and ‘Opportunities to meet and play with other children […] are formative experiences that prepare all youngsters for social functioning and adulthood’ (Rehab1: 4). This characterization of play as a site of intervention or as a ‘means to an end’ positions disabled children as youth-becoming-adult in ways that dismisses the here-and-now experiences of varied childhoods to emphasize idealized neoliberal ways of being and living. Engaging children in play during intervention is not necessarily ‘wrong’; however, the reasons for doing so need further questioning. Using play for therapeutic ends leaves unchallenged the assumption that such a life is desirable and preferable for all.

The textbooks’ formulations of play are inherently connected to the ICF’s notions of impairment, performance and participation, and the larger discourse of normal/abnormal. The conceptualization of impairment as a pre-social (biological) abnormality provides the basis upon which play-as-therapy is conceptualized. Play is invoked as a means to elicit and manipulate desirable behaviors and outcomes oriented to an unspoken normative standard. Additionally, ‘optimal’ levels of participation and performance, as defined by statistical norms, position disabled children as in need of intervention in ways that allow for the co-optation of play as a means-to-an-end. Stiker (1991) has similarly noted

Rehabilitation accepts as its norm the empirical norm. The very name alone indicates this. The most widely held belief is, in fact, that if you devote sufficient resources, it is possible to reduce the distance and bring each person, however great the burden she carries, to reoccupy a normal place in the group of the able (normal) (135).

Play is but one of many examples of the ways in which the textbooks reproduce discourses of normal/abnormal. While therapeutic play functions with the intention to positively engage children, it also operates with the intent to elicit and achieve normative standards in social, physical and cognitive ‘growth.’ This understanding of play not only dismisses how children can play for fun or recreational purposes, but it also fails to acknowledge how disabled children are often excluded and/or restricted from play because of social stigma, inaccessible environments, and/or varying physical, cognitive, and neurological differences (Beckett et al. 2020). These approaches to play provide a compelling example of the pervasiveness of discourses of normal/abnormal, which underpin other rehabilitation logics and discourses that were apparent throughout the texts.

Conclusion

Drawing on post-structuralism, CDS and DCCS, this paper has critically examined how children’s rehabilitation textbooks conceptualize disabled children and ‘childhood.’ Our analysis revealed the pervasiveness of the discourse of normal/abnormal expressed through the ICF and other rehabilitation logics. In drawing on the logics of developmentalism, social participation, self-improvement, and play-as-therapy, the texts constructed disability as a ‘problem’ in need of intervention. This representation of disabled children as ‘lacking’ functioned as a moral imperative that required disabled children to engage in self-governance in order to live a ‘good’/‘normal’ life.

In highlighting the pervasiveness of the discourse of normal/abnormal, our analysis suggests that rehabilitation risks holding young people accountable to pursuing goals and ‘outcomes’ that reflect dominant understandings and assumptions regarding positive ways of living and being. In contrast, we have argued that what counts as normal and desirable is not universally ‘real’ but rather, are discursive constructions that reflect particular assumptions and beliefs. For example, within neoliberalism, the ideal adult citizen to which disabled children must aspire to become is one who is productive, independent, and efficacious. These logics are oriented to a particular understanding of what counts as an acceptable and preferable way of living, which reflects and reproduces the discourse of normal/abnormal. In turn, disabled children’s varied needs, preferences, and desires are disavowed in favor of an unspoken normative standard. As we suggest, these principles operate as unquestioned assumptions which mediate what constitutes a problem to be addressed, and the types of therapies and interventions deemed appropriate and necessary.

To enhance children’s rehabilitation, we argue there is a need to critically explore the ‘bad effects of good intentions’ (Mol 2008). Textbooks, other rehabilitation tools, policies, and practices must question the naturalized assumption that disability is an abnormal way of being that always and necessarily requires intervention in order to live a ‘good’ life. For example, development as an organizing concept does not need to be replaced, however, its unwavering application needs questioning in terms of acknowledging the variability that characterizes disabled children’s bodies, abilities and desires. Said differently, it is imperative that rehabilitation acknowledges the origins and emergence of development as culturally produced and grounded in particular assumptions regarding what it means to live a ‘good life.’ Rehabilitation must recognize that such a concept is not ‘natural’ but a contingent human intervention with implications for how disabled children are understood and addressed. Similarly, principles of strengths-based-approaches and play-as-therapy are mediating logics which in and of themselves are not inherently wrong, however, require further consideration as to their application toward the improvement/enhancement of disabled children’s lives. Children’s rehabilitation may be more fruitful in helping disabled children and their families if difference was accepted as the default human condition—that is, if the normal/abnormal binary is disrupted as ‘fact’ and seen as only one way to characterize diverse bodies (Gibson 2019). Such an approach would circumvent the desire to homogenize difference in pursuit of an unspoken normative ideal and allow for disabled children to flourish in unique and meaningful ways.

While our analysis has addressed an important knowledge gap regarding the insidious discourse of normal/abnormal within textbooks, we would like to conclude by highlighting some implications for future research. Our CDA methodology limits analysis to the textual construction of meaning, and thus, should be interpreted with caution in relation to how children’s rehabilitation is practiced. Important avenues for future research should critically engage diverse disabled young people and their families and should expand the scope of inquiry beyond NA to include the global south.

Competing Interests

The authors have no competing interests to declare.

Author contributions

Donya Mosleh led the analysis and consulted with Barbara E. Gibson through a series of analysis meetings. Donya Mosleh wrote the manuscript, and Barbara E. Gibson consulted over several drafts.

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