International Classification of Function, Disability and Health (ICF)

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International Classification of Function,
Disability and Health (ICF)

• Dr Ger Craddock

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World Health Organization Classification
Assessment Surveys Terminology Group

• ICF

WHO Family of International Classifications
www.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 persons functioning

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ICF Structure

• Two parts
• 1. Functioning and Disability
• a) Body functions and structures
• b) Activities and Participation
• 2. Contextual Factors
• a) Environmental factor
• b) Personal factors

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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.

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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.

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International Classification of Function,
Disability and Health (ICF)

• 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

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International Classification of Function,
Disability and Health (ICF)

• Classification envisioned for three uses
• Statistics on the consequences of disease
• Statistics on use of health services
• Conditions classified according to categories

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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.

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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

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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.

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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.

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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.

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International Classification of Function,
Disability and Health (ICF)

• 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.

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Cultural Applicability

• Conceptual and functional equivalence of
  Classification
• Translatability
• Usability
• International Comparisons

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Foundations of ICF

• Human Functioning - not merely
  disability
• Universal Model - not a minority
  model
• Integrative Model - not merely medical
  or social
• Interactive Model - not linear
  progressive
• Parity - not
  etiological causality
• Context - inclusive - not person alone
• Cultural applicability - not western
  concepts ?
• Operational - not theory
  driven alone
• Life span coverage - not adult driven ?

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The ICF

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

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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 users environments

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Interaction of Concepts ICF 2001
Health Condition (disorder/disease)
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ICF Components
Body Functions Structures
Activities Participation
Environmental Factors
Barriers Facilitators
Functions Structures
Capacity Performance
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Disability
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Functioning
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• 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.

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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

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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

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Participation

• Participation is defined as individuals
  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

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Participation

• The classification of participation restriction
  is assessed on desired participation of the
  individuals 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

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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

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ICF Mechanisms for Documenting Disability Status

• .0 No Barrier
• .1 Mild Barrier
• .2 Moderate Barrier
• .3 Severe Barrier
• .4 Complete Barrier

• Environment

• 0 No Facilitator
• 1 Mild Facilitator
• 2 Moderate Facilitator
• 3 Severe Facilitator
• 4 Complete Facilitator

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Contextual Factors

• Environment
• Products
• Milieu
• Institutions
• Social Norms
• Culture
• Built-environment
• Political factors
• Nature

• Person
• gender
• age
• other health conditions
• coping style
• social background
• education
• profession
• past experience
• character style

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Structure
ICF
Classification
Part 1 Functioning and Disability
Part 2 Contextual Factors
Parts
Activities and Participation
Body Functions and Structures
Personal Factors
Environmental Factors
Components
Constructs/ qualifiers
Change in Body Structures
Capacity
Performance
Facilitator/ Barrier
Change in Body Functions
Domains and categories at different levels
Item levels 1st 2nd 3rd 4th
Item levels 1st 2nd 3rd 4th
Item levels 1st 2nd 3rd 4th
Item levels 1st 2nd 3rd 4th
Item levels 1st 2nd 3rd 4th
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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 codinge.g.

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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.

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For body function and structure, the primary
qualifier

• The primary qualifier indicates the presence of
  an impairment (5 point Scale)
• no impairment,
• mild,
• moderate,
• Severe
• Complete

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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.)

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Activity and Participation domains,2 Qualifiers

• The Capacity qualifier describes an individuals
  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.

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ICF Mechanisms for Documenting Disability Status

• Functioning
• Structures
• Activity
• Participation

• 0 No Problem
• 1 Mild Problem
• 2 Moderate Problem
• 3 Severe Problem
• 4 Complete Problem

Capacity What a person can do without
assistance Performance What a person can
actually do
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Capacity and Performance Data

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

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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??

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Capacity And Performance Answer

• the environment has facilitated performance.

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Capacity And Performance?

• If capacity is greater than performance??

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Capacity And Performance Answer

• Some aspect of the environment is a barrier to
  performance.

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Questions re Defining Capacity?Mobility
(1) In your present state of health, how much
difficulty do you have walking long distances
(such as a kilometer or more) without
assistance? (2) How does this compare with
someone, just like yourself only without your
health condition? (Or "than you had before you
developed your health problem or had the
accident?)
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Questions defining Performance?mobility
(1) In your present surroundings, how much of a
problem do you actually have in walking 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?
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Questions Defining CapacityMajor Life Areas
(1) In your present state of health, how much
difficulty do you have getting done all the work
you need to do for your job, without
assistance? (2) How does this compare with
someone, just like yourself only without your
health condition? (Or "than you had before you
developed your health problem or had the
accident?)
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Defining questions Re PerformanceMajor Life
Areas
(1) In your present surroundings, how much of a
problem do you actually have getting done 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 the work 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 you actually
do in your present surroundings?
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Use of the qualifiers
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Use of the qualifiers
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Use of the qualifiers
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Use of the qualifiers
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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
  ones 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)

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the complete list of chapters in the ICF
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the complete list of chapters in the ICF
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the complete list of chapters in the ICF
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Examples of disabilities that may be associated
with the three levels of functioning linked to a
health condition.
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The levels of disability linked to three
different levels of intervention.
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The levels of disability linked to three
different levels of intervention.
Activity Limitation
? ? ?
? ? ?
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The levels of disability linked to three
different levels of intervention.
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The levels of disability linked to three
different levels of intervention.
Participation Restriction
? ? ?
? ? ?
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The levels of disability linked to three
different levels of intervention.
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ICF in policy making

• assessment of population health
• impact of disability
• economic
• social
• evidence-base for policy makers on different
  policy interventions
• responsiveness of services
• efficiency
• performance assessment

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Function (Task Specific)
Function
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ICF in clinical practice management

• Needs assessment
• Outcome assessment
• Utilization patterns
• Comparison of different interventions
• Consumer satisfaction
• Service performance
• outcomes
• cost-effectiveness
• Electronic records
• Clinical terminology

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Characteristics of a Good Assessment of Need
(AON)

• The ICF provides a useful framework to support
  AONs that are
• Person centred
• Needs Driven
• Biopsychosocial
• Age appropriate
• Multi-disciplinary

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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.

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Joseph Pre-assessment
Example (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 accepting the 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).
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Joseph Assessment
At 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 that Joseph 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), the purpose 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).
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Joseph post assessment
The 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 2830. Joseph enjoyed playing on the
team, and the team valued Josephs 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

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End With another case study
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Johns 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.

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Johns 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
• Doesnt wait his turn
• Interrupts and intrudes upon others
• Fidgets
• Is unable to stay seated
• Has difficulty engaging in leisure activities
  quietly

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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

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Johns 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

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Johns 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

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An analysis of Johns 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

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An analysis of Johns 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

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Johns 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

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Johns 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

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Johns ICF Profile Johns ICF Profile Johns ICF Profile Johns ICF Profile
Area of Functioning ICF Code ICF Rating Description of Need
Intellectual b117 0 Intelligence assessed within average range
Regulation of behavior b127.4 3 Has 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 2 Both parents and teachers report moderate difficulties in maintaining attention
Orientation b1141/b1148 2 Has difficulties with temporal and spatial orientation
Emotional b152 2 Emotional responses are inappropriate and he has difficulty regulating them
Visual Perception b1561 2 Had difficulty with all tests involving visual perception
Motor coordination b760/b7601 2 2 Fine motor coordination and finger dexterity difficulties have been identified
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Activity /Participation ICF Code Capacity Performance
Listening d115 2 2 Has difficulty in settling down to listen to stories or instructions
Learning to read d140 2 3 Has 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 3 Has not exhibited the ability solve simple problems when presented orally
Multiple Tasks d220 2 3 Has moderate difficulty in organising himself to carry out anything other than simple task
Communication d310-d349 0 0 Has no difficulty in communicating through speech and gesture
Maintaining a sitting position d4153.3 3 3 Is constantly in motion, fidgeting and moving around
Family Relationships d720 0 3 Has difficulty relating to his father without getting angry.
Family Relationships d720 0 2 The relationship with his mother is close but dependent
Regulating behaviors within interactions d7202.2 0 3 Can react aggressively even to friendly approaches from other children
Authority d740 0 3 Finds it very difficult to respond appropriately to correction or control from teachers
Peers d7600 0 2 In the school yard he often gets into fights and has no close friends
School d820 2 3 Has been unable to adapt to formal education and is failing in school work
Recreation Leisure d9201 1 3 Is not very good at physical activities and has developed no interests sports or other pursuits
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Environmental Analysis ICF Code ICF Rating
Products Technology e1
Products for personal use in education e130 0 His 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.
Immediate Family e310 0 His father is well meaning but often absent from the home on business trips
Health professionals e355 0 His 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 -2 His mother is frustrated and fears that she may have to give up work in order to cope with his problems
Immediate Family e410 -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 0 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