International Classification of Function, Disability and Health (ICF)

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

International Classifications
World Health Organization Classification Assessment Surveys & Terminology Group ICF WHO Family of International Classifications Greetings , I am happy to greet you on behalf of the World Health Organization and it is my pleasure to provide you with this introduction on the WHO Family of International Classifications (WHO- FIC) We are now in an upgrading process and moving towards the a unified concept of integrated classification systems for health information. In this presentation, I would like to address the following points: What is the WHO Family of International Classifications ? Why is there a need for the WHO FIC ? What are the key concepts of WHO FIC And the underlying principles of family ? How can we use the WHO FIC to improve people’s health? For your information, a copy of the slides used in this presentation is available from WHO or over the INTERNET. The contact addresses are found at the end of this presentation.

International Classification of Functioning, Disability and Health
3 3 3 3

ICF Applications Health sector Social security Education sector
Labour sector Economics & development sector Legislation & law Other …. 4 4

Definitions Impairment Activity Limitations Participation Restrictions
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 5 5 5

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 6 6 6

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 7 7

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
[Keywords] concept###[Narration] ### Conceptual and functional equivalence of Classification Translatability Usability International Comparisons

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 ? [Keywords] concept###[Narration] ### 19

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

Interaction of Concepts
ICF 2001 Health Condition (disorder/disease) Body function&structure (Impairment) Activities (Limitation) Participation (Restriction) Environmental Factors Personal Factors

ICF Components Body Functions & Structures Activities & Participation
Environmental Factors Functions Structures Capacity Performance Barriers Facilitators Nach den Ausfuehrungen zum Kontext und Konzept des ICIDH-2 moechte ich Ihnen nun auf die Inhalte, Begriffsdefinitionen und Kodierungschema vorstellen. Der ICIDH-2 unterscheidet zwischen drei Dimensionen…

Activity & Participation
Body functions & structures

Limitation in activity
Restriction in participation Impaired body functions & structures

Disability

Functioning

Participation is involvement in a life situation.
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
.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 PSI LDSIG 16/04/2010 34

Contextual Factors Environment Person 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 [Keywords] structure###[Narration] ###

Functioning and Disability
Structure ICF Classification Part 1: Functioning and Disability Part 2: Contextual Factors Parts Body Functions and Structures Activities and Participation Environmental Factors Personal Factors Components Change in Body Functions Change in Body Structures Capacity Performance Facilitator/ Barrier Constructs/ qualifiers ICIDH categories are organized in a "nested" approach Broader Category  detailed subcategory The classification has two parts, each with two components. [An example may help to illustrate the point: The universe of health and disability is being classified (this is the forest). Within that forest we classify the dimensions of Impairments, Activities and Participation (the trees). In the Activities dimension we have several chapters or domains ranging from simple to complex activities - from sensing and recognizing to interpersonal behaviours (the trunks). Within, for example, the chapter on Interpersonal Behaviours are included activities such as general interactive skills (the branch) and included in that broad category are behaviours such as initiating social contact, responding to cues and so on (the leaves).] 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 Domains and categories at different levels

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) no impairment, mild, moderate, Severe 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 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 42

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 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?)

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?

Questions Defining Capacity: Major 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?)

Defining questions Re Performance: Major 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?

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

Mapping ICF to an assessment forms - eligibility for benefits
What, if any, movement difficulty is there? ICF – b (moderate impairment of one side of body) To what extent can you perform personal care? ICF – d (mild impairment maintaining one’s health) Do you require assistance to move from place to place inside your home/school/place of work? ICF– d (no problem moving around within buildings other than home) 57

the complete list of chapters in the ICF

Examples of disabilities that may be associated with the three levels of functioning linked to a health condition. HEALTH CONDITION IMPAIRMENT ACTIVITY LIMITATION PARTICIPATION RESTRICTION Leprosy Loss of sensation of extremities Difficulties in grasping objects Stigma of leprosy leads to unemployment Panic Disorder Anxiety Not capable of going out alone People's reactions leads to no social relationships Spinal Injury Paralysis Incapable of using public transportation Lack of accommodations in leads to low participation Juvenile diabetes Pancreatic dysfunction None (impairment controlled by medication) Does not go to school because of stereotypes about disease Vitiligo Facial disfigurement None participation in social relations owing to fears of contagion Person who formally had a mental health problem and was treated for a psychotic disorder Denied employment because of employer's prejudice

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 services efficiency performance assessment Gesundheitspolitik, Sozialpolitik, Behindertenpolitik and Menschenrechtspolitik (keine Entsprechung von Bedurfnisslagen, Problemlagen, Ressourcenvereilung)

Function (Task Specific)

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 (Vorhersage des Inanspruchnahmeverhaltens & Länge der Hospitalisierung)

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 PSI LDSIG 16/04/2010 70

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-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).

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 , 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 ). 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).

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 [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.

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 75

In Summary The 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 76

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. PSI LDSIG 16/04/2010 78

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 quietly PSI LDSIG 16/04/2010 79

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 80

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 PSI LDSIG 16/04/2010 81

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 82

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 83

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 84

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 85

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 ICF Rating Description of Need
Area of Functioning ICF Code ICF Rating Description of Need Intellectual b117 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 Moderate impairment in tests of STM Attention b1460 Both parents and teachers report moderate difficulties in maintaining attention Orientation b1141/b1148 Has difficulties with temporal and spatial orientation Emotional b152 Emotional responses are inappropriate and he has difficulty regulating them Visual Perception b1561 Had difficulty with all tests involving visual perception Motor coordination b760/b7601 &2 Fine motor coordination and finger dexterity difficulties have been identified 87

Activity /Participation ICF Code Capacity Performance Listening d115 2
Has difficulty in settling down to listen to stories or instructions Learning to read d140 3 Has yet to acquire introductory word decoding skills Learning to write d145 His formation of letter shapes is very immature Solving problems d175 Has not exhibited the ability solve simple problems when presented orally Multiple Tasks d220 Has moderate difficulty in organising himself to carry out anything other than simple task Communication d310-d349 Has no difficulty in communicating through speech and gesture Maintaining a sitting position d4153.3 Is constantly in motion, fidgeting and moving around Family Relationships d720 Has difficulty relating to his father without getting angry. The relationship with his mother is close but dependent Regulating behaviors within interactions d7202.2 Can react aggressively even to friendly approaches from other children Authority d740 Finds it very difficult to respond appropriately to correction or control from teachers Peers d7600 In the school yard he often gets into fights and has no close friends School d820 Has been unable to adapt to formal education and is failing in school work Recreation & Leisure d9201 1 Is not very good at physical activities and has developed no interests sports or other pursuits 88

Environmental Analysis ICF Code ICF Rating
Products & Technology e1 Products for personal use in education e130 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. His father is well meaning but often absent from the home on business trips Health professionals e355 His parent have recently identified an OT who has begun to work with him using Sensory Integration techniques Other professionals (Teachers) e360 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 e410 -2 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’ Friends e420 He has no close friends Services & Systems e5 SEN Support e5860 Is currently receiving no SEN support Health Services e5800 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 89

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