Annals of International Occupational Therapy

Original Research Supplemental Data

Extent of Use and Linkage of the International Classification of Functioning, Disability and Health to Frames of Reference and Interventions in Pediatric Occupational Therapy

Janel Anne S. Belarmino, OTD, OTR/L; Sarah L. Smith, DSc, OTR/L; Vanessa D. Jewell, PhD, OTR/L

Abstract

Objective:

This study measured the use of the International Classification of Functioning, Disability and Health (ICF) in pediatric occupational therapy practice and the linkage of frames of reference and intervention foci to specific components, categories, and subcategories of the ICF.

Methods:

A total of 78 participants completed an online survey. A standardized linking process was used to determine the linkage of frames of reference and intervention foci to the ICF.

Results:

Most frames of reference and intervention foci were linked to the ICF component of body functions, and 81% of participants reported that they did not use the ICF to make clinical decisions or communicate with other health care professionals.

Conclusion:

One limitation of this study was the small sample size; thus, the results cannot be generalized. Further, lack of contextualization of the intervention foci in the results created difficulty in identifying whether participant-identified intervention foci were linked specifically to the ICF activity or participation component. Future research should explore the use of the ICF in other areas of occupational therapy practice and linkage of the ICF to other occupational therapy data. [Annals of International Occupational Therapy. 2020; 3(2):69–77.]

Abstract

Objective:

This study measured the use of the International Classification of Functioning, Disability and Health (ICF) in pediatric occupational therapy practice and the linkage of frames of reference and intervention foci to specific components, categories, and subcategories of the ICF.

Methods:

A total of 78 participants completed an online survey. A standardized linking process was used to determine the linkage of frames of reference and intervention foci to the ICF.

Results:

Most frames of reference and intervention foci were linked to the ICF component of body functions, and 81% of participants reported that they did not use the ICF to make clinical decisions or communicate with other health care professionals.

Conclusion:

One limitation of this study was the small sample size; thus, the results cannot be generalized. Further, lack of contextualization of the intervention foci in the results created difficulty in identifying whether participant-identified intervention foci were linked specifically to the ICF activity or participation component. Future research should explore the use of the ICF in other areas of occupational therapy practice and linkage of the ICF to other occupational therapy data. [Annals of International Occupational Therapy. 2020; 3(2):69–77.]

The World Health Organization (WHO) developed the International Classification of Functioning, Disability and Health (ICF) to serve as a holistic biopsychological framework to describe and measure health and disability (Stucki et al., 2002; Vargus-Adams & Majnemer, 2014; WHO, 2002). The ICF offers a language and a lens to understand the person; their environment, health, and participation; and their relationship (Bendixen & Kreider, 2011). In addition to a widely encompassing approach to health and disability, the ICF offers a common and uniform language for multidisciplinary use (Fayed, Cieza, & Bickenbach, 2011). Evidence suggests that the ICF is relevant for use as a framework in clinical decision making and in bridging communication among interdisciplinary health care professionals (Atkinson & Nixon-Cave, 2011; Cerniauskaite et al., 2011; Darrah, 2008; Ehrenfors, Borell, & Hemmingsson, 2009; Finger, Cieza, Stoll, Stucki, & Huber, 2006; Haglund & Henriksson, 2003). Researchers have linked the standardized language of the ICF to discipline-specific assessments, interventions, and outcomes (Ehrenfors et al., 2009; Finger et al., 2006; Haglund & Henriksson, 2003).

Components of the ICF

The two ICF sections of functioning and disability and contextual factors provide a comprehensive organization for classifying a person's health. The functioning and disability section includes body functions and structures, the individual person's everyday activity, and participation. The contextual factors section includes the two components of environmental factors and personal factors. Except for personal factors, all of the ICF components are divided into domains that are further subdivided into categories, subcategories, and in some instances, lower levels of classification (Haglund & Henriksson, 2003; WHO, 2002). The breadth and depth of information that the ICF addresses allows its wide use in various health care disciplines (Atkinson & Nixon-Cave, 2011; Cerniauskaite et al., 2011; Darrah, 2008; Darzins, Fone, & Darzins, 2006; Vargas-Adams & Majnemer, 2014).

Use of the ICF in Pediatric Occupational Therapy Practice

Models and frameworks are necessary in clinical practice, research, and academia (Bendixen & Kreider, 2011). The use of a rehabilitation framework to guide the provision of service is paramount to quality health care (Darzins et al., 2006). Stamm, Cieza, Machold, Smolen, and Stucki (2005) suggested that occupational therapists should explore how occupational therapy practice models relate to international frameworks, such as the ICF. Haglund and Henriksson (2003) argued that if occupational therapists disregard the ICF as a framework and a language, they may be isolating the profession rather than facilitating and bridging interprofessional communication and relationships.

In pediatric settings, the ICF is well documented as a framework to guide, measure, and understand pediatric rehabilitation (Cramm, Aiken, & Stewart, 2012; Furze et al., 2013; Simeonsson et al., 2003). Cramm et al. (2012) emphasized that the ICF is not an assessment tool but rather a framework for gathering and integrating various assessment information. The components, categories, and constructs of the ICF are considered a guide to assess and describe a child's functioning and disability. For example, in the evaluation of children with cerebral palsy, the ICF can guide assessment of restrictions to participation, limitations of activity, and structures and functions of the body (Furze et al., 2013). Similarly, the ICF is seen as a framework for identifying a focus for intervention. In rehabilitation, health care providers may use the ICF as a guide in the identification and articulation of intervention foci (Vargus-Adams & Majnemer, 2014).

A number of studies applied ICF linking rules and identified which ICF categories were reflected in specific assessments, diagnostic instruments, interventions, and outcomes (Fayed et al., 2011). The results of ICF linking to health-related information assisted research consumers to identify assessments, instruments, interventions, and outcomes that reflect and target specific health domains (Fayed et al., 2011). In physical therapy, Finger et al. (2006) studied commonly used interventions and linked them to ICF categories. The intervention and linking to ICF categories showed that commonly used physical therapy interventions targeted body functions and activity and participation (Finger et al., 2006). For occupational therapy after traumatic hand injury, ICF linking evidence showed that interventions provided soon after surgery focused on body structures, activity, and environmental factors and that later interventions focused on participation (Fitighoff, Lindqvist, Nygad, Ekholm, & Schult, 2011).

Despite the evidence for use of the ICF in rehabilitation, limited information is available on the extent of its use in clinical decisions among pediatric occupational therapists. Previous literature reported that 70% of participant practitioners had some knowledge of the ICF, but fewer (29.2%) reported using it in practice (Farrell, Anderson, Hewitt, Livingston, & Stewart, 2007). In the United States, there is little baseline evidence on the extent of use of the ICF in pediatric occupational therapy, particularly in clinical decisions about frames of reference and intervention foci. For the purposes of this study, we defined frames of reference as a means to assist occupational therapists in linking theory to intervention strategies and to practice clinical reasoning to the desired intervention foci (Schultz-Krohn & Pendleton, 2006). We did not specifically examine therapists' selection of theory or model of practice. However for the purposes of interpreting findings from this study, we defined theory as a process of defining, describing, and understanding a phenomenon and a model of practice as “the application of theory to practice . . . often [serving] as a mechanism to engage in further testing of the theory” (Schultz-Krohn & Pendleton, 2006, p. 37). The model of practice has a wider view of the approach to occupational performance and can be applied across settings and patient groups (vs. a specific diagnostic group). This study examined frames of reference rather than models of practice and applied theory because we considered the frames of reference that linked most directly to intervention foci, one of the main features of this study.

The goal of this study was to obtain preliminary data on pediatric occupational therapists' use of the ICF in clinical decision making, choice of frame of reference, and focus of intervention. A further aim was to identify pediatric occupational therapists' currently employed frames of reference and intervention foci and to link the frames of reference and intervention foci to specific components of the ICF. This study attempted to answer the following research questions:

  1. To what extent do pediatric occupational therapists in the United States use the ICF in clinical decision making, specifically when choosing frames of reference and intervention foci?

  2. What frames of reference and intervention foci do pediatric occupational therapists in the United States currently employ in their practice?

  3. What ICF components are reflected in the frames of reference and intervention foci currently used by pediatric occupational therapists in the United States?

Methods

Research Design

This study used a cross-sectional descriptive research design with an online survey to collect information on current practices efficiently across a group of participants (Portney & Watkins, 2009). This study was approved and conducted in accordance with the guidelines of the institutional review board of Creighton University. Participants indicated consent to participate by clicking on the survey link, and they could terminate participation at any time without penalty by exiting the survey.

Participants

Study participants were pediatric occupational therapists located across the United States. To be included in the study, participants had to (1) be employed as an occupational therapist in the United States and (2) provide interventions for children during at least 50% of their practice hours, whether full time, part time, or hourly.

Instrument

The survey included 25 questions encompassing the following four categories: (1) participant demographics; (2) knowledge and use of the ICF in practice; (3) choice of assessment tools and outcome measures on ICF use; and (4) choice of intervention focus, frame of reference, and ICF use in relation to decision making. Participants chose commonly used intervention foci from a list provided in the survey. They also identified commonly used frames of reference in an open text box. Sample questions from the survey are shown in Table A (available in the online version of the article). To support content validity, four occupational therapy faculty members who were skilled in research design and five practicing pediatric occupational therapists across the United States reviewed the initial survey and provided feedback that we integrated into the final survey.

Sample Questions from the Survey Questionnaire

Table A:

Sample Questions from the Survey Questionnaire

Procedures

We recruited participants via social media, professional and personal contacts, and e-mail. To reach practitioners across the United States, researchers sent an e-mail to all 50 occupational therapy associations in the United States requesting that the associations forward the information letter to their members. The information letter described the purpose of the study, respondent rights, and the consent procedure, and provided a survey link. The research team sent e-mail reminders about the survey every 2 weeks. The survey link was available for 8 weeks.

Data Analysis

We analyzed data on demographic features, frames of reference, and ICF use with descriptive statistics, including frequency distributions, central tendencies, and percentages in Microsoft Excel to answer research questions 1 and 2. To answer research question 3, two authors (J.A.S.B. and S.L.S.) used a standardized linking process that was developed specifically for the ICF (Cieza, Fayed, Bickenbach, & Prodinger, 2019). The process of following the linking rules required us to follow four overall processes. First, we reviewed the core concepts and taxonomy of the ICF. Second, we prepared the data to be linked. Third, we linked the survey data concepts to the most accurate component, category, and subcategory of the ICF. Fourth, we categorized data as “other specified,” “unspecified,” “not definable,” or “not covered,” as appropriate. We categorized data as “other specified” if the data were not contained within any specific ICF category; “unspecified” when the data belonged to an ICF component but insufficient information was provided to assign the data to a specific ICF category; “not definable” when there was not enough information to assign the data to a specific ICF category (e.g., concepts on health, child development); and “not covered” if the data were not contained in the ICF (Cieza et al., 2019). To support study rigor, two authors (J.A.S.B. and S.L.S.) performed the linking independently and then met to discuss independent review and reach consensus on ICF categories.

Results

The survey was opened by 113 occupational therapists, partially completed by 78, and completed by 45. We included the responses of the participants who partially completed the survey to represent the largest number of occupational therapists' practices for each question.

Of the 64 participants who answered the demographic questions, 40 (63%) reported having a master's degree in occupational therapy and 28 (44%) had more than 20 years of experience in the field. The top two work settings were school systems and early intervention settings, accounting for more than two thirds of the participants. The survey participants were from all four regions of the United States, with most participants practicing in the Midwest (Table 1).

Respondent Demographics (N = 64)

Table 1:

Respondent Demographics (N = 64)

Frames of Reference

Of the participants, 45 identified the frames of reference that they regularly use in their practice within an open text box format. Table 2 shows the frames of reference that participants reported regularly using in pediatric practice. Some occupational therapists listed models or theories, such as the Model of Human Occupation or the Occupational Adaptation Model. The developmental frame of reference was the most regularly used (82%). Other participants reported regularly using sensory integration (71%), biomechanical (44%), and cognitive behavioral frames of reference (42%). The remaining frames of reference were reportedly used by fewer than 20% of participants.

Current Frame of Reference

Table 2:

Current Frame of Reference

Intervention Foci

Table B (available in the online version of the article) shows the frequency of use of intervention foci. Among the 25 intervention foci listed, improving self-regulation was the most frequently and regularly used (n = 47). The next most commonly used intervention foci were improving visual motor integration, motor skill development, play, attention, in-hand dexterity, bilateral coordination, visual perception, sensory integration, hand strength, social interaction, activities of daily living, core body strength, and dressing. Two participants reported addressing cardiovascular issues and financial management as frequently and regularly employed intervention foci.

Intervention Focus Areas UsedIntervention Focus Areas Used

Table B:

Intervention Focus Areas Used

Use of the ICF

Of the 48 participants (Table 3) who answered the question on ICF use, 81% stated that they did not use the ICF in clinical decision making related to choice of frames of reference and intervention foci. Three participants (6%) rarely used the ICF when choosing intervention foci, and 7 (15%) rarely used the ICF when making decisions about frames of reference. Further, 12% of participants reported frequently or regularly using the ICF to guide selection of the focus of intervention. Only two participants reported using the ICF frequently and regularly when choosing intervention foci.

Use of the ICF in Choosing Intervention Foci and Frames of Reference

Table 3:

Use of the ICF in Choosing Intervention Foci and Frames of Reference

Linkage of the ICF and Frames of Reference

The four frames of reference (developmental, sensory integration, biomechanical, and cognitive behavioral) that were regularly used by more than 40% of participants were linked to specific components, categories, and subcategories of the ICF. All remaining frames of reference were reportedly used by fewer than 20% of participants and were not included in the ICF linking. The available description and conceptual foundation of the developmental frame of reference in the literature was not adequate to make decisions about the most precise ICF linkage; therefore, this frame of reference was categorized as “not definable,” according to the ICF linking rules of Cieza et al. (2019).

The descriptions and conceptual foundations of the sensory integration and biomechanical frames of reference were linked to three to five subcategories that fell under the body functions component (Table C, available in the online version of the article). The cognitive behavioral frame of reference was linked to two subcategories within the ICF body functions component and to one subcategory under the activity and participation component.

Linkage of Currently Employed FOR to ICF

Table C:

Linkage of Currently Employed FOR to ICF

Linkage of the ICF and Intervention Foci

Researchers linked the intervention foci that fell in the median and above the median survey results to a specific ICF component, category, and subcategory. Eight intervention foci linked to a body functions component: self-regulation, visual motor integration, attention, bilateral coordination, visual perception, sensory integration, hand strength, and core body strength (Table D, available in the online version of the article). Five intervention foci linked to ICF categories and subcategories within the ICF activity and participation component: play, in-hand dexterity, social interaction, activities of daily living, and dressing. Motor skill development was too broad a construct to determine the most precise ICF linkage; thus, the motor skill development intervention focus was categorized as “not definable,” according to the ICF linking rules of Cieza et al. (2019).

Linkage of Currently Employed Intervention Foci to ICF

Table D:

Linkage of Currently Employed Intervention Foci to ICF

Discussion

Use of the ICF

The goal of this study was to measure the extent of ICF use in pediatric occupational therapists' clinical decision making related to frames of reference and intervention foci; to identify the currently used frames of reference and intervention foci; and to determine the linkage between the currently employed frames of reference and intervention foci and the components, categories, and subcategories of the ICF. Most of the participants (81%) reported that they did not use the ICF when making clinical decisions related to frames of reference and intervention foci. These findings are similar to those of the World Federation of Occupational Therapy (WFOT) survey of occupational therapists from a broad range of practice areas, including health care and community-based settings. Most of the occupational therapists in the WFOT study (70.2%) reported that they did not use the ICF in clinical practice (Stewart et al., 2013). Despite the documented use of the ICF within specific disciplines and in multidisciplinary settings (Atkinson & Nixon-Cave, 2011; Cramm et al., 2012; Fayed et al., 2011), a considerable number of occupational therapists do not use the ICF in clinical practice. Some barriers to its use include limited knowledge about the ICF, perceived difficulty in understanding and learning about it, and identified concerns about its fit with intervention techniques and models of practice for occupational therapy (Farrell et al., 2007). The WFOT suggested that promotion of ICF use among occupational therapists should include training of students, practitioners, and faculty members; integration of the ICF into the curricula; and incorporation of language about the ICF into documentation standards (Stewart et al., 2013).

In the current study, 12% of participants frequently or regularly used the ICF when making clinical decisions related to frames of reference and 4% used the ICF when choosing intervention foci. Participants in the current study primarily worked in early intervention, outpatient, and school settings. The current findings suggest that the ICF is being used in these practice settings but only by a small number of pediatric occupational therapists. In the WFOT survey, 29.8% of participants reported that they used the ICF in clinical practice to guide intervention, support interdisciplinary collaboration, and foster collaboration on goals and treatment between the health provider and the patient (Stewart et al., 2013). In Canada, 29.2% of pediatric occupational therapists also reported using the ICF to assist and inform frames of reference as well as for administration/organizational, research, and clinical use (Farrell et al., 2007). In addition, Farrell et al. (2007) reported the use of the ICF as an interprofessional and educational tool. Occupational therapists have been using ICF in the way that the WHO envisioned, as a framework for practice and collaboration among patients and health care providers. The current findings suggest that the ICF is used in practice to some extent, whereas other studies (Farrell et al., 2007; Stewart et al., 2013) suggested that occupational therapists use the ICF in various capacities and to varying extents in practice and other areas.

Frames of Reference and Intervention Foci

The study respondents reported the most frequent use of the developmental, sensory integration, biomechanical, and cognitive behavioral frames of reference. Of the four frames of reference regularly used, three (i.e., sensory integration, biomechanical, and cognitive behavioral) focused on problems, impairments, body functions, and performance skills. Additionally, 10 of the 14 intervention foci that were most frequently and regularly used focused on body functions and performance skills. Although these frames of reference and intervention foci that focus on body functions and performance skills may offer advantages and may be occupation based, the current findings suggest that the most frequently and regularly reported frames of reference and intervention foci may not be occupation focused.

Although a frame of reference theoretically can address body functions and/or performance skills, the intervention focus selected by a therapist can be occupation based or occupation focused, or using the language of the ICF, activity focused or participation focused. Practitioners must self-examine the extent to which intervention methods are occupation based and occupation focused (Fisher & Marterella, 2019). The ICF can assist in this self-examination because of the clear delineation of participation, activity, and body structures as well as the functional outcomes that affect a person's health.

Occupation-based intervention foci exist on a continuum, based on the client's level of engagement in occupational performance. The current study found that visual motor integration (a body function) was the second most frequently reported intervention focus. If the intervention focus was directly supporting handwriting skills or completion of schoolwork, the intervention would be occupation focused. Similarly, occupation-focused methods exist on a continuum of the therapist's proximal attention across this continuum from occupation to body functions (Fisher & Marterella, 2019). In the earlier example, if the therapist's intervention focus was on dot-to-dot worksheets or mazes to improve visual motor skills, this intervention would not be occupation focused because the focus is on a body function (visual motor skills) and not occupation. Even if the use of mazes and dot-to-dot worksheets incorporated the therapist's goal of improving visual motor skills to indirectly improve handwriting skills or completion of schoolwork (distally occupation focused), the intervention would remain immediately focused on body functions, not occupation. Therapists should not assume that this linkage between body functions and occupational performance actually occurs based on evidence suggesting an inconsistent link (Hoy, Egan, & Feder, 2011; Sakzewski, Ziviani, & Boyd, 2009). Importantly, the use of models of practice in addition to the selection of frames of reference and intervention foci can provide additional context for linkages between intervention focus and occupation. However, these were not examined in the current study and are avenues for future research.

Berry and Ryan (2002) raised concerns about the use of bottom-up approaches by pediatric occupational therapists where the foci of assessments and/or interventions are at the level of body functions and performance skills that the therapist identifies as the source of limitations on functional participation. However, there may be incongruence between a child's body functions or performance skills that the therapist is targeting with an intervention and the meaningful activities in which the child participates (Berry & Ryan, 2002). In adult practice, occupational therapists spend more time in improving body functions and performance skills than in occupations (Gillen, 2013; Jewell, Pickens, & Burns, 2019; Jewell, Pickens, Hersch, & Jensen, 2016; Smallfield & Karges, 2009). The current findings in pediatric practice reflect Gillen's (2013) assertion that despite the mandate for authentic occupation-centered therapy, occupational therapists extensively use impairment-based paradigms and interventions more than occupation-based paradigms and interventions that embody the core of the profession.

The current findings may not be in congruence with the emphasis of the American Occupational Therapy Association (AOTA, 2017) that occupational therapy should focus on an individual's participation in meaningful occupations. The underpinning philosophy of occupational therapy is that “participation in these [meaningful] occupations influences [the individual's] development, health, and well-being across the lifespan” (AOTA, 2017, p. S1). Therefore, pediatric occupational therapists should reflect on whether the selected frames of reference and intervention foci are in conjunction with the occupation-centered philosophy of the profession.

Linkage of the ICF to Frames of Reference and Intervention Foci

This study showed that the most frequently and regularly used frames of reference and intervention foci may be linked to the ICF. Two items, however, were not directly linked to any specific component of the ICF. The frame of reference and intervention focus related to development did not link specifically to a component of the ICF and were then classified as “not definable.” Moreover, for items without specific ICF linkages (e.g., development), occupational therapists may offer occupational therapy perspectives. Therefore, occupational therapists may use the ICF as a framework for common language that could be understood by other health professionals. The current findings are similar to those of earlier studies that showed that most of the occupational therapy outcome measures and conceptual models were linked to the ICF, with few items showing no direct link (Haglund & Henriksson, 2003; Stamm et al., 2005). The current findings support the assertion by Stamm et al. (2005) that occupational therapists may use occupational therapy models in combination with the ICF but not solely the ICF because the latter may not encapsulate the breadth and depth of occupational therapy.

Limitations and Future Directions

Because of the limited sample size, the current results may not be generalized and may not represent the frames of reference and intervention foci for all pediatric occupational therapists across the United States. Differentiating the ICF activity from the component of ICF participation was difficult because the study did not provide contextual information on how the participants employed an intervention focus (e.g., dressing). This difficulty is consistent with previous research (Coster & Khetani, 2008; Jette et al., 2007). Without knowledge of the context of application of a particular intervention focus, we could not specifically link an intervention focus to an ICF activity and/or ICF participation. Thus, rather than linking a frame of reference or an intervention focus specifically to activity or participation, two authors (J.A.S.B. and S.L.S.) mutually decided to link the frame of reference or intervention focus to activity and participation. Finally, we did not include survey questions on models of practice, which would clarify therapists' decision making and the inherent linkages between selected models of practice with chosen frames of reference as well as the linkage between intervention focus and occupation.

Future research could explore the use of the ICF in research and academia and the supports and barriers associated with the use of the ICF in pediatric occupational therapy. Further, linkage of the ICF with assessment tools used in pediatric occupational therapy could be explored. Examining the use of models of practice would provide further information on therapists' decision making and the linkage of interventions to an overarching model and theoretical support of interventions. We recommend further research with a revised survey to clarify the contexts of intervention foci to aid in the linking to ICF activity or participation components.

Conclusion

This study provided preliminary results on how the lens and language of the ICF may be used to assist pediatric occupational therapists in articulating currently employed frames of reference and intervention foci that would potentially facilitate interdisciplinary communication and collaboration. The study also provided baseline data on the frames of reference and intervention foci that are currently used by pediatric occupational therapists in the United States. Notably, 81% of the pediatric occupational therapists surveyed did not use the ICF when choosing frames of reference and intervention foci. Currently employed frames of reference and intervention foci target body functions and performance skills more than occupations. Most currently used frames of reference and intervention foci may be linked to a specific component, category, and sub-category of the ICF. Most of the frames of reference and intervention foci linked to ICF body functions. This study showed the potential use of the ICF in pediatric occupational therapy and reflected the current tendencies of pediatric occupational therapists to use of frames of reference and intervention foci with the ICF used as a lens.

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Respondent Demographics (N = 64)

Characteristicn
Entry-level degree in occupational therapy
  Bachelor's24
  Master's33
  Professional doctorate3
  Other4
Highest degree held
  Bachelor's15
  Master's40
  Professional doctorate6
  PhD0
  ScD0
  Other3
Years of occupational therapy experience
  0–311
  4–611
  7–103
  11–157
  16–204
  20+28
Top 2 work settings
  Academia8
  Community2
  Early intervention26
  Outpatient19
  Home health5
  Hospital5
  Neonatal intensive care unit1
  Mental health1
  School system41
  Other20
U.S. region where employed
  Region 1: Northeast17
  Region 2: Midwest38
  Region 3: South5
  Region 4: West4

Current Frame of Reference

Frame of referencePercentage
Developmental82
Sensory integration71
Biomechanical44
Cognitive behavioral42
Model of Human Occupationa18
PEOPa18
Cognitive11
Behavioral11
Sensory9
Motor learninga9
Social2
Occupation based2
Occupational behavioral2
Acquisitional2
Occupational adaptationa2

Use of the ICF in Choosing Intervention Foci and Frames of Reference

Frequency of use of ICFn
Intervention foci (N = 48)Frames of reference (N = 48)
Did not use the ICF3939
Rarely used the ICF37
Frequently used the ICF62

Sample Questions from the Survey Questionnaire

INTERVENTIONS: The next set of questions address your pediatric occupational therapy intervention practices

Please briefly describe your decision making process about how you select the areas of occupational therapy practice you address with clients in your pediatric occupational therapy practice (Open text box for answering)

I use the ICF to guide the areas of occupational therapy practice that I address in my pediatric occupational therapy practice

○ 1 N/A I do not use the ICF to guide assessments I select in my pediatric occupational therapy practice

○ 2 Rarely

○ 3 Frequently

○ 4 Regularly

Please list all pediatric occupational therapy intervention frames of reference (e.g. developmental, cognitive behavioral, sensory integration, biomechanical) that you use regularly in your pediatric occupational therapy practice: (Open text box for response)

Please briefly describe your decision making process about how you select the frame of reference you use with clients in your pediatric occupational therapy practice: (Open text box response)

I use the ICF to guide the frame of reference that I use with clients in my pediatric occupational therapy practice

○ 1 N/A I do not use the ICF to guide assessments I select in my pediatric occupational therapy practice

○ 2 Rarely

○ 3 Frequently

○ 4 Regularly

Intervention Focus Areas Used

Intervention FocusNumber of Participants (%)Total Number of Participants

Regularly UsedFrequently UsedOccasionally UsedNever Used
Self-regulation35(71%)12(24%)2(4%)0(0%)49
Visual motor integration31(63%)15(31%)3(6%)0(0%)49
Motor skill development30(63%)15(31%)3(6%)0(0%)48
Play30(63%)14(29%)4(8%)0(0%)48
Attention28(58%)15(31%)5(10%)0(0%)48
In-hand dexterity23(50%)20(43%)2(4%)1(2%)46
Bilateral coordination29(60%)13(27%)5(10%)1(2%)48
Visual perception26(53%)15(31%)7(14%)1(2%)49
Sensory integration30(63%)10(21%)5(10%)3(6%)48
Hand strength17(35%)22(46%)8(17%)1(2%)48
Social interaction19(40%)18(38%)9(19%)1(2%)47
Activities of daily living21(43%)14(29%)t13(27%)1(2%)49
Core body strength17(37%)17(37%)10(22%)2(4%)46
Dressing15(31%)18(38%)14(29%)1(2%)48
Feeding15(31%)15(31%)16(33%)3(6%)49
Parenting10(21%)12(26%)13(28%)12(26%)47
Range of motion9(19%)9(19%)24(51%)5(11%)47
Motor reflexes7(15%)7(15%)25(54%)7(15%)46
Sleep3(7%)10(22%)19(41%)14(30%)46
Toileting5(11%)8(17%)27(57%)7(15%)47
Community mobility0(0%)6(13%)16(35%)24(52%)46
Bathing2(4%)2(4%)15(33%)26(58%)45
Community recreation1(2%)3(6%)26(55%)17(36%)47
Home management1(2%)3(6%)18(38%)25(53%)47
Cardiovascular0(0%)2(4%)14(30%)31(66%)47
Financial management0(0%)2(4%)9(19%)36(77%)47

Linkage of Currently Employed FOR to ICF

Frame of ReferenceICF ComponentsICF Category and Sub-category
BiomechanicalBody Functionsb710 Mobility of joint functions
b715 Stability of joint functions
b720 Mobility of bone functions
b730 Muscle power functions
b740 Muscle endurance functions
Cognitive BehavioralBody Functions Activities and Participationb152 Emotional functions
b1649 Higher-level cognitive functions, unspecified
d199 Learning and applying knowledge, unspecified
DevelopmentalNot definable (nd): developmentNot definable (nd): development
Sensory IntegrationBody Functionsb199 Mental functions, unspecified (integration)
b249 Hearing and vestibular functions, other specified and unspecified
b279 Additional sensory functions, other specified and unspecified

Linkage of Currently Employed Intervention Foci to ICF

Intervention FociICF ComponentsICF Category and Sub-category
ADLActivities and ParticipationD5 Chapter 5 Self-care
d410-d429 Changing and maintaining body position
d430-d449 Carrying, moving and handling objects
d450-d469 Walking and moving
AttentionBody Functionsb140 Attention functions
Bilateral coordinationBody Functionsb7602 Coordination of voluntary movements
Core body strengthBody Functionsb7305 Power of muscles of the trunk
DressingActivities and Participationd540 Dressing
Hand strengthBody Functionsb7300 Power of isolated muscles and muscle groups
In-hand dexterityActivities and Participationd4401 Grasping
d4402 Manipulating
Motor Skill DevelopmentNot Definable (nd) developmentNot Definable (nd) development
PlayActivities and Participationd9200 Play
Self-regulationBody Functionsb152 Emotional functions
b122 Global psychosocial functions
Sensory integrationBody Functionsb199 Mental functions, unspecified (integration)
b249 Hearing and vestibular functions, other specified and unspecified
b279 Additional sensory functions, other specified and unspecified
Social interactionActivities and Participationd710 Basic interpersonal interactions
Visual motor integrationBody Functionsb1561 Visual perception
b7600 Control of simple voluntary movements
b7601 Control of complex voluntary movements
b7602 Coordination of voluntary movements
Visual perceptionBody Functionsb1561 Visual perception
Authors

Dr. Belarmino is staff occupational therapist, Visiting Nurses Association of Maryland, Windsor Mill, Maryland. Dr. Smith is Assistant Professor, Department of Occupational Therapy, College of Health and Human Services, University of New Hampshire, Durham, New Hampshire. Dr. Jewell is Assistant Professor and Vice Chair of Occupational Therapy, School of Pharmacy and Health Professions, Creighton University, Omaha, Nebraska.

The authors have no relevant financial relationships to disclose.

The authors thank student researchers Christina Gilleland, OTD, Leah Legate, OTD, Audra Nabinger, OTD, and Gloria Reynaga, OTD, who were involved in developing and disseminating the survey as well as recruiting the study participants.

Address correspondence to Sarah L. Smith, DSc, OTR/L, Assistant Professor, Department of Occupational Therapy, College of Health and Human Services, University of New Hampshire, 4 Library Way, Hewitt Hall, Durham, NH 03824; e-mail: s.smith@unh.edu.

Received: January 07, 2019
Accepted: October 03, 2019
Posted Online: December 02, 2019

10.3928/24761222-20191125-01

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