Applications of ICF in

Language Disorders

Presented by:
GOWHER NAZIR
Speech-Language Pathologist and Audiologist
OUTLINE OF THE PRESENTATION
+ INTODUCTION OF ICF

+ COMPONENTS AND PURPOSE OF ICF

+ LANGUAGE IMPAIRMENTS

+ ICF IN ASSESSMENT OF LANGUAGE DISORDERS

+ CODING LANGUAGE IMPAIRMENTS

+ ASSESSMENT AND CODING OF ACTIVITIES AND

PARTICIPATION ON THE ICF

+ INTERPERSONAL INTERACTIONS AND SOCIAL

RELATIONSHIPS CODING ON ICF
+ THE CHILDRENS VERSION OF ICF (ICFCY) CODES
RELATED TO COMMUNICATION DISORDERS

+ EVALUATING CAPACITY AND PERFORMANCE

+ EVALUATING CONTEXTUAL FACTORS

INTRODUCTION OF
ICF
+ The International Classification of
Functioning, Disability and Health
(ICF) is a classification of the health
components of functioning and
disability developed by World Health
Organization (WHO) and published in
2001.
+ The ICF framework can be used in
interprofessional collaborative
practice and person- centered care.
The ICD (International Classification
Diseases and Related Health Problems)
classifies disease, the ICF looks at functioning.
Therefore, the use of two together would
provide a more comprehensive picture of the
health of people.
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 WHO 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.
 Components of ICF
+ The ICF framework consists of two parts:
1. Functioning and Disability
2. Contextual factors
+ Functioning and Disability includes:
1. Body functions and structures;
+ Describes actual anatomy and
physiology/psychology of the human body.
2. Activity and Participation:
Describes the person’s functional status,
including communication, mobility, interpersonal
interactions, self-care, learning, applying
knowledge, etc.
 Contextual factors include:

1. Environmental factors:

factors that are not within the person’s control, such as family, work, laws and cultural beliefs .

2. Personal factors:

Include race, gender, 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.
 Collection of statistical data

Clinical research

Purpose of ICF
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).

The ICF provides a framework for understanding the effects of language impairments on a child’s
ability to communicate in structured and natural contexts, and the ways that environmental and
personal contextual factors influence the child’s doing so. The intent is to use the ICF framework to
determine how the person’s quality of life can be enhanced by optimizing communication.
+ Language impairments frequently are comorbid with other health
and developmental conditions, for any one child, SLPs may need
to use a variety of other codes. Language impairments manifest in
a variety of ways:

+ Specific language impairment (SLI):

+ SLI is a developmental language impairment in the absence of

obvious neurological, sensorimotor, nonverbal cognitive, or social
emotional deficits. Children with SLI typically have problems in
language comprehension and production characterized by delays
or deficits in the use of grammatical morphology (e.g., plural –s,
past tense –ed). They omit function morphemes from their speech
long after age-matched children with typical language
development show consistent production of these elements.
+ Semantic–pragmatic language disorder (SPLD):

+ Children with SPLD typically have age-appropriate morphological–syntactic skills but have atypical
social skills. They may have difficulty understanding figurative language forms (e.g., idioms, jokes).
They tend to learn language through memorization and often focus on specific details of an event or
conversation, and hence, frequently miss the overall meaning of the discourse. Initially, the term SPLD
was used to refer to children who were not considered to be autistic. In recent years, however, it is
acknowledged that verbal children on the autism spectrum disorder continuum exhibit SPLD.

+ Dyslexia:

+ Literacy is a natural extension of oral language development. Children with language delays that are not
resolved by 5.5 years of age are at high risk for exhibiting deficits in reading and writing; consequently,
literacy skills should also be assessed for school-age children with language impairments.
+ Generalized language delays:

+ The language used by children with cognitive impairments is typically like that used by children who
are chronologically younger. Children with cognitive impairments do not necessarily exhibit a
disordered language pattern that is characteristic of SLI or SPLD, but some children with cognitive
impairments may exhibit SLI or SPLD in addition to their generalized delays.

+ Typically, when using the ICF, one begins by identifying body functions that are impaired, then, if
possible, Body Structures that might account for the impairments in functions are identified. Under
the Body Functions component, language impairment is coded as a specific mental function. The
evaluator notes receptive and expressive language impairments in spoken, written, and signed
language at a short-message level and at a more complex discourse level. Although one can assume
that differences in brain structure or function account for language impairments, the specific location
or nature of these structural differences are unknown, so impairment in structure typically is not
coded.
+ Coding Language Impairments on the ICF

B167 Mental functions of language

+ B1670 Reception of language (decoding

+ messages to obtain meaning)

+ B16700 Reception of spoken language

+ B16701 Reception of written language

+ b16702 Reception of sign language

+ b1671 Expression of language

(producing meaningful messages)

+ b16710 Expression of spoken language

+ B16711 Expression of written language

+ b16712 Expression of sign language

+ B1672 Integrative language functions:

mental functions that organize semantic and
symbolic meaning, grammatical structure and
ideas to produce messages in spoke, written, or
other forms of language

+ The degree or severity of the language

impairments can be coded on a 5-point scale
from no impairment to complete impairment. For
children, impairment is typically based on the
extent to which the child differs from typically
developing children of the same age.
A child whose score on a formal language assessment is within 1 standard deviation (SD) of the mean is
considered not to have an impairment; a child with a score between –1.0 to –1.5 SD has a mild
impairment; –1.5 to –2.5 SD is a moderate impairment; –2.5 to –3.0 is a severe impairment; and more than
–3 SD is a complete impairment.

ASSESSMENT OF ACTIVITIES AND PARTICIPATION:

In the ICF, Activity refers to the execution of a task by an individual; Participation is the involvement in a
life situation. Activity limitations are difficulties a child may have in executing activities; participation
restrictions are problems a child may have in involvement in life situations. Impairments of language
functions can restrict the variety and complexity of tasks (Activities) that children can execute, which in
turn may limit the life situations in which children can or will participate (Participation).
Coding Activities and Participation on the ICF

Code Description

Communication

d310 Communicating with—receiving—spoken language

d315 Communicating with—receiving— nonverbal messages

(body gestures, general signs and symbols, drawings)

d325 Communicating with—receiving—written messages

d330 Speaking

d335 Producing nonverbal language

d340 Producing messages in formal sign language

d345 Writing messages

d350 Conversation

Cont...
Cont.…
Code Description
d3500 Starting a conversation
d3501 Sustaining a conversation
d3502 Ending a conversation
d3503 Conversing with one person
d3504 Conversing with many people
d355 Discussion
d3550 Discussion with one person
d3551 Discussion with many people
d360 Using communication devices and techniques
Interpersonal interactions and
relationships

+ d710 Basic interpersonal interactions:

+ ( Interacting with people in a contextually and socially

appropriate manner, such as by showing consideration
and esteem when appropriate, or responding to the
feelings of others)

+ d7100 Respect and warmth in relationships

+ d7104 Social cues in relationships

+ d7150 Physical contact in relationships

+
+ Cont.….
+ Cont.….

+ d720 Complex interpersonal interactions:

+ ( Maintaining and managing interactions withother people,

in a contextually and socially appropriate manner, such as by
regulating emotions and impulses, controlling verbal and
physical aggression, acting independent in social interactions,
and acting in accordance with social rules and conventions)

+ d7200 Forming relationships

+ d7201 Terminating relationships

+ d7202 Regulating behaviors within interactions

+ d7203 Interacting according to social rules

The children’s version of the ICF ( ICFCY) added some additional
codes that are relevant to communication disorders:

+ d121: Purposeful sensory exploration of objects

(with four subcodes ranging from simple objects on a single toy

[shaking, banging, dropping] to pretend actions [e.g., substituting a
novel object such as using a block as a car]).

+ d131: Learning to play

+ (with subcodes involving solitary play, onlooker play, parallel

and cooperative play)

+ d132: Acquiring language

(with subcodes for acquiring single words, acquiring phrases, and

acquiring correct syntax).
 EVALUATING CAPACITY AND PERFORMANCE

+ The ICF differentiates between an individual’s capacity

to perform an activity and an individual’s actual
performance of an activity. This is a critical distinction
for intervention planning. Children must have language
capacity; that is, they must have specific morpho-
syntactic, semantic, pragmatic, and discourse skills; and
they must perform these skills in social situations. A
child may have capacity, but not use the capacity.

+ Intervention goals should address both development in

the ability to execute activities (capacity), and
involvement in these activities in life situations
(performance).
+ Capacity and performance are rated in four ways:

+ (1) performance in the current environment(considering any

personal and nonpersonal assistance that is available); (2)
capacity without assistance; (3) capacity with assistance
(personal and/or nonpersonal assistance); and 4) performance
in the current environment without assistance.

+ SLPs are experienced in evaluating capacity without assistance

—this is the typical assessment using standardized tests that
must be administered according to strict protocols. Evaluating
capacity without assistance can also include clinician-designed
assessments such as conducting a structured play assessment
and documenting the language the child uses during the
process; asking the children to relate a personal experience,
retell a story, produce a story based on a picture or story
starter; or write a story or expository text on a topic.
+ Assessing capacity with assistance could be a type of dynamic assessment
or teaching in the child’s zone of proximal development (ZPD). The
evaluator seeks to determine the type and amount of support a child
requires to complete a task. There are three methods of dynamic assessment
that are used to determine a child’s capacity or understanding.

+ 1. Testing the limits:

+ The SLP modifies the test procedures by rephrasing the question or

encouraging the child to show what he or she knows. For example, if one is
testing vocabulary, and the child gives an incorrect response, explain why
the response was incorrect and ask the child to try again. Or with older
children, the SLP can ask them to explain ‘‘how they know’’ or ‘‘what
would happen if?’’ to understand how they were thinking about the tasks
and why they responded as they did. Testing the limits provides the
evaluator with information regarding whether the child understands the
task, and whether the child has competence that was not revealed by
standardized testing.
2. GRADUATED PROMPTING: 3. TEST–TEACH–RETEST. THIS IS A PARTICULARLY USEFUL
GRADUATED PROMPTING IS USED
STRATEGY FOR STUDENTS WHEN THE
TO DETERMINE THE CHILD’S ZPD BY
EVALUATOR IS UNCERTAIN ABOUT THE
PROVIDING THE CHILD WITH A
CHILD’S FAMILIARITY WITH THE
HIERARCHY OF PREDETERMINED
ACTIVITY TO BE ASSESSED. FOR
PROMPTS THAT VARY IN LEVEL OF
EXAMPLE, MANY CHILDREN, ESPECIALLY
CONTEXTUAL SUPPORTS THEY
THOSE OF LOW INCOME OR DIVERSE
PROVIDE. A CHILD’S MODIFIABILITY
BACKGROUNDS, MAY HAVE HAD LIMITED
OR ABILITY TO LEARN CAN BE
OR NO EXPERIENCE WITH
DETERMINED BASED ON THE TYPE
CONVERSATIONAL AND NARRATIVE
AND NUMBER OF PROMPTS NEEDED
INTERACTIONS USED IN MAINSTREAM
TO ELICIT A DESIRED RESPONSE
CLASSROOMS. SLPS CAN EXPLICITLY
AND THE LEVEL OF TRANSFER TO
TEACH THE STRUCTURE OF THESE
NOVEL TASKS.
INTERACTIONS, NOTING THE DEGREE OF
EFFORT THEY MUST EXPEND TO HAVE
THE CHILDREN LEARN THE TASKS
 EVALUATING CONTEXTUAL FACTORS:

+ The ability to execute language and communicate in life

situations is not determined solely by impairments in language
functions. Contextual Factors, which include Environmental
and Personal Factors, interact with impairments in language
functions and with Activities and Participation to either facilitate
or inhibit capacity and performance.

+ Environmental factors include elements such as the physical

environments; social supports and relationships; attitudes of
family, friends, professionals, and society; available services and
social policies; and technology.

+ Personal factors include age, gender, race, language,

educational background, and lifestyle.
+ The environmental component of the ICF assesses the degree to
which there are facilitators or barriers to activity and participation
in the following areas:

+ Available technology: If needed, does the child have access to

hearing aids, augmentative devices, or computers?

+ Natural environment and human changes to the environment:

Is the noise level in the classroom affecting the child’s
comprehension? Do allergies or air pollution limit a child’s
participation with peers?

+ Support and relationships of family, peers, teachers, and SLPs.

Children must feel comfortable and safe if they are to be willing to
participate in family and school activities. Do the child’s
peers/siblings include or exclude him or her? Are school personnel
aware of how to support the child’s best performance?
+ Attitudes (of family, peers, health/educational professionals, and
society): Do family, peers, and professionals view the child in
positive or negative ways?

+ Services, systems, and policies. What services are available? How

easy is it for children or families to access the services?

+ Personal factors are not specifically coded in the ICF because of

the wide variability among cultures, but they are included in the
framework because they have a high likelihood of influencing
functioning. Gender, past experiences, race,
cultural/linguistic/socioeconomic background, and temperament
all influence a child’s capacity and performance.
THANK YOU