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Classification of Disability

IMEW Briefing, No. 12, May 2009

Classification of Disability

Classifications structure and organise groups or things according to certain criteria (Zaiß et al. 2002). They thus create a categorisation system which can be used, for example, to classify diseases and disabilities of a population according to their cause and impact as a basis for developing health-promoting and rehabilitative measures.

Classifications of disease have existed for centuries and in all healing traditions (Ackerknecht 1992, Nutton 1993). These classifications had such distinctions as internal and outwardly visible diseases, different types of injuries and fractures, or illnesses of the body and the mind. The World Health Organisation (WHO) has published classifications of disease since 1946. The tenth International Classification of Diseases (ICD-10) is currently undergoing thorough revision and the new version is expected to be officially endorsed in 2014 (WHO 2005).

Following criticism in the late 1960s and the 1970s from scientists, disability organisations, and the growing international grassroots disability movement that disability cannot be equated with disease, the WHO developed the International Classification of Impairments, Disabilities and Handicaps (ICIDH) (Hunt 1966, Sander 1978). This classification was published in 1980, and was the first time the WHO made a distinction between disability and disease.

On account of various shortcomings, at the beginning of the 1990s the WHO initiated a revision process of the ICIDH in which, above all, the construction of disability was modified (Hirschberg 2003). For the first time the focus was expanded to include the environment of the individual. Disability was no longer regarded as the consequence of disease or damage (as it was in the ICIDH) but as the result of the interaction between various components. In 2001 the Member States of the WHO officially endorsed the current classification of disability, the International Classification of Functioning, Disability and Health (ICF). This classification is internationally valid and has been legally implemented in Germany through the Social Code Volume IX (SGB IX) and the Act on Equal Opportunities for Disabled People (Behindertengleichstellungsgesetz (BGG)).

With the disability classifications of the WHO, the extent and prevalence of disability can be described and documented worldwide, and made accessible for various purposes. For example, they can be used in order to collect data on disability for (inter)national comparisons and thus establish the extent of disability, or to develop measures for health promotion. The ICF forms the basis for rehabilitation-related measures. This is why it is of significance in the area of healthcare policy (Greving 2002). In the Guidelines on Therapeutic Appliances of the Federal Joint Committee (Gemeinsamer Bundesausschuss), for example, it forms the basis for decisions as to which therapeutic appliances can be provided as statutory health insurance benefits (GBA Guideline 2008).

The Societal Significance of Classifications

Classifications are instruments of social and healthcare policy. They are used to ascertain individual impairments and restrictions on participation in order to justify entitlement to benefits (material and personal support). However, they can at the same time foster stigmatisation as, from the medical perspective, having a disability is regarded as a deficiency.

Classifications in the area of healthcare policy and social policy are thus caught up between the conflicting poles of social participation and social exclusion. The problems associated with this dilemma can be illustrated by the example of the ICF.

Conception of the ICF

The core of the ICF is its model of disability. This shows how the WHO perceives and construes disability. While the medical model assumes that disability is entirely an individual problem, the social model attributes disability to the societal obstacles facing people with impairments (Barnes/Mercer/Shakespeare 2003). The goal of the WHO is to combine these two models in a biopsychosocial approach (WHO 2001:20). However, this approach remains a work in progress because the medical model still carries more weight than the social model (Hirschberg 2009).

In contrast to the ICIDH, the ICF relates to all people, not only those with disabilities (WHO 2001:7). Nevertheless it is primarily relevant for people with disabilities as it is their disabilities that are assessed, and this assessment is used as a basis for allocation of support benefits. However, in each case only the person's disability and not his or her special abilities are classified – the assessment is thus a purely negative one.

The WHO construes disability as the result of the combined effect of several components: bodily functions and structure, activities, participation, environmental factors, and personal factors. However, on account of their great social and cultural diversity, the personal factors have not yet been classified (WHO 2001:8).

Prerequisites for successful application

The ICF evaluates disability comprehensively. It classifies not only the physical, individual and social components of disability but also the person’s private environment and personal life experiences, as well as specific barriers and support factors. This means that not only the difficulties of living with a disability, but also the individual possibilities for compensation, are documented and included in the classification. This comprehensive classification is, however, ambivalent: whilst on the one hand the performance of a detailed assessment of a person's life situation does not reduce him or her to the disability, on the other hand a large amount of personal information is documented. Moreover, personal experience cannot be objectively compared since it is unique.

In the secondary literature on the ICF it is pointed out that the personal factors also include a person's genetic make-up (Schuntermann 2005). On account of the potential dangers associated with the evaluation of genetic factors, a German WHO working group is currently developing ethical guidelines for classification and categorisation of this component (Geyh et al. 2007). If a person's individual genetic constitution were to be assessed this could have discriminating implications.

As there is currently only a joint category list for activities and participation, a person's participation restrictions can be categorised but they cannot yet be properly operationalised. A further problem is that the individual need for a means of personal mobility and transportation, for example, is not specified in sufficient detail, since a wheelchair, a scooter, and a walking aid are all listed in the same subcategory (e1201) (WHO 2001:174). In contrast to the categories for activities, participation and environmental factors, those for bodily functions and structures have a greater number of subcategories. These examples make it clear that further development of the ICF is necessary in order to make it more suitable as a tool for the promotion of participation.

Summary: Use the innovative potential of the ICF

The ICF is characterised in particular by the fact that it makes use of concepts from both models, the medical and the social. With its biopsychosocial approach it forms a fundamental basis for implementation of the SGB IX regarding rehabilitation and participation. It would be advisable, however, to further strengthen the social perspective of disability so that it no longer lags behind the individual perspective. This would include further differentiation of the environmental factors, as well as separate classification of the component for participation, since this would make it possible to assess the social disadvantage of people with disabilities. It would be desirable if there were greater involvement of people with disabilities in the development of the classification, not only in the working group for development of the component for environmental factors, but in the process as a whole. Moreover, they should be involved not only as "people affected by the classification of their disability" but also as qualified experts.

The ICF as a classification of disability is an important building block on the path towards the goal named in the SGB IX and BGG: to achieve the social participation of all people.

Marianne Hirschberg

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