ICFCHILDREN

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ICF-CHILDREN YOUTH

• Donald J. Lollar, Ed.D.
• Centers for Disease Control Prevention
• National 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.
  classificationsICD 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 dESPINE USED NATURE OF DISEASE (GOUTY,
  HERPETIC, HEMATIC)
• INITIAL COMPROMISE--186 RUBRICS
• 20 YEARS TO RECONCILE THE DIFFERENCESFARR WON
• NOW ICD REVISED ABOUT EVERY DECADEHENCE 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

• AIMPROVIDE 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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ICF Conceptual Framework
Health Condition (disorder/disease)
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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 STRUCTURES Nervous system Eye, ear related
structures Voice speech structures Cardiovascul
ar, immunological respiratory
structures Digestive, metabolism
endocrine Genitourinary structures Movement
related structures Skin related structures
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Activities and ParticipationLimitations/Restrict
ions

• 1 Learning Applying Knowledge
• 2 General Tasks and Demands
• 3 Communication
• 4 Movement
• 5 Self Care ______________mind the gap__
• 6 Domestic Life Areas
• 7 Interpersonal Interactions
• 8 Major Life Areas
• 9 Community, Social Civic Life

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Environmental FactorsBarriers/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-not a TOOL a standard language for
documentation

• DOCUMENTATION OF CHILDRENS RIGHTS
• CLINICAL assess needs, evaluate progress and
  interventions
• RESEARCHmeasure outcomes, impact of
  environmental factors on activity limitations and
  societal participation
• SOCIAL POLICYsocial security planning,
  environmental design and implementation
• EDUCATIONALassess and monitor function
• STATISTICAL collecting data for population
  surveys or administrative data

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ICF-CY reference standard for documenting
childrens rights

• UN Convention on the Rights of the Child-emphasis
  on Article 23 (1989)
• UN Standard Rules for the Equalization of
  Opportunities (1994)
• Salamanca Statement on the Right to Education
• Education for All-World Education Forum _at_ Dakar
  (2000)

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Need for version of ICF for children youth

• Nature and form of functioning in children
  different from that of adultschildren are not
  small adults
• Child is a moving target in classification of
  functionchanges 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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Presentation overview

• Summarize development of ICF-CY as 1st derived
  version of the International Classification of
  Functioning, Disability Health
• Describe relevance of ICF-CY for current issues
  in childhood disability
• Identify emerging priorities for
• ICF-CY

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Need for ICF-CY

• Developing child as moving target

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Need for ICF-CY

• Activities differ from those of adults

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Need for ICF-CY

• Precursors of participation and life roles

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Need for ICF-CY

• Emerging habitual, frequent and occasional
  environments

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Current issues in child assessment and
intervention

• Masking of 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 interventionusually
  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
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ICF-CY Example of new code for Body Functions

• b120 General cognitive functions
• General mental functions required to represent,
  and constructively integrate knowledge of
  objects, events and experiences and apply that
  knowledge in tasks requiring mental rather than
  physical activity.
• Exclusion higher level cognitive functions
  (b164)

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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 ones time
• d5205 Caring for the nose
• d53000-10/ Indicating need for urination,
  defecation
• d880 Engagement in playsolitary, onlooker,
  parallel, shared

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Framework for use of ICF-CY in documentation
Health Conditions- Syndrome, diagnosis, category
Activities (Intervention/outcomes)
Participation (Outcomes)
Body Structures Functions (Assessment)
Environmental Personal Factors
(Assessment Factors Intervention)
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Joint use of family of ICD and ICF to document
function and health

• FOCUS DIMENSION
• What is childs health status? Health
  conditions-ICD
• How does childs 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 childs 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
autismDiagnostic 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 identify focus of
interventions or treatments

• Intervention focus
• d710-729 personal interactions
• d310-329 communication
• d235 managing ones own behavior
• d 880 engaging in play
• d220 undertaking multiple tasks

• Problems/ limitations
• social interaction
• communication
• rigid repetitive, stereotyped behavior patterns
• developmental level
• attention

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IV. Developmental tracking same ICD with
age-changes in ICF-CY codes
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ICF-CY- framing functional outcomes of child
interventions measuring progress

• Gradient of change reduction of severity level
  within code (regulating behaviors within
  interaction)
• d7202.4 --gt d7202.2
• Hierarchy of change moving from lower level code
  to higher level code (undertaking simple task)
• d2100.2 ? (undertaking complex task) d2101.2

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V. Use of ICF-CY to frame functional outcomes of
intervention
Body Functions Structures
Activities Participation
Environmental Factors
Access to needed interventions
Progressive transitions in clinical and
educational settings
Positive effects of medication on mental
functions -attention
Improvement in school functioning in personal
functioning in social relationships
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Public Health Uses/USA

• Survey of Children with Special Health Care Needs
• Early Intervention Data HandbookUS 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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ICF as common language for special education
practice example

• Manual for use of ICF for children and youth
  with disabilities
• Edited and written
• by National Institute of
• Special Education Japan,
• Approved by WHO

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Educational Outcomes of ADHD
ADHD
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
Body functions Impairments Attention, memory,
emotion regulation, higher cognitive functions
Environmental Factors General and special
education
Personal Factors
From Loe and Feldman, 2005
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Revisiting a priority classification of children
(1975) -gt classification of functioning
disability in children (2005)

• ..classification is serious business.
  Classification can profoundly affect what happens
  to a child. It can open doors to services and
  experiences the child needs to grow in
  competence, to become a person sure of his worth,
  and appreciate the worth of others, to live with
  zest and to know joy.
• (Classification of Children, Hobbs, 1975 The
  futures of children, Hobbs, 1975)

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• Don Lollar, Ed.D.
• CDC/NCBDDD, Atlanta, GA, USA
• dlollar_at_cdc.gov
• Rune J. Simeonsson, Ph.D.,MSPH
• University of North Carolina, Chapel Hill, USA
• rjsimeon_at_email.unc.edu