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Chapter

Application of the International

Classification Functioning,
Disability, and Health (ICF) as
Clinical Reasoning Tool in Pediatric
Neurorehabilitation
Hanan Demyati

Abstract

The clinical reasoning model is a theoretical framework that facilitates the trans-
formation of information into practical knowledge within the context of clinical
practice. It serves as a valuable resource for healthcare professionals, offering a struc-
tured approach for the assessment and development of treatment plans. Biomedical
disability models often influence clinical reasoning models in pediatric neurorehabili-
tation, emphasizing diagnostic reasoning and using a shared vocabulary and language
to guide thinking and communication during information gathering, assumption
formulation, and care action planning. This method prioritizes physical symptoms
over psychological, social, cultural, and environmental factors of a given condition.
This idea assumes that the health condition or pathology is the sole fundamental
factor contributing to any form of physical dysfunction and that the reduction of the
disease will lead to a restoration of the previous state of “normalcy”. The International
Classification of Functioning, Disability, and Health (ICF) framework can be used as
a clinical reasoning tool as it guides cognitive processes and decision-making based on
the interdependent relationships between the three primary components and contex-
tual factors. The ICF framework recognizes that changes in the child’s environmental
and psychological context, activity and social involvement, and pathology can affect
child outcomes without emphasizing changes in pathology.

Keywords: clinical reasoning, neurorehabilitation, ICF, pediatric, WHO-ICF

1. Introduction

Pediatric neurorehabilitation is heavily impacted by biomedical model, which

is based on acute care medicine. Consider how we treat sudden severe chest pain:
a history is taken, the child is evaluated, other options are ruled out to make the
appropriate diagnosis, the right treatment is found, the child is intervened, and the
condition is monitored after treatment. This approach focuses on fixing to imply that
a specific diagnosis will result in suitable treatment. In pediatric neurorehabilitation,
1
Neuropediatrics – Recent Advances and Novel Therapeutic Approaches

body mechanics and biopsychosocial factors are considered. Heterogeneous groups in

the same health condition as the treatment may address signs and symptoms underly-
ing biomedical aspects of the condition, but since the intervention is obvious, the
evidence to support or refute it is not enough [1].
This way of thinking has several limitations toward fixing, which refers to the
expectation that an appropriate diagnosis will lead to the right interventions. A com-
mon diagnosis, Cerebral Palsy (CP) and Autism Spectrum Disorder (ASD), seems
specific in pediatric neurology, while the heterogeneous nature of those disorders can
affect children’s development for a number of biological reasons with a wide range of
impacts. Some of our “treatments” may address biomedical aspects of the condition.
For instance, the utilization of botulinum toxin to manage spasticity and anticonvul-
sants to treat seizure disorders has been observed. However, due to the restricted com-
prehension and complexity nature of the underlying biomedical processes associated
with illnesses such as CP and ASD, even when the biological “impairments” of these
disorders can be changed, there are generally few links between bodily alterations
and functional outcomes [2, 3]. Development is fast, yet many of our treatments are
slow. It is difficult to find causal links between interventions and results due to natural
changes influenced by growth and development.
Health is “the ability to adapt and to self-manage” [4]. WHO provided a set of
concepts about how we could think about health in 2001 [5]. The International
Classification of Functioning, Disability, and Health (ICF) framework is a conceptual
framework used to record the positive and negative aspects of every person’s func-
tioning and puts every person in a context: functioning and disability are results of
the interaction between the health conditions of the person and their environment
(in Figure 1). The ICF framework provides a standard language for the definition and
measurement of people’s health and function [5].
The clinical reasoning model is a theoretical framework that facilitates the trans-
formation of information into practical knowledge in the context of therapeutic
practice. It serves as a valuable resource for therapists, offering a structured approach
for both assessment and treatment planning. This method is executed by using a
coherent sequence of activities [6].
The reciprocal interactions between the three core ICF components and envi-
ronmental factors can influence clinical reasoning and decision-making. The ICF
framework allows changes in the patient’s environmental and personal context,

Figure 1.
International classification of functioning, disability, and health (copied from WHO [5]).

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DOI: http://dx.doi.org/10.5772/intechopen.1003078

activity and social participation, and pathology to affect patient outcomes. Improved
outcomes without pathological changes are a useful clinical reasoning tool for pediat-
ric neurorehabilitation. The ICF framework allows all health issues to be considered
in a border social-ecological setting, which might turn the paradigm upside down.
This shows that any section of the framework may have influenced others in this
dynamic system [7, 8].

2. The international classification functioning, disability, and health

(ICF) model

The International Classification of Functioning, Disability, and Health (ICF) “are

functional frameworks that classify health outcomes; they can be used to describe
the functioning of all people, not only persons with a health condition(s).” The ICF
model is derived from a framework developed by the World Health Organization
(WHO) (see Figure 1) [9].
This framework presents an individual’s functioning and disability as conse-
quences resulting from the interplay between health problems and other contextual
factors, including both environmental and personal factors. The term “functioning”
encompasses the entirety of bodily functions, activities, and participation in many
living circumstances, including work, family, and leisure. The term “disability”
encompasses a range of conditions, encompassing impairments in bodily function
and structure, limitations in activities, and restrictions in participation [9].
The ICF model encompasses body functions and structures, as well as activities
and participation. A significant innovation offered by the ICF model, the concept of
a child’s environmental and personal/social context are conceptualized and imple-
mented. The consideration of the child’s needs is situated within the framework of
the family, taking into account how the nature and types of participation undergo
significant transformations from dependent ties during infancy to intricate and
more independent life circumstances during adolescence [10]. This innovation also
addresses the notion of developmental changes in participation through the imitation
of actions and behaviors. The ICF model acknowledges that variations in the environ-
ment and the timing of developmental milestones may indicate delays in development
rather than functional impairments or limitations [9, 10].
The ICF is founded upon an integration of social and medical theories of disability
and places emphasis on the constituents of health rather than the outcomes of illness
[9]. The several dimensions of the ICF framework integrate biological, psychological,
social, and environmental factors that contribute to child functioning [10]. Research
findings have indicated that just the process of diagnosing a child does not serve as
an accurate guide for determining the level of treatment provided or the functional
results experienced by the patient [9]. The utilization of a medical diagnostic as an
individual instrument may result in the omission of crucial information required for
effective healthcare planning and management [11].
According to the data presented in Figure 1, the ICF framework categorizes
health conditions into three distinct health outcomes: bodily function and structure,
activities, and participation. Disease, disorder, or injury might potentially lead to the
reduction of three different health outcomes: impairment, activity limitations, and
participation restrictions. The interplay among the three components is subject to
the influence of contextual factors, which can be categorized into two components:
environmental factors and personal factors [9].
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Neuropediatrics – Recent Advances and Novel Therapeutic Approaches

The “body” domain (body structure and body function) covers physical and
mental functions, sensory responses, multiorgan system structure and function,
movement, and reproduction. The “activities and participation” domain evaluates
the patient’s capacity to learn, apply knowledge, complete general tasks, communi-
cate, and care for themselves. The ICF also described two types of contextual fac-
tors, namely environmental and personal factors. Environmental domains include
patient-assistance items and technologies, community services, and relationships,
support, and care outside the clinical setting. Each component has a hierarchy of
categories and codes in the ICF. Personal factors such as age, sex, education, social
class, culture, past experiences, personal character traits, lifestyle, coping style, and
occupation are not coded [10, 11].

3. Pediatric neurorehabilitation services

Pediatric neurorehabilitation services include a variety of therapeutic disciplines,

such as rehabilitation medicine, physiotherapy, occupational therapy, speech therapy,
orthotics and prosthetics, nutrition, psychology, and social services. These services
are characterized by their interdisciplinary nature. The presence of divergent gov-
ernance and policy frameworks among health professionals presents challenges for
implementing uniform standards for working practices within the healthcare system.
The presence of diversity may influence the quality of services provided to such
patients by healthcare professionals [12].
Pediatric neurology affects the child’s psychological, social, and emotional well-
being as well as their physical health. This can affect children’s daily physical func-
tioning, including body structure and function and task performance. These tasks
include their everyday activities, what they desire to do in their environment, and
personal characteristics that help or hinder their functional activities (e.g., at home,
in the community, or at school) [13]. Thus, it is important to consider social and fam-
ily circumstances in pediatric neurorehabilitation.
Healthcare, education, and social services can struggle to support neurologically
manifested children and their families. This condition is complicated, so a model
like the ICF that considers bodily impairments, personal effects, and environmental
effects is needed to manage pediatric neurorehabilitation holistically.

4. Clinical reasoning model in pediatric neurorehabilitation

Clinical reasoning is important as it promotes knowledge acquisition by utiliz-

ing simple phrases to explain complicated relationships [12]. The clinical reasoning
models utilized in the field of neurorehabilitation are frequently inspired by the
biomedical model of disability. As a result, therapists might prefer diagnostic reason-
ing that aligns with the principles of the biomedical model [13, 14]. The biomedical
model applies standard terminology and discourse in the various stages of treatment
decision-making, including initial consultation, data collection, hypothesis formula-
tion, and care planning. However, it primarily concentrates on the physical symptoms
of a condition and does not adequately consider the psychological, social, cultural, or
environmental dimensions [15]. The biomedical paradigm is based on two fundamen-
tal assumptions. Firstly, it posits that disease or disorder is the primary and only fac-
tor responsible for all physical dysfunction. Secondly, it asserts that the elimination or
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DOI: http://dx.doi.org/10.5772/intechopen.1003078

reduction of the disease would lead to a restoration of the individual’s state to what is
considered “normal” [16].
The models considered significant to the practice of pediatric neurorehabilita-
tion include analytical, non-analytical, and hypothetico-deductive reasoning. The
analytical model predominantly focuses on a systematic approach to assessment prior
to decision-making, whereas the nonanalytical model includes a more spontaneous
process that is influenced by the recognition of similar earlier cases [17]. Hypothetico-
deductive reasoning involves the formulation and evaluation of diagnostic hypotheses
by analytical testing methods, such as patient history and physical examination.
These methods are employed to either validate or disapprove of solutions that have
been developed through nonanalytical means [18].

4.1 Analytical clinical reasoning model

Theoretical frameworks for clinical reasoning suggest the existence of a sequential

set of analytical procedures utilized to establish a correlation between a patient’s
symptoms and the ultimate diagnosis [19]. This method uses analytical reasoning in
a more planned way by sticking to a set of distinct steps: careful observation, data
collection, a physical exam, coming up with hypotheses, and finally diagnostic testing
to confirm these hypotheses [20]. Therapists who adopt a biomedical clinical reason-
ing approach in pediatric neurorehabilitation may prioritize the development of a
recovery strategy and the attainment of a diagnosis as the ultimate objectives.

4.2 Nonanalytical clinical reasoning model

Nonanalytical clinical reasoning refers to a cognitive process when individuals are

able to arrive at a conclusion without relying on formal analytical methods, instead
drawing upon their past interactions and experiences [18, 21]. The automation of this
process is frequently noted and seen as an indicator of heightened clinical proficiency.
This phenomenon can be attributed to the disparity in prior clinical experience
between novices and individuals with higher degrees of expertise, as supported by
earlier research [21]. This methodology enables expeditious decision-making, although
some scholars contend that it may engender erroneous inferences among less seasoned
practitioners. This approach allows for quick decisions to be made by less experienced
professionals, and there is a risk of inappropriate conclusions being drawn.

4.3 Hypothetico-deductive clinical reasoning model

The present paradigm is dependent upon the collection of data from the patient,
which is then utilized to build a hypothesis. This hypothesis is initially developed
by the therapist and then subjected to testing. The confirmation or rejection of the
hypothesis depends on the patient’s response to treatment, necessitating the need for
periodic examinations [22]. Practitioners across diverse therapeutic fields commonly
employ this approach [19, 23]. The initial phase involves the therapist being equipped
beforehand with a comprehensive and elaborate patient history, encompassing the
patient’s motivations for seeking rehabilitation treatments. Subsequently, the thera-
pist proceeds to administer an examination technique employing several tests and
assessments. Following the conclusion of the examination, the therapist proceeds to
formulate several hypotheses pertaining to “evaluation, diagnosis, and prognosis.”
These hypotheses are developed by synthesizing and analyzing the data gathered
5
Neuropediatrics – Recent Advances and Novel Therapeutic Approaches

throughout the examination, ultimately serving as a foundation for further assessment

and prognostication. The therapist may employ a collaborative reasoning approach,
drawing upon the patient’s knowledge base, in order to attain a comprehensive grasp
of the issue during the therapeutic session. During the process of hypothesis forma-
tion, the therapist may introduce generic questions and afterward reflect on the issues
expressed by the patient. Ultimately, the therapist arrives at a definitive diagnosis or
formulates a comprehensive plan for implementing a specific intervention [23].
Empirical data support the paradigms in rehabilitative treatment. Doody and
McAteer [18] employed a qualitative approach and utilized the hypothetico-deductive
model to examine the clinical reasoning abilities of expert and novice physiotherapists
in the context of outpatient orthopedic care. A group of 10 seasoned doctors and 10
students were observed and recorded via audio while they conducted a comprehensive
examination and administered treatment to an actual patient who had not been encoun-
tered previously. The findings indicated that every participant employed a hypothetico-
deductive reasoning process. However, both individuals with expertise in the field and
those with limited experience extended their analysis beyond the first diagnostic phase
to incorporate a thoughtful approach to treatment. Specifically, manual therapy treat-
ment was employed as a means to conduct more hypothesis testing. Furthermore, along-
side the application of hypothetico-deductive reasoning, the professionals also employed
a nonanalytical model, as anticipated, due to their extensive clinical expertise [18].
This model demonstrates a high level of development and serves as a valuable tool
in the field of pediatric neurorehabilitation. It effectively integrates decision-making
processes with corresponding actions and closely monitors the dynamic changes that
occur throughout the patient’s treatment journey. Kenyon [23] utilized this particular
model as an instructional tool for providing clinical reasoning skills to students
specializing in pediatric physiotherapy. However, it was noted that students exhibited
a proclivity for providing an inaccurate portrayal of their actions and thoughts during
the diagnostic procedure. However, the authors merely provided a reconstructed
conceptualization of the appropriate approach to resolving the issue [23].
The therapists mostly based their decision-making process on subjective results
obtained from physical examination rather than relying on objective testing.
Consequently, they expressed a lack of confidence in the effectiveness of practi-
cal establishment testing. Hence, based on empirical observations, it appears that
pediatric neurorehabilitation relies on a combination of analytical thinking, non-
analytical reasoning, and hypothetico-deductive reasoning, as indicated by previous
studies [22–25]. The clinical reasoning models in question likely originate from the
framework of biomedical knowledge. Consequently, therapists in the field of pedi-
atric neurorehabilitation often make the assumption that an intervention involving
the manipulation of bodily functions will yield the intended outcomes in terms of the
patient’s physical performance and ability to engage in activities [22]. For instance,
there is a common assumption that enhancing the muscular strength of an ambulant
child (body function) will influence the child’s capacity to walk with optimal effi-
ciency (related to activity).
In the field of pediatric neurorehabilitation, it is crucial for therapists to apply
a clinical reasoning model that acknowledges the significance of the biomedical
model while also offering a structured approach to recognizing and addressing both
biomedical and psychosocial factors. The ICF model facilitates the formulation of
a hypothesis by taking into account the interplay between several aspects, such as
bodily structure, function, activities, and participation, as well as environmental and
personal factors, for every individual child.
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DOI: http://dx.doi.org/10.5772/intechopen.1003078

5. Personal factors in the ICF framework

Personal factors (PFs), known as background knowledge about a person’s life and
way of living, have not been categorized by the WHO. Examples of personal factors
include assets, coping methods, education, and behavioral patterns [8]. The facilita-
tion of comprehension about the cognitive processes of children and their parents,
including their evaluation and understanding of their own situations, aspirations,
and coping mechanisms in their everyday lives, can be enhanced by the identification
of these factors pertaining to functioning. The decision-making process regarding the
choice of rehabilitation programs, measures, and other forms of support is contingent
upon the effect of PFs and their respective interpretations [24].
Numerous studies have consistently demonstrated the significant function
and special significance of PFs in the context of rehabilitation processes. Patient- and
family-centered care emphasizes the importance of prioritizing the needs and prefer-
ences of individuals and their families during various healthcare processes. Moreover,
by comprehensively comprehending and incorporating PFs into the evaluation of a
client’s functioning, professionals in neurorehabilitation can enhance their grasp of
effective strategies to bolster child and parent commitment. PFs would enable thera-
pists to engage in systematic documentation and optimize time management [24, 26].
In the meantime, it is advisable to utilize the ICF framework as a tool for organizing
information and ideas associated with functioning, even in cases where PFs have not
been officially defined within the categorical framework.

6. Roles of personal factors in pediatric neurorehabilitation

Personal factors (PFs) play an essential role in pediatric neurorehabilitation;

asking and understanding about PFs promotes respect for values, beliefs, experience,
and circumstances and the inclusion of client-defined families. PF assessment is
crucial for pediatric neurorehabilitation planning and functioning documentation.
Rehabilitation programs include multiple phases; motivation is personal, and it has
been shown to predict exercise intervention adherence. Additionally, different clients
value different things, which affect commitment. Considering how different PFs
affect commitment might help professionals encourage empowerment and strengths
[24, 26]. The rehabilitation process combines two theoretical frameworks: treatment
theory shows how to change a factor, and enablement theory recognizes that func-
tioning is complex and determined by multiple factors and models of these complex
interrelationships. Understanding child PF variation is necessary to apply enabling
theory to pediatric neurorehabilitation. The PFs provide crucial information on
functioning throughout a child’s rehabilitation. In clinical practice, the ICF organizes
and codes functioning, and environmental and child PFs can affect health, function-
ing, and the neurorehabilitation process [27, 28].

7. Environmental factors in the ICF framework

The classification of environmental factors was developed to include significant

elements of the physical, social, and attitudinal environments in which individuals
live and engage in their daily activities. The factors consisted of both immediate
factors, such as products and technology for mobility, as well as more distant factors,
7
Neuropediatrics – Recent Advances and Novel Therapeutic Approaches

such as societal attitudes, systems, and policies. These factors have the potential to
influence an individual’s functioning. Additionally, there are factors that necessitate
interventions targeted at the individual, such as the provision of accessible environ-
ments, as well as interventions aimed at society, such as the development and imple-
mentation of inclusive policies [8].
The term “disability” can be used to describe various situations. Firstly, it can refer
to an individual who solely experiences a physical issue at the bodily level, known as
an impairment, without any limitations in their activities or restrictions in their par-
ticipation. For example, this could include a person with severe scarring on their face
who does not encounter any difficulties in their daily activities or engagement in soci-
ety. Secondly, disability can represent individuals who face challenges in functioning
across all three levels: the body (impairments), the person (activity limitations), and
society (participation restrictions). Thirdly, disability may involve individuals who
have both an impairment and an activity limitation but do not experience any partici-
pation restrictions. Fourthly, disability can refer to individuals who encounter activity
limitations and participation restrictions but do not have any impairments. Lastly,
disability can also apply to individuals who do not have any impairments or activity
limitations but face participation restrictions in their daily lives [29].
An illustrative case of an individual encountering impairments, limitations
in activities, and restrictions in participation would involve a child with spina
bifida. This child, regrettably, lacks access to essential services such as orthotic and
prosthetic services, which are crucial for their well-being. Additionally, due to the
absence of assistive technology in the form of an orthosis, the child faces difficulties
in mobility. Furthermore, their ability to attend school is hindered by an inacces-
sible educational environment and the presence of negative attitudes toward their
condition. To gain a comprehensive understanding of an individual’s experience of
disability, it is necessary to delineate the various dimensions of functioning alongside
an examination of the environmental and personal elements that contribute to this
experience. The alteration of contextual elements might lead to a modification in
the outcome, consequently impacting the experience of impairment. The ICF model
offers a conceptual framework that enables the description of the various elements
involved in an interaction.

8. Roles of environmental factors in pediatric neurorehabilitation

In the relationship between environmental factors and other components of

functioning in the ICF model, disability arises from the interplay between an indi-
vidual’s health condition and the surrounding contextual elements in which the
individual is situated. This relationship is further analyzed in terms of the compo-
nents of functioning and the three viewpoints of body, person, and society. At the
social, bodily impairments, and individual activity restriction levels, it is clear that
the consequences are influenced by the interaction of an individual’s health state and
many contextual factors [30].
The child who utilizes a wheelchair and is currently not enrolled in an educational
institution does not require any modifications to their physical condition in order to
access educational opportunities. In order to enhance a child’s engagement in educa-
tion, it is imperative to address both the accessibility of the school and the prevailing
attitudes inside the education system. The education student diagnosed with epilepsy
does not necessarily have to abandon their pursuit of training. It is imperative to
8
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DOI: http://dx.doi.org/10.5772/intechopen.1003078

critically examine the perspectives held by education authorities in order to identify

a more efficacious strategy for effectively addressing the potential incidence of a
seizure during instructional sessions.
The ICF model offers a comprehensive framework for categorizing environmen-
tal influences and their impact on individuals with health conditions. The ICF model
serves as the initial step in advancing the comprehension of the influence of the
environment on impairment. The application of the ICF model within the context
of pediatric neurorehabilitation has the potential to facilitate the active involvement
of families in the process of defining goals. This approach also enables therapists
to be more adaptable to the specific requirements of the family and to effectively
communicate information in a manner that is meaningful and beneficial to them.
Moreover, applying the ICF model in the context of pediatric neurorehabilitation
could enhance a therapist’s engagement with both the child and their family. It has
the potential to facilitate the establishment of attainable objectives and facilitate
progression from one level of care to another, taking into account the child’s level of
functioning, disability, and health while also considering the child’s environment
and personal factors.

9. Clinical reasoning in pediatric neurorehabilitation

The therapist’s level of knowledge, cognitive abilities, and metacognitive skills

have a significant impact on the clinical reasoning process because they enable them
to effectively recognize and resolve problems in situations that are ambiguous or
uncertain [31].
The clinical reasoning process persists throughout the child’s neurorehabilitation
course of continuing child management. Reassessment serves the purpose of either
providing support for the hypotheses and chosen course of action or indicating the
need for revision or production of hypotheses, as well as further data gathering and
problem clarification. This may involve an additional examination or a referral for
consultation with other specialists. During a therapeutic session, clinicians engage in
the ongoing process of interpreting child and parent reactions in order to inform their
clinical judgments. Additionally, therapists regularly evaluate treatment outcomes to
assess the validity of their management hypotheses [32].
Child and parent thinking regarding their difficulties is of equal importance to the
therapist’s thinking. Children and their families typically enter their interaction with
a therapist with preconceived notions about the nature of their disorder, which are
influenced by personal experiences and guidance from healthcare professionals, as well
as input from their social network. Previous research has demonstrated that patients’
comprehension of their clinical condition has a significant influence on their pain
tolerance, impairment levels, and ultimate outcome [32, 33]. The presence of a child’s or
parent’s beliefs and emotions that hinder their management and recovery might have a
detrimental impact on their engagement in the management process, their self-efficacy,
and ultimately, their overall outcome. On the other hand, research has demonstrated
that patients who are included in the decision-making process exhibit a higher level of
accountability for their own treatment and are more likely to have improved outcomes.
By engaging in a collaborative reasoning process with their therapists, patients can
maximize their self-efficacy and level of responsibility for their management [34].
Therapists specializing in pediatric neurorehabilitation are required to thoroughly
evaluate and take into account all conceivable aspects that may have an impact on
9
Neuropediatrics – Recent Advances and Novel Therapeutic Approaches

a child’s overall well-being. Therapists are commonly associated with a primary

emphasis on the physical aspects of health. However, in line with the modern biopsy-
chosocial perspective on health and disability, it is essential for therapists to recognize
that addressing a child’s well-being necessitates a comprehensive assessment of
environmental and psychosocial factors that can impact health. This approach should
be implemented within the boundaries of the therapists’ professional training and
expertise. A successful approach to addressing this matter necessitates a compre-
hensive perspective on health and disability as well as a thorough understanding of
evaluation and management principles, including knowledge of appropriate referral
pathways. Additionally, it demands the acquisition of skills to effectively address all
potential elements that may contribute to the issue at hand.
Furthermore, the ability to engage in clinical reasoning is essential in determining
the relevance of these potential contributing factors to the specific patient, enabling
the healthcare provider to make proper clinical judgments that would ultimately
enhance the patient’s overall healthcare outcomes [35]. The ICF model offers a
standardized language and framework that facilitates communication regarding
health and healthcare across many professional disciplines and scientific fields. The
conceptual framework of the ICF emphasizes the absence of a direct cause-and-
effect relationship between a particular health condition and the resulting functional
outcomes. Additionally, it recognizes contextual elements as significant determinants
of outcomes. The ICF model offers a comprehensive framework and organizational
system for gathering and categorizing clinical, behavioral, and contextual data.
This framework has the potential to have a beneficial impact on the processes of
assessment, intervention design, and outcome evaluation [36, 37]. This facilitates
the establishment of a comprehensive clinical and contextual profile for a pediatric
patient with a neurological health condition and offers systematic guidance for the
integrated provision of services to children and their families who need to be included
in their rehabilitation management.
Most common pediatric neurological disorders have a reciprocal relationship with
their body functions and structures, their ability to conduct functional tasks, and
their subsequent engagement in familial, occupational, and recreational responsi-
bilities. The physical well-being, activities, participation, and health of individuals
can be impacted in either a positive or negative manner by a range of factors. These
factors encompass both environmental elements and various factors that contribute
to the shaping of individuals’ behaviors and experiences. These factors include social
attitudes, architectural characteristics, legal and social structures, climate, and
terrain. Gender, age, psychological traits (e.g., thoughts, beliefs, and coping styles),
health and illness behaviors, social circumstances, education, and past and present
experiences are also playing a significant role [38].

10. Application of the ICF as clinical reasoning tool in pediatric

neurorehabilitation

Therapists in pediatric neurorehabilitation typically use a degree of routine in

their evaluation process. Based on their expertise in ICF knowledge and their clini-
cal practice, the therapists have determined the specific categories of information
that have been considered highly valuable for the identification of problems and the
making of management decisions, as shown in Figure 2. These categories include
environmental data, subjective and objective attributes of the patient’s impairments
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DOI: http://dx.doi.org/10.5772/intechopen.1003078

(such as location, behavior, and history of symptoms), as well as specific evaluations

of functioning, structure, and cognition.
In addition to these established procedures, individualized investigations and
examinations are customized to accommodate the individual manifestations of each
child. The development of tailored inquiries and tests for each individual child is
prompted by the formulation of first hypotheses. The cognitive process known as
“hypothesis testing” ideally involves the systematic exploration of both confirming
and disconfirming evidence. The obtained data are further analyzed to determine
their alignment with previously collected data and relevant theories.
The interpretation of routine inquiries, tests, and spontaneous information
provided by child/family will be conducted within the framework of initial hypoth-
eses. Through this process, the therapist gains a progressive comprehension of the
child’s neurological disorder. The initial hypothesis will undergo modifications, and
further hypotheses will be taken into consideration. The process of generating and
testing hypotheses persists until an adequate amount of information is acquired to
enable a therapist to formulate a diagnosis pertaining to the physical and psychosocial
manifestations. This diagnosis also considers the suitability of therapist involvement
and/or referral to other healthcare professionals, as well as the implementation of
rehabilitation management strategies.
The clinical reasoning involved in the assessment and management using the ICF
component in child and family contexts necessitates the careful study of the cognitive
processes employed by the therapist, child, and family, as well as the collaborative
nature of decision-making among them. Figure 2 depicts an ICF model of clinical
reasoning as a collaborative process involving patients, as proposed in Figure 2.
Within the context of pediatric neurorehabilitation settings, the therapist’s cognitive
processes are initiated by the initial data and cues acquired, such as the referral infor-
mation and observations made of the patient. The initial data presented will elicit a
variety of impressions or provisional judgments. Although not commonly recognized
as such, these early interpretations can be regarded as hypotheses since they are

Figure 2.
ICF model of clinical reasoning as collaborative process between therapist in pediatric neurorehabilitation and
child & family.

11
Neuropediatrics – Recent Advances and Novel Therapeutic Approaches

not definitive or conclusive choices. However, these first impressions are evaluated
in light of additional information (data) that may either corroborate or contradict
them. While there are similarities between this procedure and hypothesis testing, it is
important to note that not all therapists may possess a comprehensive understanding
of the ICF model or be aware of this process or their thinking in general. The process
of hypothesis formation encompasses the integration of specific data interpretations
or inductions with the synthesis of many hints or deductions [36–39].
The use of the six F-word concepts at the clinical level has the potential to enable
service providers to effectively incorporate the ICF framework into the development
of child-family-neurorehabilitation team goal setting (Figure 2). This approach
would involve the inclusion of an individual’s strengths in order to customize inter-
ventions. There are six fundamental factors that play an important role in the goal-
setting process in pediatric neurorehabilitation [1]:
The first F-word, “function,” pertains to the activities performed by individuals,
encompassing their roles, jobs, occupations, and tasks. Hence, it is imperative to
promote child’s engagement in functional practice, regardless of the level of perfec-
tion attained.
The second F-word: Family serves as a fundamental component of external con-
textual influences inside child lives. Hence, the implementation of a family-centered
approach within rehabilitation services has the potential to significantly enhance
therapy outcomes and foster improved collaboration among healthcare practitioners.
Collaborating with the family to ascertain their objectives can significantly enhance
therapy outcomes and facilitate the family’s access to resources to make well-informed
decisions.
The third F-word: Fitness, the importance of physical fitness has been largely
overlooked until recently. However, evidence indicates that individuals with chronic
illnesses exhibit lower levels of fitness than what is considered optimal. While it
is widely acknowledged that engaging in an exercise program can yield numerous
advantages in terms of maintaining physical activity levels, it is imperative to incorpo-
rate physical training into rehabilitation.
The fourth F-word: Fun refers to activities that child finds enjoyable and meaning-
ful in their daily lives.
The fifth F-word: Friend, pertains to the concept of friendship, which aims to
enhance child engagement and integration within the community. Social factors have
a crucial role in the well-being of a child, and it is imperative to take into account the
quality of friendships as a facilitating factor.
The six F-words: Future, child, and family need to be involved in the plan of care
and the interventions, which are only decided for them by the health provider.
By addressing function, fitness, family, fun, friends, and constantly reminding
therapists in pediatric neurorehabilitation to be aware of the importance of children
and families in rehabilitation services. It is crucial to involve child and their relatives in
the decision-making process rather than making unilateral decisions on their behalf.

11. Conclusion

The International Classification of Functioning, Impairment, and Health (ICF)

serves as a valuable instrument in enhancing comprehension of health and impair-
ment within the context of pediatric neurorehabilitation. The utilization of this tool
facilitates the enhancement of clinical reasoning among healthcare professionals by
12
Application of the International Classification Functioning, Disability, and Health (ICF)…
DOI: http://dx.doi.org/10.5772/intechopen.1003078

including a greater amount of information that surpasses the limitations of a mere

list of diagnoses. Neurorehabilitation personnel must possess an awareness of and
familiarity with the personal and environmental elements pertaining to their patients
in order to have a comprehensive understanding of their values, desires, and objec-
tives. The incorporation of this element is seen as crucial for the implementation of
evidence-based practice within the field of pediatric neurorehabilitation.
The understanding of the impact of the environment and personal factors on
disability has experienced a substantial transformation from the ICF framework in
pediatric neurorehabilitation. The ICF recognizes the environment as a distinct and
essential element within its framework. The ICF’s conceptual framework necessitates
the inclusion and clarification of environmental elements in order to fully com-
prehend disability. The conceptualization of intervention has similarly seen a shift
in focus. This paradigm shift includes interventions aimed at both individuals and
society, with an emphasis on removing barriers and cultivating facilitators.

Conflict of interest

The author declares no conflict of interest.

Author details

Hanan Demyati
Prince Sultan Armed Forces Hospital, Madinah, Saudi Arabia

*Address all correspondence to: tomsunny54@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of
the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
13
Neuropediatrics – Recent Advances and Novel Therapeutic Approaches

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