The International Classification of Functioning, Disability and Health (ICF) in Clinical Practice

Although in the World Health Organization's (WHO's) original constitution, health was defined as “the complete, physical, mental, and social well being and not merely the absence of disease or infirmity,” health systems have still often equated health with lack of disease. Over the last decade, there has been an increasing awareness of functional health, which is having sufficient health to be involved in the life one wants to have, including work and leisure. Functional health thus includes physical, cognitive, and communication skills needed to be fully involved in life. This broader definition of health clearly includes the life circumstances of the persons speech-language pathologists serve.

Over the last decade, there has been an increasing awareness of the importance of health classification schemes in speech-language pathology because of the impacts they have on the provision of health funding and intra- and interprofession communications. In addition, there is a growing need for speech-language pathologists to understand a framework that deals with functioning and disability. The WHO's International Classification of Functioning, Disability and Health (ICF) has been used by some countries' cardinal documents, including inclusion as the framework for the field by the American Speech-Language-Hearing Association's Scope of Practice in Speech-Language Pathology and also in Speech Pathology Australia's Scope of Practice. Countries that have had communication disorders scholars publish or present on the ICF include the United Kingdom, Ireland, Japan, Canada, South Africa, New Zealand, Sweden, Finland, China, Greece, Denmark, and Italy.

Different governments have already put in place or plan to use the ICF in the evaluation of services, such as Japan, where it is used by the National Health Insurance and National Long-Term Care Insurance organizations. As these countries use the ICF and demonstrate its usefulness, it will most likely encourage more countries to use the framework. These changes in health care delivery create a need for speech-language pathologists to understand better the ICF.

To date, there has been no publication available in the field that provides a comprehensive review of this widely accepted and standardized disability framework across the diverse areas in speech-language pathology. This special issue aims to provide an overview and critical discussion on the application of the classification scheme of the ICF in speech-language pathology. Specifically, it reviews and discusses the application of ICF to different populations with a communication and/or eating or drinking disability. This special issue embraces current best practice and the latest research reports on the ICF by leading international scholars and clinicians in the profession. It seeks to provide readers with directions to expand their scope of practice from both theoretical and practical perspectives by providing descriptions of each of the ICF components relevant to the population, as well as assessments, treatments, and a case study illustrating the ICF concepts clinically.

Given that the ICF is an internationally standardized health classification scheme, readers would note the international representation of the guest editors and authors contributing to this special issue. During the process of gathering together this special issue, some common issues have emerged relevant to the ongoing use and interpretation of the ICF in speech-language pathology. These include the following:

1. The standard use of ICF terminology. The overall aim of the ICF is “to provide a unified and standard language and framework for the description of health and health-related states” (p. 3). The standardization of the language or terminology used is therefore an important function of the ICF. It allows different disciplines, stakeholders, and countries to communicate to each other about health. It is therefore vital that speech-language pathologists do not modify the ICF terms and therefore always use the ICF conventions, no matter how trivial they seem. Hence all components of the ICF are to be capitalized to denote that these are not everyday uses of the term (e.g., “Activities and Participation” infers the ICF meaning of the term, while the noncapitalized “activities and participation” is the everyday use of the word). In addition, the ICF describes a conceptual framework, not a model. A model has predictive implications but the ICF does not. Finally, users should be careful with all terms, including the negative terms of impairments, activity limitations, and participation restrictions, that are used deliberately and thoughtfully with a full understanding of their meanings. 2. Understanding the meaning of ICF terms and conceptual framework. Again, to be able to communicate appropriately inter and intraprofessionally, the conceptual framework and the terms used in the ICF need to be fully understood by speech-language pathologists. The terms are best understood by mapping each construct to the ICF codes. There are some gray classification areas in speech-language pathology that can only be resolved through careful examination of the codes. The translation between the conceptual framework and assigning specific codes is not always straightforward nor will it likely receive universal agreement. Acknowledging the possible interrater reliability issues, the American Psychological Association and the WHO are jointly to publish in 2007 or early 2008 the Procedural Manual and Guide for the Standardized Use of the ICF: A Manual for Health Professionals. In it, certain distinctions are made that are to clarify the clinical use of the ICF. For example, Body Function code b16710 (Expression of spoken language) might be used inconsistently with Activities and Participation code d330 (Speaking). In the procedural manual it states that the Body Function code b16710 is to denote the components of language such as semantics and syntax, and the Activities and Participation code is to denote being able to successfully communicate one's message. Thus someone with reduced syntactical abilities would have a more severe rating on the Body Function code than its related Activities and Participation code. 3. Environmental and Personal Factors need greater emphasis by speech-language pathologists. One of the distinguishing features of the 2001 adoption of the ICF framework was greater emphasis on the contribution of Contextual Factors in describing Functioning and Disability. The recognition that Environmental Factors have a large part to play in communication and eating and drinking disabilities is a concept that speech-language pathologists have known intuitively, but have not given enough recognition in clinical reports or research protocols. Greater research is needed to determine the Environmental and Personal Factors that predominantly influence communication and eating and drinking disabilities. 4. Should Activities and Participation be treated as one component with various aspects or as two separate components? This is a continuing debate in the broader literature about the ICF as well as in the articles in this issue. In the ICF, there is a single list of combined Activities and Participation codes. However, Annex 3 of the ICF lays out four different options for the interpretation, including two nonoverlapping sets of codes, with one for Activity codes and another for Participation codes. It could be argued that leaving these options to the discretion of the user undermines the ICF's practical clinical use. However, given that it was unresolved at the time of the voting on the ICF by the WHO Executive Board, it was decided that clinical use and research would be the best route to resolve this issue.

To conclude, this special issue provides an excellent starting point for speech-language pathologists to understand better the application of the ICF to our discipline. Plans are in progress to explore further the application of the ICF to speech-language pathology, with detailed discussions of each of the components, as well as its applications as a statistical, clinical, teaching, research, and policy-making tool in speech-language pathology. This special issue and future discussions will extend the scope of practice of speech-language pathologists by applying a holistic approach in dealing with functioning and disability. It will also help to deepen speech-language pathologists' current understanding of the ICF.