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ICF-CHILDREN & YOUTH
Donald J. Lollar, Ed.D.
Centers for Disease Control & PreventionNational Center on Birth Defects &
Developmental Disabilities
Atlanta, Georgia USA
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Presentation overview
• Place ICF-CY in the context of W.H.O. classifications—ICD and ICF
• Identify contribution of ICF/ICF-CY to documentation in public health and services to children and youth
• Describe applications in documentation with children
• Identify continuing issues in application of ICF/ICF-CY in assessment and intervention
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ICD HISTORY• 1853 FIRST INTERNATIONAL STATISTICAL
CONGRESS– FIRST UNIFORM CLASSIFICATION OF CAUSES OF
DEATH-INTERNATIONAL CAUSES OF DEATH (ICD)– TWO COMPETING APPROACHES
• 1855 CONGRESS ENTERTAINED BOTH SETS– WILLIAM FARR USED ANATOMICAL SITES AS BASIS– MARC d’ESPINE USED NATURE OF DISEASE (GOUTY,
HERPETIC, HEMATIC) – INITIAL COMPROMISE--186 RUBRICS– 20 YEARS TO RECONCILE THE DIFFERENCES—FARR
WON– NOW ICD REVISED ABOUT EVERY DECADE—HENCE
ICD-10
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ICD/ICF HISTORY• 1979 NINTH REVISION OF ICD/ICD-9
– RECOMMENDED “PROVISIONAL PROCEDURES CLASSIFICATIONS” BE PUBLISHED TO NINTH REVISION--CPT CODES BEGIN
1980 RECOMMENDED IMPAIRMENTS AND HANDICAPS CLASSIFICATIONS AS SUPPLEMENT Provisional acceptance--INTERNATIONAL CLASSIFICATION OF IMPAIRMENTS, DISABILITIES, AND HANDICAPS (ICIDH)
1993 REVISION OF ICIDH BEGUN
2001 International Classification of Functioning, Disability, and Health (ICF) APPROVED BY THE WORLD HEALTH ASSEMBLY
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WHO Family of Classifications
• ICD classifies diseases• ICF classifies health. • “Together, the two provide us with
exceptionally broad and yet accurate tools to understand the health of a population and how the individual and his or her environment interact to hinder or promote a life lived to its full potential”. (Brundtland, WHO Director General, 5/2002)
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ICF AIM AND PRINCIPLES
• AIM—PROVIDE A UNIFIED AND STANDARD LANGUAGE AND FRAMEWORK FOR THE DESCRIPTION OF HEALTH STATES
»PRINCIPLES• UNIVERSAL NATURE OF DISABILITY
EXPERIENCE• CROSSES THE LIFE SPAN— BIRTH TO
DEATH• ETIOLOGY NEUTRAL— PHYSICAL,
EMOTIONAL,etc.• NEUTRAL LANGUAGE— FUNCTION,
ACTIVITY, PARTICIPATION, ENVIRONMENT
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Health Condition Health Condition ((disorder/diseasedisorder/disease))
ICF Conceptual FrameworkICF Conceptual Framework
Environmental Environmental FactorsFactors
Personal Personal FactorsFactors
Body Body function&structurefunction&structure
(Impairment(Impairment))
ActivitiesActivities(Limitation)(Limitation)
ParticipationParticipation(Restriction)(Restriction)
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Body Functions & Structures/Impairments
BODY FUNCTIONS• Mental• Sensory• Voice, speech• Cardiovascular,
haematological,immunological & respiratory
• Digestive, metabolic, endocrine• Genitourinary & reproductive• Neuromusculoskeletal, &
movement related functions• Skin & related structures
BODY STRUCTURESNervous systemEye, ear & related structures
Voice & speech structuresCardiovascular, immunological & respiratory structures
Digestive, metabolism & endocrineGenitourinary structures
Movement related structures
Skin & related structures
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Activities and Participation:Limitations/Restrictions
1 Learning & Applying Knowledge2 General Tasks and Demands3 Communication4 Movement5 Self Care ______________mind the gap__
6 Domestic Life Areas7 Interpersonal Interactions8 Major Life Areas9 Community, Social & Civic Life
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Environmental Factors:Barriers/Facilitators
1. Products and technology
2. Natural environment and human-made changes to the environment
3. Support and relationships
4. Attitudes
5. Services, systems and policies
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USES OF ICF—a CLASSIFICATION; not a TOOL
• CLINICAL — assess needs, evaluate progress and interventions
• RESEARCH—measure outcomes, impact of environmental factors on activity limitations and societal participation
• SOCIAL POLICY—social security planning, environmental design and implementation
• EDUCATIONAL—assess and monitor function• STATISTICAL— collecting data for population
surveys or administrative data
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Need for version of ICF for children & youth
• Nature and form of functioning in children different from that of adults—children are not small adults
• Child is a “moving target” in classification of function—changes every 6-12 months throughout developing years, esp. activities
• Primary environments and participation areas differ for children
• ICF version for children and youth facilitates continuity of documentation e.g. transitions from child to adult services and communication among professionals and with parents
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Current issues in child assessment and intervention
• Masking functional characteristics within a diagnosis- same diagnosis , varied function
• Masking of functional commonalities across different diagnoses- different diagnoses, common functional problems
• Disconnect between diagnostic identification and the nature of intervention
• Selecting appropriate variables to document outcome with development and intervention—usually Activities or Participation
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Development of the ICF-CY
• Structure ICF main volume maintained
• Inclusion/exclusion criteria for codes were expanded
• New content added to unused codes at 4, 5 and 6 character level to address needs outlined before
• 2nd draft prepared for review on WHO website fall of 2005
• Publication expected 2006
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Development of the ICF-CY
Expan-sions-
I, E
New codes- 4
New codes- 5
New codes- 6
New codes- Total
B F 14 4 13 2 33
B S 0 1 2 4 7
A & P 66 21 77 4 168
E F 19 2 8 0 29
Total 99 28 100 10 237
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ICF-CY: representative new A/P codes
• d1200-03 mouthing, touching, smelling, tasting • d133 Acquiring language
– d1330 acquiring single words or meaningful symbols– d1331 combining words into phrases– d1332 acquiring syntax
• d2300 Following routines• d2304 Adapting to changes in daily routine • d2305 Adapting to changes in time demands • d2306 Managing one’s time
• d5205 Caring for the nose• d53000-10/ Indicating need for urination, defecation
• d880 Engagement in play—solitary, onlooker, parallel, shared
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Framework for use of ICF-CY in documentation
Health Conditions-
Syndrome, diagnosis, category
Body Structures& Functions:
(Assessment)
Activities(Intervention/
outcomes)
Participation(Outcomes)
Environmental PersonalFactors: (Assessment Factors& Intervention)
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Joint use of family of ICD and ICF to document function and health
FOCUS DIMENSION
• What is child’s health status? Health conditions-ICD• How does child’s Structure/Function-ICF
body/mind function?• How does the child Activities-ICF
perform daily life activities?• How is child involved in Participation-ICF
roles/situations?• What are the things, Environment-ICF
conditions, & circumstances surrounding the child?
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ICF-CY Uses in Documentation
• I. Document child’s intra-individual profile of health & functioning
• II. Clarify inter-individual variability across diagnoses with use of ICD/ICF
• III. Generate intervention or treatment plan
• IV. Track developmental status
• V. Frame measurement and select indicators of outcome
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I. Documenting intra-individual differences: autism spectrum disorders
– “…the manifestations of autism are diverse, creating difficulty in using traditional categorical classification schemes”. (Beglinger & Smith, 2001)
– Differentiation of autism and autistic-like disorders in individuals with normal intelligence (c.f. Volkmar, Klin, & Pauls, 1998)
– Regression issues in autism– Autism and early onset schizophrenia (Konstanteras
& Hewitt, 2001)
– Overlap with language disorders (c.f. Bishop & Norbury, 2002)
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Documenting criteria for diagnosis of autism—Diagnostic and Statistical Manual IV
• Preschooler with Autistic disorder• impairment in social function
– d710.3 basic interpersonal interactions– d710.2 basic interpersonal interactions– D750.2 informal social relationships– D760.3family relationships
• impairment in communication – d310.2 communicating with – receiving spoken messages– d315.4 communicating with – receiving nonverbal messages– d330.4 speaking– d335.3 producing nonverbal messages
• restricted, repetitive stereotypic behavior pattern– b7653 Stereotypies and mannerisms
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II. Use of ICF-CY and ICD to clarify inter-individual differences across diagnoses
• Child A• b1142 orientation to
person• b122 global
psychosocial functions• d310 communicating• d510 self care• d710 interpersonal
interactions• F84.4 Stereotyped
movements• F84.1 Atypical autism
• Child B• b1142 orientation to person• b144 memory functions • d1600 attending to touch,
face and voice• d130 copying• d310 communicating• d330 speaking• F84.2 Rett syndrome• F76 Moderate Mental
Retardation
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III. Use of ICF-CY to design interventions or treatments
• Limitations/delays• *social interaction
• *communication
• *rigid repetitive, stereotyped behavior patterns
*developmental level
• *attention
• Intervention focus• d710-729 personal
interactions• d310-329 communication
• d235 managing one’s own behavior
• d 880 engaging in play
• d220 undertaking multiple
tasks
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IV. Developmental tracking: same ICD with age-changes in ICF-CY codes
18 months 3 years 6 years
Health condition
ICD-F 84 ICD-F 84 ICD-F 84
Body function B132 acquiring information
B132 acquiring language
b167 language
Body structure
s230 eyes s230 eyes s230 eyes
Activity/ participation
d120 sensing d130 copying d155 skill acquisition
Environ-mental factors
e450 prof. attitudes
e585 educ services
e586 special educ training
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V. Use of ICF-CY to frame functional outcomes of intervention
Body FunctionsBody Functions&&
StructuresStructures
Activities Activities & &
ParticipationParticipation
Environmental Environmental
FactorsFactors
Access to Access to Intervention Intervention (ABA model;(ABA model;Psycho-Psycho-EducationalEducationalModel) Model) Transitions in Transitions in clinical and clinical and educational educational settingssettings
Effects of Effects of medication medication on mental on mental functions -functions -attentionattention
Improvement in Improvement in school school functioning;functioning;in personal in personal functioning;functioning;in social in social relationshipsrelationships
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Public Health Uses/USA
• Survey of Children with Special Health Care Needs• Early Intervention Data Handbook—US Dept of Educ.
– Includes A/P codes for eligibility/personal functioning, examples• Focusing attention• Solving simple problems• communicating/• Sitting/standing• Crawling/walking• toileting
• Georgia Early Intervention Project– Pilot testing in EI (0-3 years) programs– Using inventory from ICF-CY workgroup as baseline,
intermediate , and exit evaluations
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SLAITS/CSHCN Survey--2005
• Body Functions—– seeing, hearing, – breathing, swallowing/digesting food, circulation, – pain, – feeling anxious or depressed
• Activities/participation—– Eating, dressing, bathing, moving around, using hands, – Learning, understanding, or paying attention? – Speaking, communicating, being understood – Behavior problems, such as acting out, fighting, bullying, – Making and keeping friends
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Educational Outcomes of ADHDADHD
Body functions: Impairments
Attention, memory, emotion regulation,
higher cognitive functions
Activities: Limitations Learning to read, write, calculate;
carrying out tasks; managing own
behavior, stress, frustration
Participation: Restriction
Problems moving across education
levels, succeeding in program; school life
Environmental Factors
General and special education
Personal Factors
From Loe and Feldman, 2005
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• Don Lollar, Ed.D.– CDC/NCBDDD, Atlanta, GA, USA
• Rune Simeonsson, Ph.D.– University of North Carolina, Chapel Hill, USA