Underrepresented ethnically and racially diverse aging populations with disabilities: trends and recommendations. (Rehabilitation and Underrepresented Aging Populations).

Diversity and growth are two terms that best describe America's older population. This extensive population is a heterogeneous group, in as much as they differ in relation to age, gender, race, and ethnic backgrounds. Many older persons have significant financial and health problems, while others lead more secure and healthier lives. Some stay in the workforce until death, while others are able to select a more leisurely life style. The advancement of modern technology in medicine, coupled with a better understanding of health care issues, have contributed to prolonged life expectancy, thus giving seniors more options. These changing trends will continue to impact the nation's workforce and economic base well into the Twenty-First Century (U.S. Department of Commerce, 1993). Subsequently, appropriate services and financial resources will be required to support older adults in general, and ethnically and racially diverse seniors with disabilities in particular. According to Myers (1998), "The phenomenon of ageism is an unreasonable prejudice against persons based on chronological age" (p. 137). Ageism is similar in nature to racism, sexism, disabilityism, and other-isms. The lack of understanding issues related to aging by professional counselors, and rehabilitation providers has significant consequences, and further hinders the delivery of needed services to seniors. In order to rectify the disparity in services being provided to underrepresented diverse aging populations with disabilities, human service providers must be retrained and sensitized to the needs, issues and problems associated with aging.

Both the rehabilitation and counseling professions have increasingly emphasized social activism and advocacy to promote positive human growth and development in a complex society (Thomas, 1996). Two momentous pieces of legislation helped increase the activism, independence and developmental opportunities for persons with disabilities. The 1992 and 1998 amendments to the Rehabilitation Act of 1973 (hereinafter, The Rehabilitation Act) and the Americans with Disabilities Act (ADA) bring significant potential for specific reform in the State-Federal Vocational Rehabilitation Program, and American society overall. President George H. W. Bush signed the Rehabilitation Act as amended into law on October 29, 1992. The Rehabilitation Act Amendments of 1992 have many philosophical and practical implications for rehabilitation counselors seeking to expand their client base to work with older adults with disabilities.

The disability community actively lobbied for the incorporation of civil rights or affirmative action provisions in The Rehabilitation Act. These provisions are found in Sections 501, 502, 503, and 504 of Title V. As The Rehabilitation Act undergoes yet another process of re-authorization, there are a number of significant questions that must be addressed. They include questions such as, what is the relevance and implications of these and other legislative reforms for disadvantaged seniors with disabilities? What are the implications for the counselor and rehabilitation practitioner? What policies and/or practices should disability service providers and advocates continue to address? As Congress takes steps to review progress over the last five years with respect to the 1998 Amendments to The Rehabilitation Act, what barriers continue to impede progress toward carrying out these legislative mandates and reforms? These questions will be addressed in this article to increase the rehabilitation practitioners knowledge and understanding regarding the complexities involved in working with historically underrepresented ethnically and racially diverse older adults with disabilities. Before proceeding, however, having a basic understanding of the content of specific aspects of The Rehabilitation Act, its amendments, and the ADA is important for all practitioners. The following highlights a brief overview of specific sections in The Rehabilitation Act, an overview of the ADA, and a definition of "senior status."

Legislation: The Rehabilitation Act Amendments and ADA

The Rehabilitation Act of 1973 and its amendments provide for service delivery to persons with disabilities, promote consumer involvement, stresses program evaluation, provides support for research, and advances the civil rights of persons with disabilities. Section 501 of The Rehabilitation Act calls for affirmative action in federal hiring and mandates nondiscrimination by the federal government in its own hiring practices (Bayh, 1979, p.58). This action established the federal government as a model agency for promoting the recruitment, hiring, and advancing of workers with disabilities. This includes underrepresented older persons who must remain in the workforce well into their senior years. Section 21 of the 1992 Rehabilitation Amendments deals with the provision of rehabilitation services to traditionally under-served populations. Congress found that ethnic and racial members of under-represented populations have disabling conditions at a disproportionately higher rate. Patterns of inequitable treatment of these groups have been documented in all major junctures of the vocational rehabilitation process (Atkins, 1988; Rehabilitation Services Administration, 1993; U.S. Department of Commerce, 1993). The goal of Section 21 was to affirm, value, and ensure that governmental policies represented all Americans. Beyond making rehabilitation services more accessible to all, a wholesale recruitment effort to identify and increase the number of professionals sensitive to the needs of all people with disabilities was encouraged (Middleton, Flowers & Zawaiza, 1996). While these laws serve to establish a platform for the delivery of appropriate services to all underrepresented groups, they cannot and did not legislate attitudes. Hence, among the challenges before us is the need to develop innovative approaches to improve service providers' and society's perceptions of our aging population.

The 1998 amendments to The Rehabilitation Act was linked to the Workforce Investment Act, which required state vocational rehabilitation agencies to partner with the Department of Labor to create employment programs in "one stop centers." The 1998 amendments to The Rehabilitation Act also changed the Individualized Written Rehabilitation Plan (IWRP) to the Individualized Plan of Employment (IPE). Changing the IWRP to the IPE placed more emphases on employment as an important outcome for individuals with disabilities. Perhaps the most significant contribution of the 1998 amendments was the implementation of a Comprehensive System of Personal Development (CSPD). The CSPD established a priority in the hiring practices and training of practitioners to ensure that all practitioners meet the highest standards of professionalism needed to increase opportunities and meaningful outcomes for persons with disabilities. Again, the federal government established itself as a model by first requiring rehabilitation counselors employed in state and federal vocational rehabilitation agencies to meet national certification standards as a Certified Rehabilitation Counselor (CRC) (Sales, 2002). According to Sales (2002), "the challenge of CSPD provides hope for ensuring quality service provisions and improved consumer outcomes are attained." The laws and guidelines are in place; however, there appears to be a void between existing laws, policies, and application/implementation at the service level.

The Americans with Disabilities Act (ADA), which was modeled after Section 504, was signed into law in July 1990. The major difference between Sections 501/503 of The Rehabilitation Act and the ADA is that the former only applies to entities that receive federal assistance, whereas the ADA covers most establishments whether privately owned or helped with state and/or federal funds. As defined by the ADA, an individual with a disability is a person who: (a) has a physical or mental impairment that substantially limits a major life activity, (b) has a record or history of such an impairment, or (c) is regarded as having such an impairment. The ADA continues to raise the bar of service delivery standards and expectations by which professions are to perform. An outcry for policy reform is well on the way. However, as we continue to advocate for policy reform we must also emphasize the importance of improved services to meet the health care, individual, and social needs of older persons. Current laws further demonstrate the intricacies of the entire arena of working with disadvantaged aging populations. They also place pressure on academic institutions to better train graduates and provide inservice continuing education programs. These initiatives should assure improved service excellence to older adults with disabilities. Presently, there are no comprehensive service programs in place that contains all of the components of a superior delivery system for this underrepresented population.

The Population Defined

A first step in establishing services for older adults with disabilities is that of defining the population. Many agencies and programs use 65 as their definition of aged (Blake, 1981). According to Wray (1992), current health and social policies often identify persons chronologically: as younger-old (ages 65 to 74), old (ages 75 to 84), and older-old (age 85 and above). For example, the Social Security Act of 1935 established age 65 as the age of retirement, thus establishing this stage in life as old age (Ganikos, 1979). While one's chronological age is useful in determining eligibility for certain services, our greatest concern should be with capabilities or potential rather than with limitations set arbitrarily because of age (Blake, 1981). Additionally, different cultures mark entrance into older age through social changes such as becoming grandparents, retirement, or functional status, rather than chronological age. Therefore, persons may be recognized as elders at widely divergent ages (Wray, 1992). For example, in some cultures when people reach age 40 they are considered elders. This is true for many Southeast Asian and Native American groups. Consequently, beyond chronological age, older persons with disabilities may be defined as the individuals who accept the stereotypes of aging or ageism, and/or eventually experiences physical, emotional, or a psychological breakdown because of that acceptance (Middleton & McDaniel, 1990). Ageism is the general prejudice in both attitude and/or treatments toward older persons (Middleton & McDaniel, 1990). Chronological age should not be used as the only criteria for determining senior status. Rather, the emphasis is on the individual's attitude and overall adjustment toward their own aging.

As the number of people aging in our country increases, it is apparent that the demographic transformation is well underway with respect to historically underrepresented racially and ethnically diverse populations with disabilities. The U.S. Department of Commerce (1993) reported that there were 31.1 million elderly Americans in 1990. Between 1990 and 2020, this population is expected to increase to 54 million. Elderly Latino Americans made up approximately 5% of the population in 2002. By 2050 this population is estimated to comprise 16% of the population. Similarly, African Americans comprised 8% of the U.S. elderly population in 2002 and are expected to make up 12% of the elderly population by 2050 (U.S. Census Bureau, 2001). In 1990, 10% of all persons age 65 and older were ethnically diverse and by 2025, 15% of the older population is projected to be ethnically diverse, and by 2050, 20% of the population will represent persons from racially/culturally diverse backgrounds (Wray, 1992).

During the last century, life expectancy has improved dramatically, although unevenly, across minority and majority groups. According to Wray (1992) for example, in 1987 life expectancies at birth for all persons was 75 years, ranging from a low of 65 years for African American men to 79 years for White women. While Asian and Pacific Islanders tend to have life expectancies equivalent to or exceeding Whites, the higher numbers obscure considerably intragroup diversity: For example, the life expectancy of Japanese Americans is many years higher than the life expectancy of recent Cambodian refugees. The lower life expectancy for many ethnic minority groups and subgroups stem largely from their disproportionately higher rates of poverty, malnutrition and poor health care. Each of these factors has a bearing on the high rate of disability found among ethnically and racially diverse underrepresented groups. It is interesting to note that Native Americans differ from all other ethnic groups in that they have the highest incidents of disabling conditions. They are faced with a multitude of health and social issues such as suicide, alcoholism, diabetes, low levels of education, domestic violence, unemployment, language barriers, and a host of other problems. Ultimately, all of these issues contribute to the quality of life and longevity. Even those who are fortunate enough to live into their senior years will be confronted with a plethora of health and social issues/needs (Bryan, 1999).

The U.S. Department of Commerce reported in a June, 2001 news release that people age 65 years and older represent 14% of the civilian job force, and 9.7% had incomes below the poverty level (U.S. Department of Commerce, 2001). Given their generally low socioeconomic status and limited access to health care, it is not surprising that elderly women, African Americans, and Latino/Latina Americans top the list of having the highest prevalence of chronic disabling conditions. For example, the U.S. Census Bureau (1995) reported that 16% of elderly women live in poverty verses 9% of their male counterparts. Diabetes, hypertension and heart problems are among the top five most common health problems in older adults. The rates of hypertension are especially high among elderly African Americans. The U.S. Census Bureau (2001) reports that 59% of African Americans and Latino/Latina Americans suffer from hypertension at a rate of 59% and 11% respectively, greater than their European American counterparts. Additionally, aging African Americans are more likely to suffer from complications of diabetes such as vision problems, renal problems, and amputations. Given the aforementioned demographics relative to poverty and health issues, the single most significant development in the field of rehabilitation in the new millennium continues to be the issue of serving aging Americans with disabilities. Legislation and current rehabilitation practices must extend service provisions necessary to increase opportunities for this growing population.

Disability Policy Reform

Older persons with disabilities are an underserved population within the counseling and rehabilitation professions (Hansen & Perlman, 1991; Myers, 1986, 1998). This is largely because counseling and rehabilitation systems currently in place to serve individuals with disabilities are woefully unprepared to address the rapidly growing problems and needs of the elderly. In the past, the aging was not considered a constituency of the counseling and rehabilitation profession; however, conditions have altered the way we view this population. This phenomenon has occurred because people are living longer and placing greater demands on existing infrastructures. Additionally, this lack of preparedness has stemmed from the absence of strong social, economic, and political advocacy on behalf of older Americans. This country guarantees all of us certain basic rights, however, policy development and enforcement are critical to the process of systems being changed. To eliminate the problems associated with underserved older persons with disabilities, we must restructure our core values to embrace a more inclusive set of policies and procedures.

Older persons in general face major challenges related to aging; however, seniors with disabilities experience even greater stereotypes. Often when there is no real evidence of a physical or mental impairment, seniors are perceived as having an impairment (Butler, 1994; McCracken, Hayes, & Dell, 1997; Middleton & McDaniel, 1990). Consequently, either by regard or actuality, older persons with disabilities are covered under the ADA. Some examples of disabling conditions covered by the ADA that some older persons may be currently dealing with includes anxiety disorders, manic-depression, AIDS, narcolepsy, alcohol or drug addiction (so long as the individual is not a current user or unlawful drug user) cardiac disease, etc. The courts have held that these impairments and other conditions may render a person disabled (Lindsay, 1989/90). However, some of these same conditions might not result in making an individual disabled if it is unclear whether the impairment limits a "major life activity."

It is clear, however, that older persons with disabilities--like any other population--can benefit from counseling and other health care and human services. If we are to plan and provide effective services for older persons, assessing and evaluating the combined impact of both physical and mental conditions is important (Myers, 1994). Physical illness and disability do not occur in isolation. Rather, biological processes interact with psychological and social factors. Therefore, the importance of avocational activities and meaningful socialization in an individual's personal and social adjustment to aging is also important (Middleton, Rollins, Flowers & Crow, 1997). We also know that physical problems can lead to mental and emotional disturbance, emotional distress can exacerbate physical symptoms, and other combinations of both can lead to significant clinical impairments (Cohen, 1990; Kemp, 1986).

From a rehabilitation standpoint, people who experience the onset of a disability in their senior years may take a fatalistic and passive approach toward an acquired disability. Disability may initially be thought of as a disengagement from common life activities, of approaching an end, and sometimes an accelerated course toward death (Hansen & Perlman, 1991). Thus, as we strive to improve human service professionals and society's attitudes and perceptions of older persons, we must also work to improve the perceptions of older persons themselves. With respect to the entire disability-related service system, we can attribute the independent living movement with having a dramatic effect on challenging many premises upon which the system had been built (Nosek, 1992). However, where this population is concerned, there yet exists an extraordinary potential for real reform in disability policy and practice in both the counseling and rehabilitation professions.

If we are to achieve real reform, the authors believe that rehabilitation and counseling practitioners seeking to serve older persons with disabilities must also become proactive in seeking collaborative involvement with other health care and human service professions (nursing, biology, sociology, psychiatry, social work, etc.). Rehabilitation education and counselor education training programs must begin thinking and training their students to recognize the importance of interdisciplinary assessment and treatment for older persons (Myers, 1994; 1998). This truly becomes an important consideration when working with older ethnically and racially diverse populations given the demographic information previously cited regarding the growth of members in this group. What is painfully true is that the combination of advanced age, disability, and ethnic/racial diversity status further complicates the rehabilitation process (Middleton, Rollins, Flowers & Crow, 1997).

The rehabilitation and counseling professions must advance a facilitative service-oriented process enabling persons with disabilities to attain usefulness and satisfaction in life. Additionally, the need for preventive and innovative strategies in rehabilitation service provision for older persons is a continuing need (Middleton & McDaniel, 1990). Working in concert, rehabilitation and counseling professionals could, with unmatched efficiency, assist this population in obtaining or maintaining their desired quality of life. Nevertheless, there are far too many barriers that prevent this from happening.

Barriers and Recommendations for Change

One noted barrier to collaborative service provision between the counseling and rehabilitation professions is the fact that rehabilitation too many times is not deemed to be rehabilitation unless it has work as a necessary outcome. This belief creates a vacuum of much needed services by many older persons with disabilities. Some may just be exiting the work force, or making personal and social adjustment transitions from work roles to avocational roles (Middleton & McDaniel, 1990). For many older persons with disabilities, counseling may be needed to effectively make these transitional adjustments. However, in the current state-federal rehabilitation program, counseling would not be deemed an appropriate service simply because work is not the primary outcome (Middleton et al., 1997). Service providers and advocates must continue to strengthen and/or reform present policies to meet the unique needs of the aging. The rehabilitation plan must also build in safeguards that allow consultation services that assist older persons with disabilities to achieve a smooth transition as they exit the world of work. Additionally, this aging population must be viewed as a diverse group with varying ethnic and racial backgrounds. While this article does not lend itself to a discussion of multicultural issues as they relate to ethnic and racial minorities, the reader is advised to become knowledgeable about diverse populations and social/political influences affecting these diverse groups individually and collectively.

Second, attitudinal barriers and social integration remain obstacles to overcome (Hershenson, 1992; Kaplan, 1990). As a counselor for older individuals, the goal should be to assist them in dealing effectively with present and future difficulties. Or, with those difficulties that occur because one is "perceived" or "treated" as if they are disabled. A third barrier is the fact that the provision of mental health counseling to older persons continues to be an emerging specialty (Sue et al., 1999). This issue also relates to the fourth barrier identified: counselor training programs rarely provide opportunities for interdisciplinary collaborations. This practice is inconsistent with the belief that no single discipline--rehabilitation, counseling, medicine, nursing, biology, sociology, or psychiatry--can meet the needs of this multifaceted population. Fifth, the preparation of counselors who have specialized training and skills to meet the multifaceted needs of older persons with disabilities must be expanded to reflect the demographic changes of our society if they are to effect positive changes. This can be partially addressed through specialized practicum and internship placements in agencies serving an aging population. Additionally, course curricula should be expanded to include relevant information on the multifaceted needs of aging persons. Inservice training specifically designed to train professionals to work effectively with an aging population is another method for addressing this issue. Practitioners are also encouraged to "know the cultures" of the multicultural client population they are serving in the United States (Arredondo et al., 1996). Therefore, it becomes the responsibility of the rehabilitation service provider and the rehabilitation educator to seek and offer expanded experiences that are a part of aging, dying, and death (Kemp, 1984) if these experiences and opportunities are not a part of one's counselor preparation program (Middleton et al., 1996). The older person becomes the teacher and the practitioner becomes the student (Kemp, 1984).

If collaboration among the professions is to become a reality, as professionals we must advocate for a national policy that supports interdisciplinary efforts on behalf of aging Americans. This policy reform should also be paired with needed policies supporting appropriate services for older persons with disabilities. The professions have been asking for years for a coordinated federal policy in each of these areas (Bass, Kutza, & Torres-Gil, 1990; Hansen & Perlman, 1991; Myers, 1994). The "graying of America" is rapidly becoming a reality. It is predicted that during the first half of the Twenty-First Century more than half of the America population will be over the age of 50. Bryan (1999) believes that this population will have tremendous political and financial influences, thus changing the way we provide services to this group. As professional service providers, rehabilitation and counseling professionals must be prepared to meet the needs of this vital population.

Conclusion

Service needs among aging historically underrepresented racially and ethnically diverse populations with disabilities are increasing at an alarming rate in the United States. Consequently, it is obvious that current rehabilitation legislation and practices must be refined and extended to provide opportunities for this population. The Rehabilitation Act of 1973, the 1992 and 1998 amendments to the Act, and the Americans with Disabilities Act (ADA) are but three vital prices of legislation that have assisted all people with disabilities to be more inclusive in society's mainstream. It is also apparent that each of these legislative initiatives establishes the potential for real reform for future disability policy and practice for the disadvantaged aging population, well into the next century.

In summary, it is clear that rehabilitation and counseling practices desperately need to be reformed. In addition to reinforcing present laws, we must tweak the present system to make sure no disadvantaged aging individual is left behind. Aging should not become a burden, but should represent the crowning point of one's life. Not only do we have a legal responsibility to provide appropriate services to seniors, but we have a moral responsibility as well. The key to effective service reform will include effective leadership, communication, collaboration, training, advocacy, and innovative legislative initiatives. These issues are particularly important to ethnically and racially disadvantaged aging people with disabilities. Additionally, we must also educate the general population to be more accommodating and sensitive to the needs of these individuals.

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Dr. Vivian M. Larkin, Department of Rehabilitation and Special Education, 1228 Haley Center, Auburn University, AL 36849-5226. E-mail: [e-mail]

Vivian M. Larkin
Auburn University

Reginald J. Alston
University of Illinois

Renee A. Middleton
Auburn University

Keith B. Wilson
The Pennsylvania State University