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1/7/2003 The Conceptual Framework of ASHA's New Scope of Practice for Speech-language Pathology Travis T. Threats, Ph.D. | |
| In 2001, ASHA decided to use the World Health Organization’s International Classification of Functioning, Disability, and Health (WHO, 2001) as the framework for the profession in its Scope of Practice for Speech-Language Pathology. (ASHA, 2001) This scope of practice document paves the way for a more comprehensive view of what constitutes speech-language intervention and the methods of determining whether that intervention is successful. The first fundamental area the scope of practice document addresses is what can be included in the term "speech-language and swallowing intervention." This issue is answered broadly in the Scope of Practice with the following: "The overall objective of speech-language pathology services is to optimize individual’s ability to communicate and/or swallow in natural environments, and thus improve their quality of life." (p. 22a) and "That is, speech-language pathologists work to improve quality of life by reducing impairments of body functions and structures, activity limitations, participation restrictions, and environmental barriers of the individuals they serve" (p.22c) In the above definition, the ultimate goal is to facilitate an improvement in quality of life. The next issue is that this goal can be reached in a variety of ways. For example, in addition to working with a person with dysarthria on his/her speech production (Body Function), one might also work on talking with the head of a social club he/she belongs to, to encourage the person to start attending the meetings again (Activity/Participation restriction). The environmental barrier of the person’s negative attitudes toward the client because he believes the client’s disordered speech is a result of "senility" could be addressed by speech-language intervention (Environmental Factors). Quality of life is not addressed by the International Classification of Functioning (ICF) but the items in this classification can certainly have an effect on quality of life (Andresen and Meyers, 2000). To fully understand the implications of adopting this framework, it is necessary to provide more information about this classification system. This system is updated and the revised version of the 1980 International Classification of Impairments, Disabilities, and Handicaps (ICIDH), which was for trial purposes only. To view the web searchable version of the ICF, go to www.who.int/classification/icf. From that web site, one can also purchase a hardbound copy of the book. The applications of the ICF are 1) as a statistical tool (e.g. surveys); 2) as a research tool (e.g. outcomes research); 3) as a clinical tool (e.g. evaluation of rehabilitation effectiveness); 4) as a social policy tool (e.g. determination of disability benefits); and 5) as an educational tool (e.g. used as framework in education to understand disability). In this fully operationally coded classification system, there are four main constructs: 1- Body Structure, 2- Body Function, 3- Activity/Participation, and 4- Contextual Factors. "Body Structure" is defined as the anatomic parts of the body such as organs, limbs with "Body Function" being the physiological or psychological functions of body systems. For communication, Body Functions would represent essential component behaviors such as sustaining attention, voice production, articulation, or receptive semantic knowledge as demonstrated by a visual confrontation-naming task. They are not the communication act itself (e.g. sending and receiving messages, using language to share memories) but are those component cognitive, motoric, and sensory skills that are used in communication. Body Function items have qualifiers after the decimal point to indicate the severity of the dysfunction on a 1 to 4 scale. For example, a person’s voice might be rated using b3100 "Production of voice" as b3100.2 which would indicate a moderate problem with this aspect of speaking. "Activity/Participation" are represented in the ICF as a single list of tasks. This construct represents global communication behaviors such as being able to successfully tell a narrative, using e-mail, or understanding traffic signs. For Activity/Participation, each code has, after the decimal point, qualifiers which indicate the extent of limitation of that code. These qualifiers range from "1" for mild to "4" for complete restriction. The Activity/Participation items are modified by one primary "Performance" qualifier and two "Capacity" qualifiers. The Capacity qualifiers describe an individual's ability to execute a task or an action in a standardized or uniform environment (e.g. clinic room), with one of two qualifiers being the ability to do without assistance and the other representing one’s ability with assistance (e.g. cueing, assistive device). The primary "Performance" qualifier describes how a person executes a task or an action in his or her actual life. For "Conversation" which is d350, then d350.321 would mean a severe restriction in the client’s demonstrated ability to have conversations in their current natural environment, a moderate restriction with the clinician in the therapy room with no overt assistance from the clinician, and a mild restriction with a clinician utilizing highly facilitative techniques such as using multiple modalities. "Contextual Factors" are defined as including both Environmental Factors that are external to an individual’s control (e.g. ability to access rehabilitation services, spousal support, attitudes of others) and Personal Factors that are characteristics of the person (e.g. coping mechanisms, age, lifestyle). Environmental factors are coded with both facilitative and barrier qualifiers. These environmental factors are viewed as crucial to determining why a person’s Capacity measures would be different from his or her Performance measure on any given Activity/Participation tasks. In addition, different environments could be specified to indicate different performance in each. Personal Factors are included in the ICF framework because of their acknowledged importance but are not classified in the actual ICF book. Thus, the use of the ICF framework represents a broad view of what would constitute speech-language or swallowing intervention. The Body Function component is already practiced by most clinicians and most clinicians have moved to more so called "functional therapy." However, the word "functional" is too limiting in that it implies that the purpose of communication is simply to transact the basic wants and needs and understanding common commands or statements (Elman and Bernstein-Ellis, 1995) For example, re-joining a social group, enjoying sporting events, discussing one’s fears of the future, or having intimate banter with one’s mate seem broader than simply being "functional." Yet these Activity/Participation behaviors are essential to being interacting, engaged human beings and can be important to quality of life. Intervention geared towards these broader life goals should thus be considered as an essential part of providing intervention. However, this is not to be interpreted as meaning that Body Function items are not important enough to evaluate or directly treat. A person with a moderately aphonic voice has a Body Function level impairment but this difficulty with voicing could interfere with his or her ability to have conversations or to continue belonging to a social club. Thus, the key is to focus squarely on quality of life issues with the dominant question being "Is this given Body Function or Activity/Participation limitation producing a negative effect on the person’s quality of life?" Perhaps, the biggest challenge the ICF framework will have on our profession is to fully acknowledge and try to influence Contextual Factors, Environmental Factors and Personal Factors, of the persons we treat. Speech-language clients do not exist in a vacuum and their environment has a tremendous effect on ultimate outcomes. What good is it to see great improvements in clinic to the point of discharge and then have the person exit in an environment where his or her speech-language or swallowing problems are met with inattentiveness, strife, and/or condescension? The ultimate therapeutic outcome is not what happens in clinic; it is post-therapy communication functioning of the person. That functioning is largely dependent upon the person’s environment. Inasmuch as intervention can affect this environment, speech-language pathologists must try - because it is essential to reach the best possible Activity/Participation and, hopefully, subsequent quality of life. Personal Factors do have an effect on the therapeutic process. These aspects of a person that are independent of the disorder may or may not be amenable to intervention. When they are not, then therapy must adapt to meet their quality of life needs, which could depend upon their culture. Diversity is not simply about race or socioeconomic level. A true look at diversity acknowledges that a given person’s particular past experiences and upbringing influence how they approach the communication or swallowing disorder and how they approach the therapeutic process. By having Personal Factors listed at the same level as Body functions, the ICF, and ASHA’s use of it, state these Personal Factors should be looked at as systematically, and without previous bias, as say a speech-language pathologist would examine the articulatory proficiency of a client. In other words, the clinician should not make assumptions but seek to determine the particular circumstances for the particular client he/she has in front of them. Perhaps the most underused and simplest diversity assessment task is asking the person or their significant other "Tell me about yourself and how your difficulties have affected things most important to you" For those Personal Factors that can possibly be amenable to intervention, such as coping styles or other health problems unrelated to the speech-language disorder, it might be possible for the speech-language pathologist or other professional to address in the course of evaluation and intervention. Because clients with communication disorders can have barriers to obtaining needed services, their speech-language pathologists should advocate for the extra services needed. It is only of benefit to our speech-language or swallowing intervention to addressing any Personal Factors that may facilitate or hinder the therapeutic process. A second fundamental question to be addressed concerning ASHA’s use of the ICF in the new Scope of Practice is, "How can all of these identified aspects of functioning be documented?" One of the reasons Body Function oriented therapy is common is because the manner in which results can be documented appears relatively straightforward. One can evaluate voice with instrumentation. One can evaluate language by looking at utterance length, syntax, and phonology. One can evaluate stuttering by counting dysfluencies. One can evaluate pharyngeal swallowing by looking at the results of a radiographic exam. Thus, what needs to be developed are reliable and valid assessments tools and protocols to evaluate the Activity/Participation and Contextual Factors constructs. There also needs to be more Body Function assessment measures developed which demonstrate that items on them have an important effect on Activity/Participation. Finally, communication quality of life measures need to be developed as the ultimate indication that intervention was successful. The development of more comprehensive and varied assessment techniques is directly tied to the question of clinical effectiveness using the ICF as the framework for the profession. Everyone wants to be able to show that therapy has "worked" In speech-language pathology, as well as other professions, the dominant question in these days of outcomes and accountability is the question "Does therapy work?" (Frattali, 1998). The problem with this question is the word "work." How do we define "work?" Is it improved scores on the Boston Diagnostic Aphasia Examination? Is it improved ability to express wants and needs? Is it an improved communication environment whereby the persons in the environment learn how to interact with the person with the communication disorder? Is it improved overall quality of life because the patient is better able to participate in his or her previous activities such as being a member of a social club? Is it improvement in the clinic? Is it improvement in the person’s natural environment? Is it being able to be a better father to one’s child? Is it improvement because of being given some type of assisting device such as an alternative communication system? The answer is that all of the above constitute that something in therapy has "worked." Thus, instead of the question, of "Does therapy work?" the question should be "What can therapy do to demonstrate a change in behavior or functioning in our clients and is this change of behavior or functioning beneficial to our clients?" The above described ICF system has a method for separately documenting all legitimate claims of therapy "working." The ultimate goal of therapy is improvement in the person’s actual life for the activities he or she finds important. However, in the course of therapy this ultimate goal needs to be worked up to in a systematic manner. For some clients, they can go directly to Activity/Participation component type of therapeutic methods such as role-playing needed communication situations. For other clients, the persons in their environment need intervention to help them cope and/or interact with the person with the communication disability. Some tasks need to be developed in the clinic before they can be generalized to the home and thus the two Capacity qualifiers of the Activity/Participation construct could demonstrate that the person is progressing with relevant communication tasks within the clinic. Some clients will need extensive cueing or other facilitators such as a voice amplifier in order to communicate. A client’s superior performance on the Capacity with assistance qualifier could be used to demonstrate the client’s potential with adequate environmental support in their actual life. Clinical research needs to go beyond the simplistic "Does therapy work?" mindset. By using the ICF, researchers can broaden their questions regarding what interventions could result in improvement, and agreed upon methods to document improvement. Improvement is multi-faceted and thus the best clinical research would state which ICF component is being evaluated to determine therapy effectiveness. Is this a study of environmental influences on improvement? Is this a study of changes in a person’s natural environment? Is this a study of improvements only within the clinical setting? It is this line of research that could lay the foundation for a wider variety of appropriate assessment measures or protocols for the different components of the ICF (Threats, 2001). One of the reasons this effort has lagged behind basic communication research is the lack of a common language and framework between researchers and clinicians. The ASHA Scope of Practice, which embraces the ICF, can facilitate this correction. Additionally, currently there is no way for the clinical researcher to review data normally collected in clinical practice to determine the effectiveness of one therapeutic approach as compared to another, because there is no standardization across therapists and settings (National Committee on Vital and Health Statistics, 2001) However, what is needed is not standardization of therapeutic approaches, which still need to be individualized to the client, but a standardized way of documenting and reporting results according to the components of the ICF. Without a standardized system, speech-language pathologist researchers have difficulty with even basic questions such as saying that 30 sessions of therapy produces better real-life outcomes than would 10 sessions. The World Health Organization (WHO) stated that the ICF is to be considered the partner to the International Statistical Classification of Diseases and Related Health Problems (ICD). Only by looking at both can a true picture of the health of a population or an individual be determined. The National Committee of Vital and Health Statistics, which is an academic advisory committee of the Department of Health and Human Services, has recommended studying the use of ICF for all federal health reporting, including Medicare reporting and reimbursement (www.ncvhs.hhs.gov/010716rp.htm). The use of the ICF by ASHA in its Scope of Practice document reflects ASHA’s present and future need to broaden our view and demonstrate that the profession makes an important impact on the lives of our clients and on the health of the nation. The ICF is a classification system with many uses. In it’s current form, it is not sufficiently detailed enough to provide for clinically reliable use. In recognition of that, the American Psychology Association (APA) in a joint project with the WHO is currently developing the Procedural Manual and Guide for a Standardized Application of the ICF. The purpose of the manual will be to provide a multi-disciplinary guide for the reliable and valid use of the ICF for practicing clinicians by providing item by item further clinically oriented descriptions of the codes, clinical examples and cases given for each, and general assessment guidelines for each code. In summary, the ICF is used by ASHA as the framework for the profession because it has international recognition and emphasizes real life outcomes for the people we serve. The ICF does not, of course, design therapy or choose therapy goals. It is best to think of ICF as the constitution of a country. A good constitution sets up principals and guidelines to insure optimum functioning of the country. It may have contradictions, ambiguity and important areas that are not directly addressed. These limitations are left to the ingenuity and wisdom of the citizenry. Similarly, the new Scope of Practice sets forth a challenge and a mission, and it’s up to individual speech-language pathologists to claim that mission, and to improve the quality of our services so we may assist our clients in achieving their optimum functioning and quality of life. References: American Speech-Language-Hearing Association. (2001). Scope of practice in speech-language pathology. Rockville, MD: Author Andresen, E. & Meyers, A. (2000). Health-related quality of life outcomes measures. Archives of Physical Medicine and Rehabilitation. 81, Suppl. 2, p. S30-S45. Elman, R. & Bernstein-Ellis, E. (1995). What is functional? American Journal of Speech-Language Pathology, 4 (4), 115-117. Frattali, C. (1998). Outcome Measurement: Definitions, Dimensions, and Perspectives. In C. Frattali (Ed.) Measuring outcomes in speech-language pathology (pp. 1-27). New York: Thieme. National Committee on Vital and Health Statistics. (2001). Classifying and Reporting Functional Status. Washington D.C.: Department of Health and Human Services Threats, T. (2001). Evidence based practice research using the WHO framework. Journal of Medical Speech-Language Pathology, 10 (3). World Health Organization. (2001) . The International Classification of Functioning, Disability, and Health. Geneva, Switzerland: Author | |