The International Classification of
Functioning, Disability and Health
(ICF): Implications for
Rehabilitative Audiology
Travis Threats
Donna Fisher Smiley
Jean-Pierre Gagné
David Wark
Travis T. Threats, Ph.D.
Associate Professor, Chair
Department of
Communication Sciences and
Disorders
Saint Louis University
3750 Lindell Blvd.
St. Louis Mo, 63108
[email protected]
World Health Organization’s
Definition of Health
“Health is the state of
complete physical, mental,
and social well-being and
not merely the absence of
disease or infirmity.”
n
National Committee of Vital
Health and Statistics (NCVHS)
n
n
n
Medical Advisory Board of the Department
of Health and Human Services
In 2001, wrote report entitled “Classifying
and Reporting Functional Health Status”
Documented lack and need of data on
functional status
NCVHS report
n
The point has already been made that
administrative data generally do not include
information on functional status. The
significance of this fact is that information
on this dimension of healthincreasingly
the sine qua non for understanding
healthis not available to the health care
system (e.g., insurers and health plans), nor
to the researchers, public health workers,
and policy makers who depend on
administrative data
NCVHS report
n
Without functional status information,
the researchers, policy makers, and
others who are already using
administrative data have at best a
rough idea of how people, individually
and collectively, are doingand at
worst they are making erroneous
assumptions and decisions.
ICIDH (1980)
1980 Version- International Classification of
Impairments, Disabilities, and Handicaps (ICIHD)
n
Set out broad framework of health and disability
having more than one aspect
n Existed with competing frameworks, particularly
Nagi
n Widely discussed, but the classification system
itself was too ambiguous and narrow in scope to
be used for epidemiology or as an outcome
measure.
2001 International
Classification of Functioning,
Disability, and Health (ICF)
In 1995, WHO began to revise it in such a
way as to take advantage of the additional
knowledge in the field of disability and
make classification that people WOULD
ACTUALLY USE.
Significant changes including 1) no longer
unidirectional, 2) use of neutral
terminology, 3) greatly expanded with
operational definitions, 4) addition of
Environmental Factors, and 5) extensively
field tested.
Why is this needed?
Knowing the disorder/disease
does not predict functional
health outcomes
ICF
n
n
Biopsychosocial approach- Does not
fall into only medical or social model
camps
Thus, individual’s health is viewed
from a biological, individual, and
social perspective
Aims of ICF
ICF is a multipurpose classification designed
to serve various disciplines and different
sectors. Its specific aims can be
summarized as follows:
To provide a scientific basis for
understanding and studying health and
health-related states, outcomes and
determinants;
Aims - 2
To establish a common language for
describing health and health-related states
in order to improve communication
between different users, such as health
care workers, researchers, policy-makers
and the public, including people with
disabilities;
Aims - 3
To permit comparison of data across
countries, health care disciplines, services
and time;
To provide a systematic coding scheme for
health information systems.
Applications of ICF
n
n
As a statistical tool – in the collection
and recording of data (e.g. in
population studies and surveys or in
management information systems);
As a research tool - to measure
outcomes, quality of life or
environmental factors
Applications - 2
n
n
n
As a clinical tool – in needs assessment,
matching treatments with specific conditions,
vocational assessment, rehabilitation and
outcome evaluation;
As a social policy tool – in social security
planning, compensation systems and policy
design and implementation;
As an educational tool – in curriculum design and
to raise awareness and undertake social actions.
ICF Framework
Health Condition
(disorder/disease)
Body
function&structure
(Impairment)
Activities
(Limitation)
Environmental
Factors
Participation
(Restriction)
Personal
Factors
Body Structures
CHAPTER
CHAPTER
CHAPTER
CHAPTER
1
2
3
4
CHAPTER 5
CHAPTER 6
CHAPTER 7
CHAPTER 8
Structures of the nervous system
The eye, ear and related structures
Structures involved in voice and speech
Structures of the Cardiovascular,
Immunological and Respiratory systems
Structures related to the Digestive,
Metabolic and Endocrine systems
Structures related to the Genitourinary
and Reproductive system
Structures related to movement
Skin and related structures
Body Functions
CHAPTER
CHAPTER
CHAPTER
CHAPTER
1
2
3
4
CHAPTER 5
CHAPTER 6
CHAPTER 7
CHAPTER 8
Mental Functions
Sensory Functions and Pain
Voice and Speech Functions
Functions of the Cardiovascular,
Hematological, Immunological and
Respiratory Systems
Functions of the Digestive, Metabolic
and Endocrine systems
Genitourinary and Reproductive
Functions
Neuromusculoskeletal and movementrelated functions
Functions of the skin and related
structures
ACTIVITIES AND
PARTICIPATION
CHAPTER 1
CHAPTER
CHAPTER
CHAPTER
CHAPTER
CHAPTER
CHAPTER
2
3
4
5
6
7
CHAPTER 8
CHAPTER 9
Learning and applying
knowledge
General tasks and demands
Communication
Mobility
Self-care
Domestic Life
Interpersonal interactions
and relationships
Major life areas
Community, social and civic
life
ENVIRONMENTAL
FACTORS
CHAPTER 1
CHAPTER 2
CHAPTER 3
CHAPTER 4
CHAPTER 5
Products and technology
Natural environment and
human-made changes to
environment
Support and relationships
Attitudes
Services, systems and
policies
Personal Factors
n
n
n
Not coded in ICF because of wide
international variability and thus could not
agree upon codes
Still is included in framework because of
its importance to understanding
functioning and disability
Includes lifestyles, socioeconomic level,
education, race, ethnicity, coping
mechanism, past experiences, other
health factors, cultural factors, etc.
Universal Qualifiers
ICF codes are never to be used without
qualifiers
xxx.0
xxx.1
xxx.2
xxx.3
xxx.4
xxx.8
xxx.9
NO problem (none, absent, negligible)
0-4%
MILD problem (slight, low…) 2-24%
MODERATE (medium, fair) 25-49%
SEVERE (high, extreme, …) 50-95%
COMPLETE (total…) 96-100%
not specified
not applicable
Activity/Participation Qualifiers
n
Uses Universal Qualifier ranges for all four
qualifiers
• Performance- how person does in their natural
environment
• Capacity without assistance – how person does
in clinical setting without assistance
• Capacity with assistance – how person does in
clinical setting with assistance
• Performance without assistance- how person
would perform in environment without
assistance
Environmental Factors Qualifiers
Can either be a Barrier or a Facilitator
n
n
Universal qualifier applies to barriers
or impediments to function
Facilitating qualifiers
• +0
• +1
• +2
• +3
• +4
– No facilitator
– Mild facilitator
- Moderate facilitator
- Substantial facilitator
– Complete facilitator
Clinical/Research outcomes using ICF
framework
1.
2.
3.
Increased attention regarding
Activity/Participation domains, especially
how to assess, enhance, and quantify
changes in persons’ actual lives
Increased attention regarding
examination of Environmental Factors in
the rehabilitation process, including
family members
Increased attention regarding
understanding the relationship between
Body Structure/Function and the
Activity/Participation domains
ICF outcomes - 2
4. Increased attention regarding possible
relevant Personal Factors in the
rehabilitation process
5. Increased attention regarding quality of
life issues related to specific clinical
outcomes
6. Increased attention regarding the
functioning and disability of family
members (i.e. “third-party disability”)
ICF Future
n
n
n
Procedural Manual and Guide for the
Standardized Use of the ICF: A
Manual for Health Professionals,
expected publication 2007
ICF for Children and Youth, expected
publication 2007
Increased integration/separation of
ICF with ICD
ICF – Health Policy and
Reimbursement
n
n
n
n
Interest of Margaret Gianniti, M.D. who is
appointee of Director of Office of Disability
in the Department of Health and Human
Services
Centers for Medicare and Medicaid and
Social Security Administration considering
it
Veteran’s Administration Hospitals have
high interest in it
Private insurances, including ones
handling disability insurance looking at it.
ICF – Health Policy
n
n
n
Classifying Functional Health Status- a
report discussing ICF for administrative
records by the National Vital Health
Statistics Committee of the Department of
Health and Human Services
In all Centers for Disease Control and
Prevention documents relating to
functional health and in health/disability
surveys
To be used in 2007 AMA Guide for
Determination of Permanent Impairment
NCVHS report and ICF
n
“The concepts and conceptual
framework of the ICF have promise
as a code set for reporting functional
status information in administrative
records and computerized medical
records. In the Committee’s view,
the ICF is the only existing
classification system that could be
used to code functional status across
the age span”
ICF and Professional
Organizations
n
n
n
n
n
In American Speech-Language-Hearing
Association (ASHA) Scope of Practice for SpeechLanguage Pathology, and Scope of Practice for
Audiology
In key practice documents for American
Occupational Therapy Association, National
Association of Social Workers, American
Recreational Therapy Association
Significant work and inclusion by American
Psychological Association
Being considered by American Nursing
Association
Adopted by International Society for Physical
Medicine and Rehabilitation
ICF – International sampling
n
n
n
n
n
Adopted in Japan’s national health
program
Use in Scandinavian countries
Training to health professionals including
Italy, South Africa, and Australia
Considerable study in Canada, Germany,
Thailand, France, Austria, Brazil, Russia,
United Arab Emirates, Netherlands, China
ICF Global Awareness Campaign,
spearheaded out of the UK
Applications of the ICF to
Educational Audiology
Donna Fisher Smiley, Ph.D., CCC-A
Assistant Professor & Audiologist
Department of Speech Language Pathology
University of Central Arkansas
201 Donaghey Avenue
Conway, AR 72035
[email protected]
Children and Youth with
Auditory Disorders
n
n
n
Old view: Medical model
New view (ICF): Biopsychosocial
model
Need to consider functional status of
our pediatric patients
The “TEAM”
n
n
n
n
n
n
n
n
The Individual
The Individual’s Family Members
Regular Education Teacher
Special Education Teacher
Deaf Educator
Managing Audiologist
Educational Audiologist
Speech-Language Pathologist
Case Example
n
n
n
n
3rd grader; female
Moderate, bilateral sensorineural
hearing loss
Wears binaural amplification
Uses a personal FM system at school
n
n
Has speech and language
impairments/delays (receptive and
expressive)
Is experiencing limitations/restrictions in:
•
•
•
•
•
Hearing in background noise
Analyzing problems
Reading
Writing
Telling a story
ICF Coding: Body Functions
n
B1: Mental Functions
• b1646 Problem solving
• b16700 Reception of spoken language
• b16701 Reception of written language
• b16710 Expression of spoken language
• b16711 Expression of written language
n
B2: Sensory function and pain
• b2300.2 Sound detection
n
B3: Voice & speech function
• b320 Articulation function
Activities and Participation
n
D1: Learning & Applying Knowledge
•
•
•
•
n
d115
d140
d145
d175
Listening
Learning to read
Learning to write
Solving problems
D3: Communication
•
•
•
•
•
d310
d325
d330
d345
d350
Receiving spoken messages
Receiving written messages
Speaking
Writing messages
Conversation
n
D8: Major Life Areas
• d820 School education
Environmental Factors
n
E1: Products and technology
• e125 Products for technology for
communication
• e1301 Assistive products for technology
for education
n
n
n
E3: Support and relationships
E4: Attitudes
E5: Services, systems and policies
References
Fisher, D.L. & Thelin, J.W. (1999). The World Health
Organization model of functioning and disability applied to
audition. Journal of Educational Audiology, 7, 42-49.
Simeonsson, R.J. (2003). Classification of communication
disabilities in children: Contribution of the International
Classification on Functioning, Disability and Health.
International Journal of Audiology, 42, S2-S8.
World Health Organization. (2001). International classification
of functioning, disability and health. Geneva: Author.
The ICF: A major paradigm shift
for adult audiological rehabilitation
Jean-Pierre Gagné
École d’orthophonie et d’audiologie
Université de Montréal
C.P. 6128, succursale Centre-Ville
Montréal, Québec, Canada, H3C 3J7
[email protected]
Outline of Presentation
1.
2.
3.
4.
Implications of ICF re: AR
Definition of AR
A problem-solving approach to AR
Some key elements of problem solving
International Classification of Functioning,
Disability and Health (ICF: WHO, 2001)
Health Condition
(disorder/disease)
Body
function&structure
(Impairment)
Activities
(Limitation)
Environmental
Factors
Participation
(Restriction)
Personal
Factors
1. Implications of ICF (WHO, 2001)
re: Audiological Rehabilitation
Implications for AR…:
§ The domains of ACTIVITY and
PARTICIPATION forces a much more
functional approach to rehabilitation
§ It places the focus of AR on optimizing
participation in activities rather than on focusing
on impairments and disabilities
§ participation in real-life every day activities
§ activities judged important (relevant) by the
persons who participate in the intervention
program (not by the professional)
48
Implications for AR…:
§ It recognizes that there is a very personal and
“subjective” dimension to what constitutes
activity limitations and restricted participation
§ Each activity is unique
Due to:
• the personal factors of the persons
(participants) involved in the activity
• the environmental factors (physical and
social) in which the activity takes place
Implications for AR…:
It makes it possible (almost necessary) for the
people involved in the activity limitations and/or
participation restrictions to play an active role in
every component of the intervention program.
Implications for AR …:
Generic intervention programs (such as wearing a
hearing aid, participation in a communication
management training program, etc..) may
constitute potential intervention strategies (tools)
that may be applied to overcome activity
limitation and participation restriction.
*Tools/approaches/strategies • GOALS
Implications for AR…:
It clearly specifies that persons who do not have a
hearing impairment may be candidates for AR
intervention.
Third party disabilities
2. DEFINITION OF AR
Based on the nomenclature of the
ICF (WHO, 2001)
The goal of AR is to restore or optimize
participation in activities considered
limitative by persons who have a hearing
impairment and/or by other individuals
who partake in activities that include
persons with a hearing impairment.
(Gagné, E&H, 21, p. 65s., 2000)
4. AR is a solution-centered
problem-solving process
General sequence of events that
apply to problem-solving in AR
1. Recognize that there is a problem associated
with an activity.
2. Identify the problem.
3. Describe
the
limitations).
problem
(participation
Sequence of events…
4. Set objectives and define desired outcome
taking into account:
• the impairment
• the activity
• the nature of the participation restriction
• the personal factors of all the persons
involved
• the environmental factors (physical and
social)
Sequence of events…
5. Identify possible solutions (Hearing aid,
HAT, communication strategies, etc.).
6. For each solution identified, analyze and
evaluate the implications of choosing that
solution.
7. Select one (or more) acceptable solution.
8. Implement the solution (the therapy: practice
in implementing the solution: clinic, secure
environment, real-life)
sequence of events…
9. Evaluate the effect of applying the solution
(re: the objective
10. Identify the factors that facilitated, or
constituted and impediment to, the
implementation of the solution
11. Identify and evaluate the impacts and
consequences of the intervention program.
sequence of events…
9. Evaluate the effect of applying the solution
(re: the objective
10. Identify the factors that facilitated, or
constituted and impediment to, the
implementation of the solution
11. Identify and evaluate the impacts and
consequences of the intervention program.
4. Key elements of a
problem solving approach
Key elements ..:
Functional approach
The goal is to solve specific problems experienced
by the people who participate in certain activities.
Problems that are identified as being important by
the persons.
Key elements ..:
The client must be involved in every step of the
problem solving process.
Key elements ..:
Defining the objective of an intervention program
and identifying the critical elements of goal setting
(McKenna, 1987).
Keywords:
Who
Will do what
Under what circumstance
What is the criterion
The timeline
Example of goal setting…
After watching the evening news, Mr. So-and-so, will be
able to discuss the main news report of the day without
having to ask his wife for any clarifications concerning
the news story. This goal will be reached within three
weeks, after Mr. So-and-so purchases and installs an
infrared amplification system for watching the television.
Whenever she uses the agreed upon strategy (flicking the
light switch) Mr. Smith will come upstairs for dinner after
the first time that Mrs. Smith calls him. This goal will be
reached constantly (100% of the time) within a week of its
implementation in the household.
Key elements ..:
Teach the problem solving approach to
the client(s)
Thank you for your time
and for the interest you
may have in my work.
I welcome your:
qReactions
qQuestions
qComments
References
Gagné, J.-P., & Jennings, M.-B. (2000). Intervention services for
adults with acquired hearing impairment. In M. Valente, R. J.
Roeser, & H. Hosford-Dunn (Eds.), Audiology Treatment. NY:
Thieme Press. (2nd edition to be published in March 2007).
Gagné J.-P. (2000). What is treatment evaluation research? What is its
relationship to the goals of audiological rehabilitation? Who are
the stakeholders of this type of research? Ear Hear 2000;
21(Suppl):60-73S
Gagné J.-P. (2003). Treatment effectiveness research in audiological
rehabilitation: fundamental issues related to dependent variables.
International Journal of Audiology, 2003:42, S104-S111.
McKenna, L. (1987). Goal planning in audiological rehabilitation.
British J. Audiology, 21, 5 - 11, 1987.
The International Classification of
Functioning (ICF): Implications for
Rehabilitative Audiology
David J. Wark
School of Audiology & Speech Pathology
University of Memphis
807 Jefferson Avenue
Memphis, Tennessee 38105
[email protected]
“I saw no evidence in my survey
of the literature of a widespread
clinical routine in this country in
which there is a systematic and
comprehensive effort to assess
the full implications of an
adventitious hearing loss so as to
develop an effective rehabilitative
strategy.”
Ross, 1987
Audiology is
Rehabilitation
“Consulters appear to have more
disability (measured by performance
testing and self-report) than nonconsulters with similar impairment,
and they rate themselves more
handicapped than non-consulters
with similar disability.”
Swan & Gatehouse, 1990
ICF Framework
Health Condition
(disorder/disease)
Body
function&structure
(Impairment)
Activities
(Limitation)
Environmental
Factors
Participation
(Restriction)
Personal
Factors
Audiology Assessment (ICF)
Health Condition
(disorder/disease)
Impairment
Case History
Test Battery
Activities
Interview
Self-Report
Environmental
Interview
Self-Report
Participation
Interview
Self-Report
Personal
Interview
Self-report
Assessment of Activity & Participation
Case History/Interview
Tell me about:
The problems you are having with your hearing
The effects of hearing problems on your life
The kinds of activities you are involved in
The problems you have in these activities
The activities you like to do that you have
stopped doing
The new activities you would like to undertake
Kiessling et al. (2003)
“It seems that audiologists assume
that by improving Impairments and
Activity Limitations, this will reduce
Participation restrictions.” and
recommend “…the direct assessment
and management of Participation…”
Hickson & Worrell, (2001)
Assessment of Activity & Participation
Case History/Interview
Emphasis on Participation:
What would you like to participate in?
What is stopping you from participating?
What were you involved in two years ago?
What are you doing now?
Why the change?
What can be done so that you can return to things
you used to like to do?
Hickson & Worrall (2001)
Assessment of Activity & Participation
Self-Report
Screening
HHIE
Hearing Aids (Benefit/Satisfaction)
APHAB
GHABP
Comprehensive Assessment
CPHI
Self-Report Interpretation
n
Content-based interpretation
• Measurement intent, construct
• Item content
• Response Scale
n
Norm-based interpretation
• Mean, SD
Demorest & Walden, 1984
Assessment of Activity and
Participation Domains
Self-Report
n
Screening Instruments
Hearing Handicap Inventory for the
Elderly. (HHIE)
Hearing Handicap Inventory for the Elderly
(HHIE)
Ventry & Weinstein (1982)
n
n
Does a hearing problem cause you to
visit friends, relatives or neighbors
less than you would like?
Does a hearing problem cause you to
listen to TV or radio less often than
you would like?
Assessment of Activity and
Participation Domains
Self-Report
n
Hearing Aid Instruments
• Abbreviated Profile of Hearing Aid
Benefit (APHAB)
• Glasgow Hearing Aid Benefit Profile
(GHABP)
Abbreviated Profile of Hearing Aid Benefit
(APHAB)
Cox & Alexander (1995)
n
n
n
n
I have difficulty hearing a conversation when
I’m with one of my family at home.
I miss a lot of information when I’m listening
to a lecture.
Traffic noises are too loud.
The sound of screeching tires is
uncomfortably loud.
Glasgow Hearing Aid Benefit Profile
(GHABP)
Gatehouse (1999)
n
n
n
n
Listening to the television with other family or
friends when the volume is adjusted to suit
other people.
Having a conversation with one other person
when there is no background noise.
Carrying on a conversation in a busy street or shop
Having a conversation with several people in a
group.
Assessment of Activity and
Participation Domains
Self-Report
n
Comprehensive Instrument
• Communication Profile for the Hearing
Impaired (CPHI)
Demorest & Erdman, 1987
Erdman & Demorest, 1998
ICF and Audiology Litigation
Hearing Impairment
Question on 1st examination for new
Au.D. students in a basic testing
course.
“Briefly describe how the 2001 ICF
framework might provide you with
guidance in your approach to a new client
in your audiology clinic.”
“During the initial interview with a new client, one
of the most important things to learn is why they
have come in. Most of the time a client comes to an
audiologist because of a specific hearing related
problem and it’s effect on his or her lifestyle. It is
important to understand the specific frustrations an
individual is experiencing because, ultimately, the
audiologist’s goal is to address those issues.”
“If a person is unable to perform his or her job
(activity limitation) or unwilling to spend time with
others (participation restriction) due to hearing loss,
the audiologist’s goal is not just to raise the
person’s thresholds, but also to help that person be
rehabilitated into the activities that he or she needs
and wants to be part of.”
A Student
References
Alpiner, J. Chevrette, W., Glascoe, G., Metz, M. & Olsen, F. (1977)
in: J. Alpiner (Ed.) (1978): Handbook of adult rehabilitative
audiology (1st ed.) (pp. 53-56). Baltimore: Williams & Wilkins.
Cox, R. & Alexander, G. (1995). The Abbreviated Profile of Hearing
Aid Benefit. Ear & Hearing, 16;176-186.
Demorest, M. E., & Erdman, S. A. (1987). Development of the
communication profile for the hearing impaired. Journal of Speech
and Hearing Disorders, 52(2), 129-143.
Demorest, M. E., & Walden, B. E. (1984). Psychometric principles in
the selection, interpretation, and evaluation of communication selfassessment inventories. Journal of Speech and Hearing Disorders,
49, 226-240.
Dillon, H. James, A., & Ginis,J. (1997). Client Oriented Scale of
Improvement (COSI) and it’s relationship to several other
measures of benefit and satisfaction provided by hearing aids.
Journal of the American Academy of Audiology, 8;27-43.
References cont.
Erdman, S. A., & Demorest, M. E. (1998a). Adjustment to hearing
impairment i: Description of a heterogeneous clinical population.
Journal of Speech, Language, and Hearing Research, 41(1), 107122.
Erdman, S. A., & Demorest, M. E. (1998b). Adjustment to hearing
impairment ii: Audiological and demographic correlates. Journal of
Speech, Language, and Hearing Research, 41(1), 123-136.
Gatehouse, S. (1999). Glasgow Hearing Aid Benefit Profile: Derivation
and validation of a client-centered outcome measure for hearing aid
services. Journal of the American Academy of Audiology, 10(2), 80103.
Giolas, T., Owens, E., Lamb, S., and Schubert, E. (1979). Hearing
Performance Inventory. Journal of Speech and Hearing Disorders,
44;169-195.
Hickson, L. & Worral, L. (2001). Older people with hearing impairment
application of the new World Health Organization International
Classification of Functioning and Disability. Asia Pacific Journal
of Speech, Language, and Hearing, 6, 129-133.
References cont.
Hickson, L. & Worral, L. (2003). Beyond hearing aid fitting:
Improving communication for older adults. International
Journal of Audiology, 42, S84-S91.
Kiessling, J., Pichora-Fuller, M., Gatehouse, S., Stephens, D.,
Arlinger, S., Chislom, T. et al. (2003). Candidature for and
delivery of audiological services: Special needs of older people:
International Journal of Audiology, 42, S92-S101.
Schow, R. L., & Nerbonne, M. A. (1982). Communication screening
profile: Use with elderly clients. Ear and Hearing, 3(3), 135-14.
Stephens, D. & Hétu, R. (1991). Impairment, disability and handicap in
audiology: Towards a consensus. Audiology, 30, 185-200.
Swan, I. R. C., & Gatehouse, S. (1990). Factors influencing consultation
for management of hearing disability. British Journal of Audiology,
24, 155-160.
Ventry, I. M., & Weinstein, B. E. (1982). The hearing handicap
inventory for the elderly: A new tool. Ear and Hearing, 3(3), 128134.