American Speech-Language-Hearing Association

International Classification of Functioning, Disability, and Health (ICF)

The ICF was developed by the World Health Organization (WHO) and published in 2001. The WHO would like the ICF classification system to be considered a partner to the ICD (International Classification of Diseases and Related Health Problems) system used in the U.S. and abroad. Whereas the ICD classifies disease, the ICF looks at functioning. Therefore, the use of the two together would provide a more comprehensive picture of the health of persons and populations.

Key Points

  • The ICF is not based on etiology or "consequence of disease," but as a component of health. Thus, while functional status may be related to a health condition, knowing the health condition does not predict functional status.
  • The World Health Organization defines "health" as "the complete physical, mental, and social functioning of a person and not merely the absence of disease." In this definition, functioning as classified in the ICF is an essential component of health.
  • The ICF describes health and health related domains using standard language.
  • The purposes of the ICF include:
    • Collection of statistical data
    • Clinical research
    • Clinical use
    • Social policy use
  • The ICF is stated as the framework for the field in both the Scope of Practice for Speech-Language Pathology (2001) and the Scope of Practice for Audiology (2004).

Components of ICF

The ICF framework consists of two parts: Functioning and Disability and Contextual Factors. These parts are further broken down in the following manner:

Functioning and Disability includes:

  • Body Functions and Structures—describes actual anatomy and physiology/psychology of the human body.
  • Activity and Participation—describes the person's functional status, including communication, mobility, interpersonal interactions, self-care, learning, applying knowledge, etc.

Contextual Factors include:

  • Environmental Factors—factors that are not within the person's control, such as family, work, government agencies, laws, and cultural beliefs.
  • Personal Factors—include race, gender, age, educational level, coping styles, etc. Personal factors are not specifically coded in the ICF because of the wide variability among cultures. They are included in the framework, however, because although they are independent of the health condition they may have an influence on how a person functions.

ICF Coding

ICF codes utilize an alphanumeric system to describe health and health-related domains, with the following letter codes:

b=body functions

s=body structures

d=activities and participation

e=environmental factors

The letters are followed by a numeric code that starts with a one digit chapter number, a second level denoted by two-digits, and third and fourth levels represented by one digit each.

Codes are only complete when a qualifier has been added. Qualifiers denote the severity of the problem and are represented by one or more numbers following a point or separator. The first number after the separator is a universal qualifier that ranges from 0 (no problem) to 4 (complete problem). If a code is not applicable, the code will be followed by a .9. Further qualifiers have different meanings, depending on the component being coded. For example, the second qualifier for body structures indicates the nature of the anatomical change, while the second qualifier for activity/participation denotes the person's ability to perform in a standard environment such as a clinic room without assistance. It is important to note that in the Activity/Participation construct, there is a distinction made between a person's ability to perform a skill in the clinic and their ability to perform the same skill in their natural environment. This is vital information about a person's true functional abilities. 

Examples of ICF Codes

Activity/Participation

  • Speaking=d330
  • Communicating with–receiving spoken messages=d310
  • Conversation=d350
    • Ending a conversation=d3502
  • Using communication devices and techniques=d360
  • Using communication techniques (includes speech reading)=d3602
  • Producing messages in formal sign language=d340

Body Functions

  • Quality of voice=b3101
  • Articulation functions=b320
  • Manipulation of food in mouth=b5103
  • Speech discrimination=b2301
  • Vestibular function of balance=b2351

Environment

  • Sound intensity=e2500
  • Individual attitudes of people in positions of authority=e430
  • Assistive products and technology for communication (includes hearing aids and cochlear implants)=e1251
  • Communication services (includes TTD and TTY)=e5350

Again, a qualifier is needed to complete the codes. For example, a severe spoken language comprehension problem in the person's natural environment would be coded as d310.3.

ICF for Children and Youth (ICF-CY)

In October of 2007, the International Classification of Functioning, Disability, and Health for Children and Youth (ICF-CY) was published by the WHO. The ICF-CY was developed to cover the developmental aspects of childhood. The ICF now is considered for persons 18 years of age and older and the ICF-CY for birth to age 17. The ICF-CY for children has the same organization as the ICF with the same hierarchical structure of codes:

  • Body Functions/Structures
  • Activities & Participation
  • Environmental Factors

The modifications for children consist of:

  • modifying existing descriptions
  • assigning new content to unused codes
  • modifying inclusion/exclusion criteria

As with the ICF, the ICF-CY had extensive field trials throughout the world. In addition to new codes, a few codes of the ICF are not included in the ICF-CY due to not being appropriate for children such as a code that dealt with behaviors surrounding menopause. An important addition in the ICF-CY is a possible use of the qualifiers to represent different degrees of developmental delay. Some examples of communication codes in the ICF-CY that are not in the ICF include the following:

  • solitary, parallel, and cooperative play
  • acquiring single words or symbols
  • acquiring correct syntax
  • orientation to objects
  • acquiring skills to recognize symbols, characters and alphabet
  • mouthing
  • learning through actions and playing
  • responding to human voice

Use of ICF by Government Agencies

At this time, the ICF classification system is not widely used in the U.S. The WHO is leading the campaign to have the ICF universally adopted and utilized. In the United States, several leading medical advisory boards and government agencies have recommended that the ICF be used for health and educational records to describe functional health status, including:

  • The National Committee for Vital and Health Statistics (NCVHS), a medical advisory board of the Department of Health and Human Services. In their report entitled Classifying and Reporting Functional Status [PDF] it states that the ICF is currently the most developed system to be considered for use in recording functional health status. The report discusses one of the reasons for limited use of the ICF for clinical and administrative records-the lack of specific clinical guidelines.
  • The WHO and the American Psychological Association are working on a joint publication entitled Procedural Manual and Guide for a Standardized Application of the ICF: A Manual for Health Professionals. This manual is expected to be published in 2009.
  • The Institute of Medicine (IOM) has also provided support to the use of the ICF by health agencies. Their latest report was published in 2007 and is entitled The Future of Disability in America. This report recommends the use of the ICF for study to use in the US health system.
  • The Department of Health and Human Services is government organization overseeing the Consolidated Health Informatics (CHI) Initiative. This initiative was designed to bring together experts from throughout the federal government to identify standards for the electronic exchange of health information. Their report [PDF] recommends formal government adoption of the ICF for federal US-wide use and that it is included in the National Library of Medicine's Unified Medical Language System (UMLS).
  • In July 2007, the Interagency Committee on Disability Research, a subcommittee of the National Institute on Disability and Rehabilitation Research hosted a conference entitled "ICDR State of the Art Conference- New Federal Applications of the ICF." The invited speakers were experts in various aspects of the use of the ICF.

Additional Resources

Communication Disorders and the ICF [PDF]
Article by Travis Threats

ICF Research Branch Core Sets Project

ICF Resources

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