Presentation at the Nordic APA Conference 2019, Korsør, Denmark. Sport classification, Washington Group, Disabilities, self-reporting for children, surveillance and health promotion.

1. UEF // University of Eastern Finland
https://www.slideshare.net/kwok/function-difficulties-a-pseudonym-for-disabilities
Nordic APA conference, 15th May 2019 Kwok Ng
School of Educational Sciences and Psychology, University of Eastern Finland
Department of Physical Education and Sport Sciences, University of Limerick, Ireland
Kwok.ng@uef.fi @kwokwng
How are functional difficulties a
pseudonym for disabilities?

2. UEF // University of Eastern Finland
Outline
•Lets talk about Disability sport classification!
•Introduction to the Washington Group on Disability Statistics and the
UNICEF Child functioning module
•Conversion process for self-reporting
– TUTKA study
– Test-retest
•Discussions for applications
Nordic APA conference 2019 @kwokwng 2

3. UEF // University of Eastern Finland
Need for classifying people in sports
On 1st May 2019 the Court of Arbitration for Sports decided that Caster Semenya would need to take
testosterone suppressants to compete in the women’s division in sanctioned IAAF events.
The IAAF’s argument was that high testosterone in female athletes confers significant advantages in
size, strength and power from puberty onwards, and said the policy was “necessary, reasonable and
proportionate” to ensure fair competition in women’s sport.
https://www.iaaf.org/news/press-release/questions-answers-iaaf-female-eligibility-reg
Nordic APA conference 2019 @kwokwng 3
Tracey Nearmy / AAP

4. UEF // University of Eastern Finland
Functional assistance
14th Jan 2008, IAAF found that Oscar Pistorius’s cheetah prosthetics offered clear mechanical
advantages
16th May 2008, CAS overturns the ruling, so that he may compete for the Olympics. After failing to
make the team in 2008, he managed to qualify for 2012.
https://www.iaaf.org/news/news/oscar-pistorius-independent-scientific-stud-1
https://jurisprudence.tas-cas.org/Shared%20Documents/1480.pdf
Chang W Lee/The New York Times
Nordic APA conference 2019 @kwokwng 4

5. UEF // University of Eastern Finland
Less complicated cases
• Classification by age
– Youth events
– Juniors
– Masters
• Classification by weight
– Contact sports
– Weight lifting
• Classification by equipment
– Motor racing
– Sailing
Nordic APA conference 2019 @kwokwng 5

6. UEF // University of Eastern Finland
International Paralympic Classification
• 1. Does the athlete have an eligible
impairment for this sport?
• 2. Does the athlete’s eligible
impairment meet the minimum
disability criteria of the sport?
• 3. Which sport class describes the
athlete’s activity limitation most
accurately?
Nordic APA conference 2019 @kwokwng 6
Impaired muscle power
Impaired passive range of
movement
Limb deficiency
Leg length difference
Short stature
Hypertonia
Ataxia
Athetosis
Visual Impairment
Intellectual Impairment

7. UEF // University of Eastern Finland
WHO International Classification of Functioning,
Disability and Health (ICF)
7Nordic APA conference 2019 @kwokwng

8. UEF // University of Eastern Finland
International Classification of Functioning, Disability
and Health (ICF)
•WHO published the ICF in 2001, with a Children
and Youth version in 2007, and revised a combined
version in 2017.
•Places an impairment within the perspective of the
ability to complete an activity or participate in a life
experience
•Furthermore, the ICF considers limitations and
restrictions to these experiences
•It includes the environmental factors that contribute
so significantly to these restrictions
8Nordic APA conference 2019 @kwokwng

9. UEF // University of Eastern Finland
Aims of the ICF
•to establish a common language to improve communication across
disciplines and sectors;
•to provide a systematic coding scheme for health care information
systems;
•to provide a scientific basis for understanding health and health-
related states, outcomes and determinants;
•to enable data comparison across different countries, health care
systems, services and among health conditions.
19/03/2015kwok.ng@jyu.fi, ICF 9

10. UEF // University of Eastern Finland
Classification
19/03/2015kwok.ng@jyu.fi, ICF 10

11. UEF // University of Eastern Finland
Hierarchical Classifications
19/03/2015kwok.ng@jyu.fi, ICF 11

12. UEF // University of Eastern Finland
Washington Group (WG) on Disability Statistics
12
19/03/2015kwok.ng@jyu.fi, ICF

13. UEF // University of Eastern Finland
Children have a voice, that should be heard
•Finland has a long history of collecting health related survey data
from children
– 1977 - NTTT (health behaviour of young Finns) – biennial
– 1983/4 – HBSC (health behaviour of school aged children) –
quadrennial; international survey, currently 49 member countries
– 1996/7 – SHP (school health promotion study) – biennial
– 2014 – F-SPA (Finnish school-aged physical activity study) – biennial
•Until recently, children with disabilities have been excluded from
participating in such surveys
Kwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 13

14. UEF // University of Eastern Finland
•The HBSC study goals are to increase the understanding of adolescent
health and well-being by identifying related health behaviours, life
styles and contexts and describe adolescent health behaviour between
countries. (Boyce et al, 2009)
•Issues to developing items
– A short set of questions
– Items need to remain comparable between collection years and between
countries
– It must compliment other mandatory questions
– Advantageous to be comparable with Census questionnaires
14Kwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng
Example context

15. UEF // University of Eastern Finland
Any suggestions?
•How to measure adolescents’ disability status?
15Nordic APA conference 2019 @kwokwng

16. UEF // University of Eastern Finland
Conversion for self-report

17. UEF // University of Eastern Finland
Long-term Illnesses or disability (LTID) Optional
Package
•What makes an illness into something that is consider as ‘chronic’?
– 3 months
– 6 months
– Over a year
– Permanent?
•A non categorical approach suggests, irrespective of diagnosis, there
are common health disparities
17Nordic APA conference 2019 @kwokwng

18. UEF // University of Eastern Finland
Chronic conditions short questionnaire
3.1 Yes 3.1 No
3.1 Do not have False No LTID
3.3 Yes Severe False
3.3 No LTID No LTID
18Nordic APA conference 2019 @kwokwng

19. UEF // University of Eastern Finland
Based on 2013/14, Armenia also data on Chronic Conditions
19Nordic APA conference 2019 @kwokwng

20. UEF // University of Eastern Finland
0%
5%
10%
15%
20%
25%
30%
Populationpercentage
Percentage adolescents with LTID across Europe
No LTID
LTID
Severe LTID
Ng, et al, (2017). APAQ
20Nordic APA conference 2019 @kwokwng

21. UEF // University of Eastern Finland
National Items on Disability 2002
•Does this disability, illness or
medical condition cause you
to have:
– Difficulty seeing things (does
not include prescription eye
glasses)?
– Difficulty hearing others?
– Difficulty speaking to others?
– Difficulty in moving around?
– Difficulty in handling objects?
– Difficulty in breathing?
– Epileptic seizures (fits)?’
Population divided into LTID Categories
Not Specified Breathing
Motor Comms.
Visual Epilepsy
Motor & Breathing Breathing & Comms
Ng, et al, 2014
21Nordic APA conference 2019 @kwokwng

22. UEF // University of Eastern Finland
HBSC study in Finland
• If yes, (check box) what difficulties
– Seeing
– Hearing
– Speaking
– Moving around
– Handling objects
– Breathing
– Epileptic Seizures (Fits)
2002 2006 2010 2014 2018
Long term illnesses or Disabilities (Yes | No)
• Do you have difficulty..
• in seeing, even with glasses?
• hearing, even with a hearing aid?
• In speaking fluently?
• In moving?
• In handling objects?
• In breathing, for example, shortness of breath?
• In remembering things?
• In concentrating?
• In sitting still during lessons?
No difficulties
Difficulties do not affect functioning
Difficulties affect functioning somewhat
Difficulties affecting functioning a lot
Difficulties affect functioning very much
Self-reported CFM
2016 F-SPA
Seeing
Hearing
Speaking
Moving
Breathing
Remembering or
concentration
(Osteras et al, 2008)
22Nordic APA conference 2019 @kwokwng

23. UEF // University of Eastern Finland
Child Functioning Module
Do you have difficulty seeing, even if wearing your glasses or contact lenses?
Do you have difficulty hearing sounds like people’s voices, even if using a hearing aid?
Do you have difficulty walking 100 yards/meters on level ground, even if you use any equipment
or receive assistance? That would be about the length of a football field [or insert country specific
example]
Do you have difficulty with self-care such as feeding or dressing yourself?
When you speak, do you have difficulty being understood by people outside of your home?
Compared with students of the same age, do you have difficulty learning things?
Compared with students of the same age, do you have difficulty remembering things?
Do you have difficulty concentrating on an activity that you enjoy doing?
Do you have difficulty accepting changes in your routine?
Compared with students of the same age, do you have difficulty controlling your behaviour?
Do you have difficulty making friends?
23
https://data.unicef.org/resources/module-child-functioning-concept-note/
None Some A lot Cannot do
Nordic APA conference 2019 @kwokwng

24. UEF // University of Eastern Finland
HBSC 2014 (left) and WG themes (right)
• seeing things
• hearing others?
• speaking to others?
• moving around?
• handling objects?
• breathing?
• Epileptic seizures (fits)?
• Remembering?
• Concentrating?
• Sitting Still?
• Vision (seeing)
• Hearing
• Walking (mobility)
• Communication
• Learning
• Playing
• Relationship
• Self-care
• Emotion
• Behaviour
• Attention
• Coping with Change
Other HBSC
Items
24Kwok Ng – Testing self-report CFM
Nordic APA conference 2019 @kwokwng

25. UEF // University of Eastern Finland
Nordic APA conference 2019 @kwokwng
What about emotional difficulties?
CFM
• How often does (name) seem very
anxious, nervous or worried?
– Would you say: daily, weekly, monthly, a
few times a year or never?
• How often does (name) seem very sad or
depressed?
– Would you say: daily, weekly, monthly, a
few times a year or never?
HBSC Symptoms Checklist
• In the last 6 months: how often have you
had the following....?
– Feeling low
– Irritability or bad temper
– Feeling nervous
• About every day, More than once a week,
About every week, About every month,
Rarely or never
25
?
?
?
Kwok Ng – Testing self-report CFM

26. UEF // University of Eastern Finland
2014 Prevalence Data
13y & 15y (N=3665) WG Themes
•Vision – 1.4%
•Hearing – 0.5%
•Walking – 1.7%
•Communication – 1.7%
•Learning – 4.0%
•Behaviour – 3.1%
•Attention – 4.9%
Ng, et al, 2017 Injury Epid.
26Nordic APA conference 2019 @kwokwng

27. UEF // University of Eastern Finland
Tutka Project
HBSC and F-SPA in Special Education Settings
Funded by the Finnish Ministry of Education and Culture and the
University of Jyvaskyla

28. UEF // University of Eastern Finland
TUTKA-project overview
1 Pre-pilot
Oct – Dec 2017
Timing (60 Q)
Survey modes
Paper and pencil
Online
Easy-to-read
2 Pilot Testing
Jan – Feb 2018
Test-Retest (2 week)
Face Validity (Focus Groups)
Construct Validity (Teachers)
Construct Validity (Parents)
Focus Groups (pupils)
3 Additional Pilot
Mar – Apr 2018
S version
Refinement
4 National Data Collection
Apr – May 2018
Recruitment
Survey administration
Online
Teacher feedback
Kwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 28

29. UEF // University of Eastern Finland
TUTKA-project Questionnaire development
L
10-13 yrs
49 Q
14-18 yrs
56 Q
Standard
language
M
10-13 yrs
36 Q
14-18 yrs
40 Q
Easy-to-
read
S
10-18 yrs
24 Q
Easy-to-
read
HBSC
92
questions
F-SPA
31
questions
71
Kwok Ng – Testing self-report CFM
Nordic APA conference 2019 @kwokwng 29

30. UEF // University of Eastern Finland
Questionnaire items were …
• aided by images
• modified to easy-to-read language
Kwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 30

31. UEF // University of Eastern Finland
A tool for teachers to choose the right version
L-version
(standard language)
M-version
(easy-to-read language)
S-version
(easy-to-read language)
 challenges in being physically
active, hearing, seeing, or
behaving
 mild challenges in attention
deficit or regulating one’s
activity
 mild challenges in
understanding and learning
 cognitive challenges
 severe challenges in attention
deficit or regulating one’s
activity
General support Intensified support Special support
The level of support is minimal The level of support is maximal
Kwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 31

32. UEF // University of Eastern FinlandKwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 32

33. UEF // University of Eastern Finland
Intra-rater Test-Retest
Reliability

34. UEF // University of Eastern Finland
Study Design
•Pilot study on 6 special schools, with a target of 60 pupils in 5th – 9th
grade pupils.
•Location – South of Finland
•Administration – Research led
•2- week gap
•Versions
– L & M versions
•Incentive – sports equipment for the school
Ng et al, (submitted). Intra-rater test-retest reliability of self-reporting child functioning module. IJDDE
Kwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 34

35. UEF // University of Eastern Finland
Study Characteristics
Ng et al, (submitted). Intra-rater test-retest reliability of self-reporting child functioning module. IJDDEKwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 35

36. UEF // University of Eastern FinlandKwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 36

37. UEF // University of Eastern Finland
Points of Discussion based on the re-test study
•Substantial agreement with vision item, but it is perceived as complex
and difficult to understand
•Poor agreement with self-care
– Examples are too varied – 1) feeding, 2) dressing oneself
– ICF (WHO, 2007), 5 codes related to ‘feeding’
•Poor agreement with attention (concentration)
– Knowing what a person enjoys may vary by time
•Poor agreement with coping with change (own routine)
– Difficulties in understanding what a routine is
Kwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 37

38. UEF // University of Eastern Finland
Major points of discussion
•School staff were pleased and proud to take part in such studies.
– It is the first time their children’s voice were included in such
surveys.
•Language development between easy-to-read and standard
language requires further work
•Items that can be comparable between general schools and special
education settings require more research
– The use of the CFM is a starting point for possible alignment to
improve our understanding of all adolescent development
Kwok Ng – Testing self-report CFM Nordic APA conference 2019 @kwokwng 38

39. UEF // University of Eastern Finland
Concluding Points
•Functional difficulties is a new approach towards disability
classification.
•The Washington Group on Disability Statistics is the endorsed method
for collecting data on disabilities, and it is based on two main
assumptions
– There are universal core functions in relation to disability
– These functions operate at a level of severity
•The translation into self-report is important for health promotion
•The work to translate that into sport and APA is in the early days
Nordic APA conference 2019 @kwokwng 39

40. UEF // University of Eastern Finland
Disability Measures – A Maze
THANK YOU & QUESTIONS!
Nordic APA conference 2019 @kwokwng 40