International Classification of Function, Disability and Health (ICF) Dr Ger Craddock

International Classification of Function, Disability and Health (ICF)

Dr Ger Craddock

ICF

World Health Organization Classification Assessment Surveys & Terminology Group

WHO Family of WHO Family of International International

ClassificationsClassificationswww.who.int/classification/icf

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International Classification of Functioning, Disability and Health

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ICF Applications

Health sector Social security Education sector Labour sector Economics & development sector Legislation & law Other ….

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Definitions

Impairment Loss or abnormality in body structure or function (including mental function)

Activity Limitations

Difficulties individual may have in executing activities in terms of quantity or quality

Participation Restrictions

Problems an individual may experience in involvement in life situations

Facilitators & Barriers

Environmental factors may be a facilitator for one person & barrier for another

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ICF Components

Body functions Physiological functions of body systems

Body Structures Structural or anatomical parts of the body

Activities Execution of a task or action by an individual (individual perspective)

Participation Persons involvement in a life situation (societal perspective)

Environmental Factors All aspects of the external world that impact on the

person’s functioning

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ICF Structure

Two parts:1. Functioning and Disability

a) Body functions and structuresb) Activities and Participation

2. Contextual Factorsa) Environmental factorb) Personal factors

Family of Who Classifications

ICF belongs to the WHO family of international classifications, the best known member of which is the ICD-10 (the International Statistical Classification of Diseases and Related Health Problems). ICD-10 gives users an etiological framework for the classification, by diagnosis, of diseases, disorders and other health conditions.

WHO Family

By contrast, ICF classifies functioning and disability associated with health conditions. The ICD-10 and ICF are complementary.

Encouraged to use them together to create a broader and more meaningful picture of the experience of health of individuals and populations.

In short, ICD-10 is mainly used to classify causes of death, but ICF classifies health.


Originally ICIDH (international Classification of Impairments, disabilities and Handicaps 1980) now ICF (International Classification of Function, disability and health 2001)

Classification was conceived as means to evaluate the effectiveness of health care processes


Classification envisioned for three uses Statistics on the consequences of

disease Statistics on use of health services Conditions classified according to

categories

Why ICF?

There is also an increased recognition among policy makers and service agencies that reductions in the incidence and severity of disability in a population can be brought about by 1)enhancing the functional capacity of the person

and 2) by improving performance by modifying features of

the social and physical environment. To analyze the impact of these different interventions,

we need a way of classifying domains of areas of life as well as the environmental factors that improve performance.

ICF allows us to record this information.

THE MODEL OF ICF

The medical model views disability as a feature of the person, directly caused by disease, trauma or other health condition, which requires medical care provided in the form of individual treatment by professionals. Disability, in this model, calls for medical or other treatment or intervention, to 'correct' the problem with the individual

The ICF Model

The social model of disability, on the other hand, sees disability as a socially created problem and not at all an attribute of an individual. On the social model, disability demands a political response, since the problem is created by an unaccommodating physical environment brought about by attitudes and other features of the social environment.

The ICF Model

On their own, neither model is adequate, although both are partially valid.

Disability is a complex phenomena that is both a problem at the level of a person's body, and a complex and primarily social phenomena. Disability is an interaction between features of the person and features of the overall context in which the person lives, but some aspects of disability are almost entirely internal to the person, while another aspect is almost entirely external.

Summary: Both medical and social responses are appropriate to the problems associated with disability; we cannot wholly reject either kind of intervention.

The ICF Model

A better model of disability,? synthesize what is true in the medical and social models, without making the mistake each makes in reducing the whole, complex notion of disability to one of its aspects.

This model of disability is called the biopsychosocial model.

ICF is based on this model, an integration of medical and social. This provides a coherent view of different perspectives of health: biological, individual and social.


The ICF was given a mandate to develop a “global common language” in the field of health and disability. The overall objective of the ICF was to develop an operational classification system on human functioning and disability that

Was applicable to every human being. (universality) Addressed multiple dimensions regarding the

‘person’ and ‘environment’ (at body, person and society levels)

Was sensitive to International practices, Was based on user needs Was empirically based with field trials on

applicability, reliability and utility.

Cultural Applicability

• Conceptual and functional equivalence of Classification Conceptual and functional equivalence of Classification • TranslatabilityTranslatability• UsabilityUsability• International ComparisonsInternational Comparisons

Foundations of ICFFoundations of ICF

Human Functioning Human Functioning - - notnot merely disability merely disability

Universal Model Universal Model - - notnot a minority model a minority model

Integrative Model Integrative Model - - notnot merely medical or social merely medical or social

Interactive Model Interactive Model - - notnot linear progressive linear progressive

Parity Parity - - notnot etiological causality etiological causality

Context - inclusive Context - inclusive - - notnot person aloneperson alone

Cultural applicability Cultural applicability - - notnot western concepts ? western concepts ?

Operational Operational - - notnot theory driven alone theory driven alone

Life span coverage Life span coverage - - notnot adult driven ? adult driven ?

The ICF

Uses neutral terms to identify function at the Body function, activity and participation level rather that impairment, disability and handicap

The ICF The addition of the emphasis on the

interaction of environmental features, both physical and social, adds an important context within which persons with disabilities can be evaluated

Increased emphasis on function i.e. does the intervention you propose maintain or improve function

Accordingly when measuring outcomes, the effectiveness of the intervention must be seen in the context of the user’s environments

Health Condition Health Condition ((disorder/diseasedisorder/disease))

Interaction of ConceptsInteraction of ConceptsICF 2001ICF 2001

Environmental Environmental FactorsFactors

Personal Personal FactorsFactors

Body Body function&structurefunction&structure

(Impairment(Impairment))

ActivitiesActivities(Limitation)(Limitation)

ParticipationParticipation(Restriction)(Restriction)

ICF Components

Body FunctionsBody Functions&&

StructuresStructures

Activities Activities & &

ParticipationParticipation

Environmental Environmental FactorsFactors

BarriersBarriers

FacilitatorsFacilitators

Functions Functions

Structures Structures

CapacityCapacity

PerformancePerformance

Activity & Participation

Body functions& structures

Impairedbody functions& structures

Limitation in activityRestriction in participation

Disability

Functioning

Activity is the execution of a task or action by an individual.

It represents the individual perspective of functioning.

Participation is involvement in a life situation.

It represents the societal perspective of functioning.

Body structures and functions

The ICF includes 4 dimensions Impairments at a body level Activities at the person level (formerly

disability) Participation at the social level (formerly

handicap) Contextual factors which list physical

environment factors, such social environment factors, laws, attitudes

Interaction of the environmental factors with the 3 levels result in functioning that is either positive or negative

Activities

Activities are performance of person-level tasks or activities undertaken by the person

Domains of activity are communication, movement, self care, interpersonal and performing the simple to complex tasks involved in major life activities

Activities are the observable and reportable performance of actions of individuals in the context of their culture

Participation Participation is defined as “individual’s

involvement in life situations in relation to health conditions, body functions and structures, activities and contextual factors

A key term is Involvement “means inclusion of the individual in life activities in the context of how and where they live”

Participation

The classification of participation restriction is assessed on desired participation of the individual’s life activities within society

It is measured by placing the observed involvement in a life activity in 1- 9 participation domains that include personal maintenance, mobility, exchange of information, social relationships, home life and assistance to others, education, work and employment, economic life, community, social and civic life

Participation

Participation is qualified by the degree of restriction experienced

For example, if mobility outside the home is moderately restricted as a function of the lack of the availability of accessible transport, then the participation code (p) would be assigned as follows: chapter 2 (participation in mobility) under the 2nd level heading (230) titled “Participation in mobility outside the home and other buildings” and restriction qualifier of moderate (2) resulting in the full code of p230.2

ICF Mechanisms for Documenting Disability Status

Environment

.0= No Barrier

.1= Mild Barrier

.2= Moderate Barrier

.3= Severe Barrier

.4= Complete Barrier

+0= No Facilitator+1= Mild Facilitator+2= Moderate Facilitator+3= Severe Facilitator+4= Complete Facilitator

PSI LDSIG 16/04/2010

Contextual Factors

Person gender age other health

conditions coping style social background education profession past experience character style

EnvironmeEnvironmentntProductsProductsMilieuMilieuInstitutionsInstitutionsSocial NormsSocial NormsCultureCultureBuilt-Built-environmentenvironmentPolitical Political factorsfactorsNatureNature

StructureClassification

Parts

Components

Constructs/qualifiers

Domains and categories at different levels

ICF

Part 1:Functioning

and Disability

Part 2:Contextual

Factors

Body Functions

and Structures

Activities andParticipation

Environmental

Factors

Personal Factors

Change inBody

Structures

Capacity

Performance

Facilitator/Barrier

Item levels:

1st 2nd3rd4th

Item levels:

1st 2nd3rd4th

Item levels:

1st 2nd3rd4th

Change inBody

Functions

Item levels:

1st 2nd3rd4th

Item levels:

1st 2nd3rd4th

THE DOMAINS OF ICF

The domains of ICF are arranged in a hierarchy (Chapter, second, third and fourth level domains), which is reflected in the coding:e.g.

The Qualifiers

The list of domains in ICF becomes a classification when qualifiers are used. Qualifiers record the presence and severity of a problem in functioning at the body, person and societal levels.

For body function and structure, the primary qualifier

The primary qualifier indicates the presence of an impairment (5 point Scale)

1. no impairment, 2. mild, 3. moderate, 4. Severe5. Complete

Activity and Participation domains,2 Qualifiers

The Performance qualifier describes what an individual does in his or her current environment. Since the current environment always includes the overall societal context, performance can also be understood as "involvement in a life situation" or "the lived experience" of people in their actual context. (The 'current environment' will be understood to include assistive devices or personal assistance, whenever the individual actually uses them to perform actions or tasks.)

Activity and Participation domains,2 Qualifiers

The Capacity qualifier describes an individual’s ability to execute a task or an action. This indicates the highest level of functioning of a person in a given domain at a given moment.

ICF Mechanisms for Documenting Disability Status

Functioning Structures

Activity Participation

0= No Problem 1= Mild Problem2= Moderate Problem3= Severe Problem4= Complete Problem

Capacity: What a person can do without assistance

Performance: What a person can actually do

Capacity and Performance Data

Having access to both performance and capacity data enables ICF user to determine the 'gap' between capacity and performance.

Capacity and Performance Data?

If capacity is less than performance, then the person's current environment has disabled/enabled him or her to perform better:??

Capacity And Performance: Answer

the environment has facilitated performance.

Capacity And Performance:?

If capacity is greater than performance??

Capacity And Performance: Answer

Some aspect of the environment is a barrier to performance.

Questions re Defining Capacity?Mobility

(1) In your present state of health, how much difficulty do you have walking longdistances (such as a kilometer or more) without assistance?(2) How does this compare with someone, just like yourself only without your healthcondition?(Or: "…than you had before you developed your health problem or had the accident?)

Questions defining Performance?mobility

(1) In your present surroundings, how much of a problem do you actually have inwalking long distances (such as a kilometer or more)?(2) Is this problem walking made worse, or better, by your actual surroundings?(3) Is your capacity to walk long distances without assistance more or less than what you actually do in your present surroundings?

Questions Defining Capacity:Major Life Areas

(1) In your present state of health, how much difficulty do you have getting done all thework you need to do for your job, without assistance?(2) How does this compare with someone, just like yourself only without your healthcondition?(Or: "…than you had before you developed your health problem or had the accident?)

Defining questions Re Performance:Major Life Areas

(1) In your present surroundings, how much of a problem do you actually have gettingdone all the work you need to do for your job?(2) Is this problem fulfilling your job requirements made worse, or better, by the way thework environment is set up or the specially adapted tools you use?(3) Is your capacity to do your job, without assistance, more or less than what youactually do in your present surroundings?

Use of the qualifiers




Activity

For example, inability to walk and use of a wheelchair for mobility would be classified as follows: chapter 4 (Activities of moving around under the level 2 heading of walking activities (410) level of difficulty qualifier (4) and assistance qualifier (1) for a resulting code of a410.41

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Mapping ICF to an assessment forms - eligibility for benefits

What, if any, movement difficulty is there? ICF – b7302.2 (moderate impairment of one side of body)

To what extent can you perform personal care? ICF – d5702.1 (mild impairment maintaining one’s health)

Do you require assistance to move from place to place inside your home/school/place of work? ICF– d4601.0 (no problem moving around within buildings other than home)

the complete list of chapters in the ICF



HEALTHCONDITION

IMPAIRMENT

ACTIVITYLIMITATION

PARTICIPATIONRESTRICTION

Leprosy

Loss of sensation ofextremities

Difficulties ingrasping objects

Stigma of leprosyleads tounemployment

Panic Disorder

Anxiety

Not capable of goingout alone

People's reactionsleads to no socialrelationships

Spinal Injury

Paralysis

Incapable of usingpublic transportation

Lack ofaccommodations inpublic transportation

leads to low participation

Juvenile diabetes

Pancreaticdysfunction

None (impairmentcontrolled bymedication)

Does not go to schoolbecause of stereotypes about disease

Vitiligo

Facial disfigurement

None

participation in social relations owing to fears of contagion

Person who formallyhad a mental healthproblem and wastreated for apsychotic disorder

None None

Denied employmentbecause ofemployer's prejudice

Examples of disabilities that may be associated with the three levels of functioning linked to a health condition.

The levels of disability linked to three different levels of intervention.


Activity Limitation

???

???



Participation Restriction

???

???


ICF in policy making assessment of population health

impact of disability

economic

social

evidence-base for policy makers on different policy interventions

responsiveness of servicesefficiency performance assessment

Function (Task Specific)

Disorder or Disease

Activity/Participation

Environmental Factors

Impairments

Function

Needs assessment Outcome assessment Utilization patterns

Comparison of different interventions

Consumer satisfaction

Service performance outcomes cost-effectiveness

Electronic records Clinical terminology

ICF in clinical practice & management


Characteristics of a ‘Good’ Assessment of Need (AON)

The ICF provides a useful framework to support AONs that are:Person centredNeeds DrivenBiopsychosocialAge appropriateMulti-disciplinary

Suggested Framework for Assistive Technology Assessment

Identify Functional Limitation Identify Impairments that cause

functional limitation Work with rehabilitation specialists to

address impairment level issues. Maximize function by collaborating with

rehabilitation specialist to create assistive technology solutions which take into account individual impairments.

Joseph Pre-assessmentExample (including ICF components and International Standards Organisation (ISO) 9999 (AT) products)

Joseph is a 22-year-old male who received a T-12 incomplete spinal cord injury [body functions and structures (b)] from a diving accident 4 years ago

After rehabilitation, he returned to his parents’ home and both his mother and father worked hard to meet his physical needs. During the past 3 years, however, he has had a difficult time recognising and acceptingthe changes in his lifestyle he must make [emotional functions (b1) and personal factors, identity]. As a result, Joseph frequently feels angry and depressed (b1, temperament and personality) and often prefers to be alone (d7, interpersonal interactions).

At first family and friends would stop by to visit, but his withdrawal, anger and depression led to strained interactions and eventually the visits became rare occurrences (d7, e3 and e4).

Joseph AssessmentAt Time Point 2, 3 years post-injury, Joseph learned about the existence of a wheelchair basketball team in his city that was looking for an additional player.

Joseph is fortunate that he lives in a large enough city that has the facilities and resources to foster a wheelchair basketball team [e5]

Joseph uses a lightweight manual wheelchair (e1,ISO 9999 class 12.22.03, bimanual wheel driven wheelchairs), but to play on the team required thatJoseph have an additional specialised wheelchair, that is a sport wheelchair (e1, ISO 9999 class 12.22.03).

His physician recommended an assessment at a local AT centre that focussed on his preferences as well as needs (b7, d4, d7, d9, personal factors), thepurpose and environments of wheelchair use (d9, e2) and desirable product features and add-ons such as special tires and a means for transporting himself and his wheelchair (ISO 9999 class 12).

Joseph post assessmentThe outcome of the comprehensive assessment was the selection of a wheelchair among multiple choices that Joseph could afford, was a good match with his needs and preferences, and that performed well for him as a wheelchair basketball player [28–30].

Joseph enjoyed playing on the team, and the team valued Joseph’s contribution (e3 and e4). Joseph interacted with other individuals, some who become closer friends than others (d7).

The addition of Joseph affected the group identity as a whole as well as each individual (e3 and e4,personal factors). As a group they performed very well and won a regional championship.

Now,almost 4 years post-injury, Joseph is finding he is less depressed and angry (b1) and greatly looks forward to being with his teammates not only on the basketball court but socially as well [d7]. He is now thinking of returning to university and wants to explore additional ATs to save time and energy.

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In Summary : ICF

ICF describes all aspects of health in terms of health domains

ICF is integration of the medical and social models – biopsychosocial approach

ICF is designed in a hierarchical scheme based on commonly understood principles and language

The ICF facilitates collaboration and communication amongst system supports

ICF describes situations for functioning and its restrictions and provides a framework to organise this information

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In SummaryThe New Approach: ICF

The ICF is an active system, it is constantly changing

The ICF understands that disability is the interaction between a person and their environment

The ICF provides an assessment tool and a means to classify data collection using simple, common language and forms

End: With another case study

John’s Profile

Intellectual Functioning:: Average Age 12 .5 years Gender Male Address Dublin 11 Medical Diagnosis ADHD

(ICD 10 Code F90.0/ DSM IV 314.1) Family Status Father: Information Technologist

Mother: Dental Secretary Educational Status First Year Secondary

Reason for Referral Assessment of Need as a result of class disruption and

aggressive behaviour during recreation. Bedwetting is also reported by his parents as an issue. GP has identified ADHD as the most likely cause.


John’s Behaviour Profile

John has difficulty: Paying attention to details

Sustaining attention Listening to stories and instruction Finishing tasks Organising himself Keeping track of his belongings

John Blurts out answers before a question is finished Doesn’t wait his turn Interrupts and intrudes upon others Fidgets Is unable to stay seated Has difficulty engaging in leisure activities quietlyPSI LDSIG 16/04/2010

John Learning Strengths

Articulate Artistic Popular with school friends Interested in sports Supports in place for him already e.g. OT and Tuition Willing to participate Good relationship with his mother Support and interest from home Reflective ability Good Auditory Discrimination Good Expressive language Ability to understand directions when presented clearly Can interpret body language

John’s Activity and Participation Profile

Has difficulty in settling down to listen to stories or instructions

Has yet to acquire introductory word decoding skills His formation of letter shapes is very immature Has not exhibited the ability solve simple problems

when presented orally Has moderate difficulty in organising himself to carry

out anything other than simple task Has no difficulty in communicating through speech and

gesture Is constantly in motion, fidgeting and moving around


John’s Activity and Participation Profile

Has difficulty relating to his father without getting angry. The relationship with his mother is close but dependent Can react aggressively even to friendly approaches from

other children Finds it very difficult to respond appropriately to

correction or control from teachers In the school yard he often gets into fights and has no

close friends Has been unable to adapt to formal education and is

failing in school work Is not very good at physical activities and has developed

no interests sports or other pursuits

An analysis of John’s Environment

His father has given him a number electronic toys and gadgets including a electronic spelling tutor all of which he refuses to use

His mother works flexi-time in order to be available to him when problems arise.

His father is well meaning but often absent from the home on business trips

His parent have recently identified an OT who has begun to work with him using Sensory Integration techniques

His teacher is frustrated and has yet to find a way to manage his behaviour in class. He is on The waiting list for the Learning Support Teacher but is unlikely to receive help in the current school year

An analysis of John’s Environment

His mother is frustrated and fears that she may have to give up work in order to cope with his problems

His father is distant emotionally and tends to underplay the problems as something ‘he will grow out of’

He has no close friends Is currently receiving no SEN support Apart from the GP and the occasional visits to the

OT his parents are paying for privately he is receiving no health or social care intervention

John’s Learning Needs

Needs support to organise and manage personal possessions

Needs to deal with authority better Needs a review of what he has been doing in learning

support to identify what works and what needs to change Needs to get agreement on using alternative format for

presenting his academic work Extend his ability to communicate emotionally Needs to be encouraged to attend and stay in school Need to feel better about himself and be more confident

about communicating with others

John’s Learning Needs

Needs to related better to his father He needs to start using assistive technology Needs to work cooperatively with his class

mates Eyes and ears need to be checked Family may need to work to improve

relationships Appropriate programme to facilitate

transfer to secondary school

John’s ICF Profile

Area of Functioning

ICF CodeICF

Rating

Description of Need

Intellectual b117 0 Intelligence assessed within average range

Regulation of behavior

b127.4 3Has great difficulty adapting behaviour appropriately to classroom context

Impulse control b1304.3 2 Has difficulty resisting sudden urges to do things

Short term memory

b1440 2 Moderate impairment in tests of STM

Attention b1460 2Both parents and teachers report moderate difficulties in maintaining attention

Orientation b1141/b1148

2 Has difficulties with temporal and spatial orientation

Emotional b152 2Emotional responses are inappropriate and he has difficulty regulating them

Visual Perception

b1561 2Had difficulty with all tests involving visual perception

Motor coordination

b760/b7601 &2

2Fine motor coordination and finger dexterity difficulties have been identified

Activity /Participation

ICF Code

Capacity

Performance

Listening d115 2 2Has difficulty in settling down to listen to stories or instructions

Learning to read d140 2 3Has yet to acquire introductory word decoding skills

Learning to write d145 2 3 His formation of letter shapes is very immature

Solving problems d175 2 3Has not exhibited the ability solve simple problems when presented orally

Multiple Tasks d220 2 3Has moderate difficulty in organising himself to carry out anything other than simple task

Communicationd310-d349

0 0Has no difficulty in communicating through speech and gesture

Maintaining a sitting position

d4153.3 3 3Is constantly in motion, fidgeting and moving around

Family Relationships d720 03

Has difficulty relating to his father without getting angry.

2The relationship with his mother is close but dependent

Regulating behaviors within interactions

d7202.2 0 3Can react aggressively even to friendly approaches from other children

Authority d740 0 3Finds it very difficult to respond appropriately to correction or control from teachers

Peers d7600 0 2In the school yard he often gets into fights and has no close friends

School d820 2 3Has been unable to adapt to formal education and is failing in school work

Recreation & Leisure

d9201 1 3Is not very good at physical activities and has developed no interests sports or other pursuits

Environmental Analysis

ICF CodeICF

Rating

Products & Technology e1

Products for personal use in education

e130 0His father has given him a number electronic toys and gadgets including a electronic spelling tutor all of which he refuses to use

Supports e3

Immediate Family e310+2

His mother works flexi-time in order to be available to him when problems arise.

0His father is well meaning but often absent from the home on business trips

Health professionals e355 0His parent have recently identified an OT who has begun to work with him using Sensory Integration techniques

Other professionals (Teachers)

e360 0

His teacher is frustrated and has yet to find a way to manage his behaviour in class. He is on the waiting list for the Learning Support Teacher but is unlikely to receive help in the current school year

Attitudes e4

Immediate Family e410

-2His mother is frustrated and fears that she may have to give up work in order to cope with his problems

-2 His father is distant emotionally and tends to underplay the problems as something ‘he will grow out of’

Friends e420 0 He has no close friends

Services & Systems e5

SEN Support e5860 0 Is currently receiving no SEN support

Health Services e5800 0Apart from the GP and the occasional visits to the OT his parents are paying for privately he is receiving no health or social care intervention

Documents

International Classification of Function, Disability and Health (ICF) Dr Ger Craddock