The document discusses issues raised by proposals and reviewers of the ICF Update and Revision Platform that point to a need for an ontological review of the ICF structure. Specifically, it identifies issues with the placement of codes, developmental sequencing, differentiation between basic and complex concepts, function versus observable function, special user groups, granularity, boundaries, and temporal aspects. An analysis was conducted of the nature of reviews and comments on proposals in order to identify fundamental structural problems in the ICF that are highlighted by discussions.

1. WHAT ISSUES RAISED BY PROPOSERS AND
REVIEWERS OF THE URC PLATFORM POINT
TO A NEED FOR AN ONTOLOGICAL REVIEW?
J Jelsma1 M Cuenot2
1 South African CC, University of Cape Town
2 French CC, Ecole des Hautes Etudes en Santé Publique (EHESP),

2. Background
Starting point:
• Why do some proposals lead to so much discussion and
sometimes the issues raised seem insoluble?
• Could it be that there are fundamental problems with the
existing structure that are being highlighted by these
proposals?
• If so, what are the implications of these problems for
ongoing revision of the ICF?

3. Method
• All proposals submitted for review on the
Update and Revision Platform undergo a
standardised review process, in collaboration
with members of the FDRG, and often leading
to modification before a final vote by members
of the URC.
• An analysis of the nature of the reviews
proposed and the reviewer’s comments was
undertaken to identify the type of issues raised.
• Specific issues relating to the fundamental
structure of the ICF were identified.

4. Example
• d4107 Rolling over
• note
• Moving the body from one position to another while lying
such as turning from side to side or from stomach to back
Included under
d410-d429 CHANGING AND MAINTAINING BODY
POSITION
• d410 Changing basic body position
•What could be easier?

5. Placement
Proposal Suggested insertion Comments
d4107 Rolling over
note
Moving the body from
one position to another
while lying such as
turning from side to side
or from stomach to back
Would rolling fit better
under

6. Developmental sequencing
Proposal Comments
d4107 Rolling over
note
Moving the body from
one position to another
while lying such as
turning from side to side
or from stomach to back
d410-d429 CHANGING
AND MAINTAINING
BODY POSITION
d410 Changing basic
body position
Rolling is developed at
about 6 months.
Squatting only after
about 8 months – does it
make sense for it to be
inserted after Squatting,
standing and kneeling?
d4100 Lying down
d4101 Squatting
d4102 Kneeling
d4104 Standing
d4106 Shifting the body's
centre of gravity?

7. Issues identified
Structure:
• Placement of codes- multi-parent codes?
• Developmental sequencing – related to insertion of codes
within existing codes
• Basic/ complex: parent codes
• Function/expression of that functioning
• Granularity
• Boundaries
• Temporality
• Special groups

8. Placement of codes – case of play in
children
Proposal Comments
Subcategories d8800,
d8801 etc were added to
the ICF-CY : when children
engage in play they are not
engaging in leisure activities
but rather in a major life
activity analogous to work
or education in adults.
Other major life areas
(d880-d889)
d880 Engagement in play
d8800 Solitary play
d8801 Onlooker play
d8802 Parallel play
d8803 Shared cooperative
play
Adding these codes,
given that d9200
Play already exists,
implies that children can
sometimes play as a
major life activity and
sometimes play as a
leisure activity: this
creates confusion.

9. Placement of codes – case of
communication
Proposal Comments
d530 Toileting
note
Indicating the need for,
planning and carrying
out the elimination of
human waste
(menstruation, urination
and defecation), and
cleaning oneself
afterwards.
‘Indicating the need for’ is a
communication task that is separate to
the physical activity of eliminating human
waste.
To indicate the need to eliminate human
waste is a communicative act. Indicating
need also applies to many needs and
indeed many activities (e.g., eating,
sleeping, drinking, washing, moving,
most self-care, chapter 5, chapter 6).
Communication underlies almost all
areas of activities and participation.
Therefore, including ‘indicating need’ as
part of the eliminating human waste
activity runs the risk that it will have to be
included in many other areas.
Indicating need probably belongs as
an additional example or code in
Communication chapter 3

10. Placement of codes – case of
communication
Proposal Comments
d332 Singing
note
Producing tones in a
sequence resulting in
a melody or
performing songs on
one’s own or in a
group.
Singing is an example in the
category “d9202 Arts and culture”
but not in communication. Certainly
singing is a form of communication
but also are many other
communicative activities, such as
writing poetry, chanting and
repeating liturgy. Why should we
single out singing and not the
others?

11. Developmental sequencing/logical order
Proposal Comments
d132 Acquiring
language
d134 Acquiring
information
d137 Acquiring
concepts
d1370 Acquiring basic
concepts
d1371 Acquiring
complex concepts
The order needs to be
amended again to a more
logical order. As acquiring
concepts is required for
acquiring knowledge as
defined, the codes relating
to the acquisition of
concepts have to be
presented first.
d137 Acquiring concepts
d1370 Acquiring basic
concepts
d1371 Acquiring complex
concepts
d138 Acquiring information

12. Placement of codes – case of
communication
Proposal Comments
d7107 Taking turns in
social interactions
Sharing ability to
alternate activity in non-verbal
social
interactions, as a
playground equipment or
in games.
Exclusion: Starting a
conversation
(d3500); Sustaining a
conversation (d3502)
Taking turns in social
interactions does not
need to be included
amongst the basic
interpersonal
interactions. It is one
example of Interacting
according to social rules,
a complex interpersonal
interaction. Suggest add
as an inclusion to d7203

13. Confusion in parent code
Proposal Comments
This proposal may come
unstuck with ontological
modelling. There seem to be
two concepts under the
one parent code. Types of
memory (short, long and
working) mixed with exercise
of memory retrieval and
processing which may be
better linked with functions to
establish memory.
The differentiation between
the modified existing code
b1442 “Retrieval & processing
of memory” and b1443
“Working memory” is unclear.

14. Basic/complex
• constructs within A&P (e.g. “d210: undertaking multiple
tasks”) which can be considered as parent concepts to
other constructs in the same component (e.g. “d630
preparing meals”)

15. Basic/complex
Proposal Comments
b163 Basic cognitive
functions
Mental functions involved in
acquisition of knowledge about
objects, events and
experiences; and the
organization and application of
that knowledge in tasks
requiring mental activity.
Inclusion:functions of cognitive
development of representation,
knowing and reasoning
Exclusion: higher level cognitive
functions (b164)
The concept b163 Basic
cognitive functions might
make sense as opposed
to b164 Higher-level
cognitive functions, but as
such it is potentially a
ragbag of many other
concepts listed in the whole
block b140-b189
Specific mental
functions (Attention
functions, Memory
functions, Psychomotor
functions, Emotional
functions, Perceptual
functions, Thought
functions, etc.)

16. Differentiation between function and the
observable function
• some constructs with similar meaning (e.g. “b16711
expression of written language” and “d345 writing
messages”) and hardly differentiable by observation are
positioned in different components of the classification
with not mutually exclusive attributes.

17. Differentiation between function and the
observable function
Proposal Comments
Is it possible to differentiate
the functions of retrieving a
memory, processing a
memory and working
memory by assessment
processes?

18. The case of special education
e585 Education and training services, systems and policies
note: Services, systems and policies for the acquisition, maintenance and improvement of knowledge, expertise
and vocational or artistic skills. See UNESCO's International Standard Classification of Education (ISCED-1997).
Inclusions: general and special education
e5850 General Eeducation and training services
note: Services and programmes concerned with general [former proposal ID 191, rejected] education and the
acquisition, maintenance and improvement of knowledge, expertise and vocational or artistic skills, such as those
provided for different levels of education (e.g. preschool, primary school, secondary school, post-secondary
institutions, professional programmes, training and skills programmes, apprenticeships and continuing education),
including those who provide these services.
e5851 General Eeducation and training systems
note: Administrative control and monitoring mechanisms that govern the delivery of general education
programmes, such as systems for the implementation of policies and standards that determine eligibility for public
or private education and special needs-based programmes; local, regional or national boards of education or
other authoritative bodies that govern features of the education systems, including curricula, size of classes,
numbers of schools in a region, fees and subsidies, special meal programmes and after-school care services.
e5852 General Eeducation and training policies
note: Legislation, regulations and standards that govern the delivery of generaleducation programme, such as
policies and standards that determine eligibility for public or private education and special needs-based
programmes, and dictate the structure of local, regional or national boards of education or other authoritative
bodies that govern features of the education system, including curricula, size of classes, numbers of schools in a
region, fees and subsidies, special meal programmes and after-school care services.

19. The case of special education
e5853 Special education and training services
note: Services and programmes concerned with special education and the acquisition,
maintenance and improvement of knowledge, expertise and vocational or artistic skills, such as
those provided for different levels of education (e.g. preschool, primary school, secondary school,
post-secondary institutions, professional programmes, training and skills programmes,
apprenticeships and continuing education), including those who provide these services.
e5854 Special education and training systems
note: Administrative control and monitoring mechanisms that govern the delivery of special
education programmes, such as systems for the implementation of policies and standards that
determine eligibility for public or private education and special needs-based programmes; local,
regional or national boards of education or other authoritative bodies that govern features of the
education systems, including curricula, size of classes, numbers of schools in a region, fees and
subsidies, special meal programmes and after-school care services.
e5855 Special education and training policies
note: Legislation, regulations and standards that govern the delivery of special education
programmes, such as policies and standards that determine eligibility for public or private
education and special needs-based programmes, and dictate the structure of local, regional or
national boards of education or other authoritative bodies that govern features of the education
system, including curricula, size of classes, numbers of schools in a region, fees and subsidies,
special meal programmes and after-school care services.

20. The case of special education
• ‘Special education’ is not well defined and it is a concept that can
evolve.
• But it is a term well recognized in policy and by families. It is a reality
that has to be recognized although no general definition exists.
• The introduction of ‘special education’ went against the structure of
chapter e5 of ICF. It introduced a granularity which was not present for
other codes of the same chapter.
• Special needs exist not only in school but also in transports, health,
work, etc. If services for are coded separately, there is a risk of
marginalization of those services.
• Others noted that, in e585, the term ‘education’ as such includes both
general and special education. If necessary (but maybe not, see e585),
a distinction between general education and special education might be
introduced at a lower level. The problem is at what level of the
classification ‘special education’ should be included.
• Moreover, titles of codes should be mutually exclusive.

21. The case of special education
Another suggestion would be to think of a new "transversal" code
(usable across all service systems) for individual support or
assistance (individual support or assistance services, individual
support or assistance systems, individual support or assistance
policies). This would also pick up on the trend to create person-centred
rather than system-centred services.
Much will also depend on the future content model of the ICF. We
may be able to code several dimensions separately in the future: for
example availability, accessibility, adaptability, acceptability

22. Special user groups
• Are children a special group?
• If we have specific codes for children, should we have
specific codes for other groups?
• If we have “special education” should we also have
“special transport”, “special workplaces” etc.?

23. Granularity
Proposal Comments
e3100 Support from
mother
e 3101 Support from
father
e3102 Support from
spouse/partner
e 3103 Support from
siblings
e 3104 Support from
son
e3105 Support from
daughter
e3106 Support from
grandparents
These proposals
introduce a level of
detail into the
Environmental Factors
codes which is not there
in many other codes, so
they introduce apparent
imbalance into Chapters
3 and 4 of EF.
The list does not cover
all the present
inclusions.

24. Granularity
Proposal Comments
s11000 Frontal lobe, white
matter
s11001 TemporalFrontal lob
e, grey matter
s11002 ParietalTemporal lob
e, white matter
s11003 OccipitalTemporal lo
be, grey matter
s11004 Parietal lobe, white
matter
s11005 Parietal lobe, grey
matter
s11006 Occipital lobe, white
matter
s11007 Occipital lobe, grey
matter
This level of granularity is
rarely required in clinical
practice as the information is
often not available in the
absence of sophisticated
imaging. This in comparison
with the lack of detail in the
other brain structure
classifications does not
make sense to me. Do we
need to differentiate between
the substantia nigra and other
parts of the basal ganglia,
white and grey matter in the
spinal cord etc?

25. Boundaries
Proposal Comments
Genetic diseases are not
found within the structural
aspects of the
ICF classification and we
have some diseases such
as Sd. Down that
affects chromosome
structure and thereare func
tional deficiencies, activity
limitations and participatio
n restrictions, we do not
find how to do it from the
structure in the
classification
It is not clear what ‘genetic structure’ refers to – a person’s genotype,
a specific gene, a chromosome structure, the overall genetic code of
an individual, the overall genetic structure of human beings, and so
on.
- Would ‘genetic structure’ be a single code, but then at what level; if
at 2nd or 3rd level, what would there be embedded codes?
- The proposed classification entity lacks plausibility, since the ICF
explicitly limits the scope of functioning to the observable level: “Thus
impairments coded using the full version of ICF should be
detectable or noticeable by others or the person concerned by
direct observation or by inference from observation.” To now
bring in an additional item that was below this threshold (i.e. that is, an
item that was not detectable or noticeable by direct observation or
inferable from observation) would be an exception to the structure of
the ICF that logically would require the additional of all sub-observable
biological functions and structures. This would require a massive
alteration in the ICF, even if it were feasible to do so.

26. Temporal aspects
Environmental Factor ?
Time is a barrier to communication for people with little or no speech - either lack of
time or the addition of time can influence the success of a communicative
interaction. The most recent publication on this subject arises from my postdoctoral
work examining communication in hospital for people with the most severe
communication disabilities - little or no speech. The reference for the publication is:
Title: Nursing the patient with complex communication needs: time as a barrier and
a facilitator to successful communication in hospital.
Author(s): Hemsley, B.; Balandin, S.; Worrall, L.
Source: J Adv Nurs Volume: 68 Issue: 1 Pages: 116-26 Published: 2012
This is just one example of research indicating that time can function as both a
barrier and a facilitator to better communication.
This instance of 'time' does not relate to 'orientation' but rather to 'duration' of
available time or time spent - which might allow additional environmental factors
such as use of tools or strategies to proceed.

27. Conclusions
CartoonStock

28. Acknowledgements
• Funding from the University of Cape Town Research
Committee is gratefully acknowledged.
• The review process is made possible by the thoughtful
participation of FDRG and URC members. Their
commitment, insight and dedication are recognised