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

International Classification of Function,
Disability and Health (ICF)
Dr Ger Craddock
World Health Organization
Classification Assessment Surveys & Terminology Group
ICF
WHO Family of
International Classifications
www.who.int/classification/icf
International Classification of
Functioning, Disability and Health
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ICF Applications
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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 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 ICD10 (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
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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.
International Classification of Function,
Disability and Health (ICF)
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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
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
Why ICF?
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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
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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
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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
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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.
International Classification of Function,
Disability and Health (ICF)
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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
• 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 ?
The ICF
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Uses neutral terms to identify
function at the Body function,
activity and participation level
rather that impairment, disability
and handicap
The ICF
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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)
Environmental
Factors
Participation
(Restriction)
Personal
Factors
ICF Components
Body Functions
&
Structures
Activities
&
Participation
Environmental
Factors
Functions
Capacity
Barriers
Structures
Performance
Facilitators
Activity & Participation
Body functions
& structures
Limitation in activity
Restriction in participation
Impaired
body functions
& structures
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
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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
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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
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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
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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=
.1=
.2=
.3=
.4=
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No Barrier
Mild Barrier
Moderate Barrier
Severe Barrier
Complete Barrier
Environment
+0= No Facilitator
+1= Mild Facilitator
+2= Moderate Facilitator
+3= Severe Facilitator
+4= Complete Facilitator
PSI LDSIG 16/04/2010
Contextual Factors
Person
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gender
age
other health
conditions
coping style
social
background
education
profession
past
experience
character style
Environme
nt
Products
Milieu
Institutions
Social Norms
Culture
Builtenvironment
Political
factors
Nature
Structure
ICF
Part 1:
Functioning
and Disability
Body
Functions
and Structures
Classification
Part 2:
Contextual
Factors
Activities and
Participation
Environmenta
l
Factors
Change in Change in
Body
Body
Capacit Performanc Facilitator/
Functions
y
e
Barrier
Structures
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
Parts
Personal
Factors
Components
Constructs/
qualifiers
Domains and categories
at different levels
THE DOMAINS OF ICF
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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
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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.
2.
3.
4.
5.
no impairment,
mild,
moderate,
Severe
Complete
Activity and Participation domains,
2 Qualifiers
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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
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Functioning
Structures
Activity
Capacity: What a
Participation person can do
without assistance
Performance: What a
person can actually
do
0=
1=
2=
3=
4=
No Problem
Mild Problem
Moderate Problem
Severe Problem
Complete Problem
Capacity and Performance Data
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Having access to both performance
and capacity data enables ICF user
to determine the 'gap' between
capacity and performance.
Capacity and Performance Data?
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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
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the environment has facilitated
performance.
Capacity And Performance:?
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If capacity is greater than
performance??
Capacity And Performance: Answer
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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
Use of the qualifiers
Use of the qualifiers
Use of the qualifiers
Activity
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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?
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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)
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the complete list of chapters in the
ICF
the complete list of chapters in the
ICF
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
public transportation
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
None
None
Denied employment
because of
employer's prejudice
The levels of disability linked to
three different levels of intervention.
The levels of disability linked to
three different levels of intervention.
Activity
Limitation
?
?
?
?
?
?
The levels of disability linked to
three different levels of intervention.
The levels of disability linked to
three different levels of intervention.
Participation
Restriction
?
?
?
?
?
?
The levels of disability linked to
three different levels of intervention.
ICF in policy making
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assessment of population health
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impact of disability
 economic
 social
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evidence-base for policy makers on
different policy interventions
 responsiveness
of services
 efficiency
 performance
assessment
Function (Task Specific)
Disorder or Disease
Function
Activity/Participation
Impairments
Environmental
Factors
ICF in clinical practice & management
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Needs assessment
Outcome assessment
Utilization patterns
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Comparison of different interventions
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Consumer satisfaction
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Service performance
 outcomes
 cost-effectiveness
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Electronic records
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Clinical terminology
Characteristics of a ‘Good’
Assessment of Need (AON)
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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
Suggested Framework for Assistive
Technology Assessment
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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 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).
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
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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 Summary
The New Approach: ICF
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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
John’s Profile
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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
John’s Behaviour Profile
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John has difficulty:
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Sustaining attention
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Paying attention to details
Listening to stories and instruction
Finishing tasks
Organising himself
Keeping track of his belongings
John
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Blurts out answers before a question is finished
Doesn’t wait his turn
Interrupts and intrudes upon others
Fidgets
Is unable to stay seated
PSI LDSIG 16/04/2010
Has difficulty engaging
in leisure activities quietly
John Learning Strengths
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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
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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
John’s Activity and Participation Profile
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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
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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
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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
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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
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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
ICF Code Ratin
g
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/b1
148
2
Has difficulties with temporal and spatial orientation
Emotional
b152
2
b1561
2
b760/b76
01 &2
2
Visual
Perception
Motor
coordination
Description of Need
Emotional responses are inappropriate and he has
difficulty regulating them
Had difficulty with all tests involving visual
perception
Fine motor coordination and finger dexterity
difficulties have been identified
Activity
/Participation
ICF
Code
Listening
d115
2
2
Learning to read
d140
2
3
Learning to write
d145
2
3
Solving problems
d175
2
3
Multiple Tasks
d220
2
3
Communication
d310d349
0
0
3
3
Maintaining a sitting
d4153.3
position
Capacit
Performance
y
3
Family Relationships d720
0
2
Regulating
behaviors within
interactions
d7202.2
0
3
Authority
d740
0
3
Peers
d7600
0
2
School
d820
2
3
1
3
Recreation & Leisure d9201
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
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
Environmental
Analysis
ICF Code
Products & Technology
e1
Products for personal
use in education
e130
Supports
e3
ICF
Rating
0
+2
Immediate Family
e310
0
Health professionals
e355
0
Other professionals
(Teachers)
e360
0
Attitudes
e4
-2
Immediate Family
e410
-2
Friends
e420
0
Services & Systems
e5
SEN Support
e5860
0
Health Services
e5800
0
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
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