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27 Feb 2018

Bölte S et al. Eur Child Adolesc Psychiatry 2018; 27: 1261-1281

The World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) promotes the idea that ADHD should be considered in terms of personal, social and environmental factors and functioning. The ICF comprises of functioning and disability factors* and contextual factors, and offers a comprehensive, integrative framework which complements the Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-5TM) and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). The Child and Youth version of the ICF (ICF-CY) was published in 2007 and encompasses additional functional characteristics and environments of developing individuals.

Use of the ICF in the management of ADHD promotes an emphasis on individual abilities, disabilities and specific context on functioning. Since functioning is often perceived as less stigmatised than diagnosis or psychopathology, the ICF can be used to assess an individual’s strengths and not just their impairments. Moreover, functional problems are often the reason that people with ADHD are initially referred to specialist services, and describing an individual’s functioning can be useful in guiding a treatment plan and identifying real-life challenges, as well as aiding calculation of the cost of health-related services. However, despite these reported advantages, applying the ICF in a routine setting can be difficult as the ICF is less well known than the ICD and DSM, and the comprehensiveness of the ICF can make its use in daily practice time consuming. Therefore, shortlists of ICF categories related to specific health conditions, or ‘ICF Core Sets’, have been developed to aid the diagnosis of specific health conditions, and at a recent international consensus conference, ICF Core Sets for ADHD were established.

A total of 20 experts from 12 countries representing all 6 WHO world regions participated in the consensus conference,§ and of the 132 second-level candidate categories (which describe basic levels of functioning and are distributed across the four ICF components of body functions, body structures, activities and participation, and environmental factors) that were identified in preparatory studies, 72 (55%) were included in the Comprehensive Core Set. The majority of the included categories were from the activities and participation component (n=35; 49%), followed by environmental factors (n=29; 40%) and body functions (n=8; 11%), with all body functions categories related to mental functions, except for “control of voluntary movement functions”. For the Common Brief Set for ADHD, 38 second-level ICF categories were included, which were from the environmental factors component (n=7; 45%), activities and participation (n=14; 37%), and body functions (n=7; 18%). Brief ICF Core Sets were also established for pre-school age children (aged 0–5 years), school-age children and adolescents (aged 6–16 years), and older adolescents and adults (aged ≥17 years), which included 47, 55 and 52 second-level ICF categories, respectively, from the environmental factors, activities and participation, and body functions components. These results show that the experts included categories in the Comprehensive Core Set and the Brief Core Sets for ADHD that emphasise aspects of daily living and functioning in various environments.

Development of the ICF Core Sets for ADHD faced some challenges which may have limited this study. For example, not all parts of the world were equally represented, which may have caused culture-sensitive categories to be overlooked; however, to address this, conference participants were asked to discuss country- and culture-specific aspects that could affect the applicability of the ICF Core Sets for ADHD when making their decisions. In addition, some professional groups were underrepresented, with few speech-language pathologists and nurses participating in the consensus conference, and although individuals with ADHD and their families were involved in the preparatory studies, they were not involved in the consensus conference. Therefore, future research should encourage shared decision-making, with active input from individuals with ADHD and their families.

The authors advised that standardised, user-friendly ICF Core Set-based tools should be developed, e.g. a questionnaire with a scale that applies established measurement standards, or observation schedules and interviews, so that clinicians can use the ICF Core Sets in a similar way to scales derived from ICD-10 and DSM-5TM diagnostic criteria. Aside from its clinical use, the authors suggested that the ICF Core Sets for ADHD could enable service-quality improvement and functioning, and aid policy-making at local, regional and national levels.

Read more about development of the ICF Core Sets for ADHD at the consensus conference here

Read more about identification of potential categories for the ICF Core Sets for ADHD in the preparatory clinical study here


*Functioning and disability factors included the following components: body functions (i.e. physiological and mental functions), body structures (i.e. anatomical body parts), activities (i.e. execution of tasks) and participation (i.e. involvement in life situations)
Contextual factors included the components of environmental factors not inherent to the individual, e.g. family, work, recreational opportunities, government agencies, and laws and societal attitudes, in addition to personal factors, e.g. experience, race, gender, age, educational level and coping styles
The ICF-CY comprises 1685 categories: 531 in the body functions component; 329 in body structures; 552 in activities and participation; and 273 in environmental factors
§International experts participated in a 3-day iterative decision-making and consensus conference at the KIND centre in Stockholm, Sweden in September 2016 following attendance at an ICF workshop. The first stage of the consensus process aimed to generate the Comprehensive ICF Core Set for ADHD via discussions and voting in working groups and in plenary sessions. The second stage involved a two-round ranking and cut-off exercise to generate brief versions of the Comprehensive ICF Core Sets. For the first stage, ≥75% of experts had to vote in favour of including a given category for it to be automatically included in the Comprehensive Core Set for ADHD. Categories receiving ≤40% of votes were automatically rejected, and those receiving >40% but <75% of votes were carried over into the next session for re-discussion

Bölte S, Mahdi S, Coghill D, et al. Standardised assessment of functioning in ADHD: consensus on the ICF Core Sets for ADHD. Eur Child Adolesc Psychiatry 2018; 27: 1261-1281.

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