International Journal of Speech-Language Pathology, 2008; 10(1 2): 18 26

The ICF Activities and Participation related to speech-language

pathology

ROBYN OHALLORAN1 & BRIGETTE LARKINS1,2

1
The University of Queensland, Australia, and 2Older Persons Health Service, Canterbury District Health Board,
New Zealand

Abstract
Increasingly speech-language pathologists are considering the effects of a clients communication and/or swallowing
disability on the clients day to day life. The activities and life situations that make up a persons everyday life are described in
the Activities and Participation component of the World Health Organizations International Classification of Functioning,
Disability and Health (ICF). This paper describes the Activities and Participation component of the ICF and how
communication is currently represented in this component. This paper then explores the current debate between the
concepts of activities and participation and how this can continue to inform and develop our understanding of
communication activity and communication participation into the future.

Keywords: ICF, World Health Organization, speech-language pathology, Activities and Participation.

costs for the healthcare sector. In response, third

Introduction
Many influences may direct a speech-language
pathologist to consider the effects of a clients
communication and /or swallowing disorder on his/
her everyday life. Three key influences are the clients
themselves, payers, and the clinician him/herself.
Clients with communication and/or swallowing
disorders have a reasonable expectation that speech
pathology assessment and intervention will have a
positive effect on their everyday lives. In fact some
individuals, particularly those whose disorders are
associated with cognitive deficits, often refuse to co-
operate, or may make little effort, unless they
perceive that the clinicians requests or therapy goals
have significance to the goals of their lives (Ylvisaker,
Jacobs, & Feeney, 2003). In addition, many indivi-
duals with communication disorders may fail to
spontaneously integrate therapeutic tasks at the level
of impairment into complex real life activities
(Ylvisaker, Szekeres, & Feeney, 2001). This further
underscores the need to address communication as it
occurs in everyday life. Payers too want evidence that
speech pathology interventions make a difference to
peoples everyday lives (Frattali, 2000). The ad-
vances in medical technology added to the ageing
population have resulted in increased demand and
party payers have required health professionals to
extend their accountability beyond diagnosis to
precisely describing the meaningful outcomes of
rehabilitation (Tarvydas, Peterson, & Michaelson,
2005). Finally, speech-language pathologists own
values and the values of the organization within
which they work may also orient clinicians towards a
better understanding of how their assessment and
intervention influences their clients everyday lives.
Clinicians, and/or organizations, who promote values
such as respecting the individuality of the client,
shared decision making, open communication and
mutual respect are more able to consider the impact
of a communication disorder on the clients life
(Byng, Cairns, & Duchan, 2002; Worrall, 2000).
From a theoretical viewpoint, a persons ability to
carry out activities and be involved in life situations
may be represented by the Activities and Participa-
tion component of the World Health Organizations
International Classification of Functioning, Disability
and Health (ICF) (WHO, 2001). This paper de-
scribes the Activities and Participation component of
the ICF and how it currently defines and measures
the full range of a persons everyday activities and life
situations. It then discusses some of the problems
with the Activities and Participation component of

Correspondence: Robyn OHalloran, Communication Disability Centre, The University of Queensland, St Lucia, 4072, Queensland, Australia.
E-mail: s374859@student.uq.edu.au
ISSN 1754-9507 print/ISSN 1754-9515 online The Speech Pathology Association of Australia Limited
Published by Informa UK Ltd.
DOI: 10.1080/14417040701772620
 ICF Activities and Participation 19

the ICF, in particular the alternative ways in which in which the ICF currently conceptualize commu-
activities and participation have been proposed to nication activities and participation is described in
relate to each other. The final section of this paper the following section.
draws on the discussion of the relationship between
activities and participation to further clarify the
Communication in the Activities and
concepts of communication activity and commu-
Participation component
nication participation as they relate to the assessment
and management of adults with acquired commu- Chapter 3 of the Activities and Participation compo-
nication disabilities. nent is Communication and is one of the nine
chapters in this component. It describes commu-
nication activities and participation at the broad three
The Activities and Participation component
digit level in terms of Communicating receiving
of the ICF
(d310 d329); Communicating producing
The Activities and Participation component of the (d330 d349); and Conversation and use of com-
ICF describes the complete range of human func- munication devices and techniques (d350 d369).
tioning from both an individual and a societal Communication receiving and Communica-
perspective (WHO, 2001). The individual perspec- tion producing are described in further details in
tive is expressed through the concept of activity terms of the type of message the person is receiving
which is defined as the execution of a task or action or producing, that is, whether it is non-verbal or
by an individual (p. 10, WHO, 2001). The societal verbal and in terms of the modality the person uses to
perspective is expressed through the concept of communicate such as through body gestures and
participation and is defined as involvement in a life drawings. Conversation and use of communication
situation (p. 10, WHO, 2001). These two perspec- devices and techniques is described in further detail
tives of functioning and disability make up the ICF by differentiating conversations from discussions and
Activities and Participation component. in terms of the number of people involved.
The Activities and Participation component con- However, communication activity and participa-
sists of a single list of nine chapters or domains. tion is also part of many other activities and
These are Learning and applying knowledge (d1); participation domains. For example, within the
General tasks and demands (d2); Communica- Learning and applying knowledge (d1) domain
tion (d3); Mobility (d4); Self-care (d5); are the items: Reading (d166), Writing (d170)
Domestic life (d6); Interpersonal interactions and Solving problems (d175) which includes
and relationships (d7); Major life areas (d8); and resolving a dispute between two people. Similarly,
Community, social and civic life (d9). As with the the Domestic life (d6) domain includes items such
organizational structure of other parts of the ICF, as the Acquisition of goods and services (d620)
each domain in the Activities and Participation and Assisting others (d660) and not surprisingly
component is described in further detail by first, the Interpersonal interactions and relationships
second, and sometimes third and fourth level items. (d7) domain is replete with communication activities
For example, the domain Learning and applying such as showing Respect and warmth in relation-
knowledge (d1) consists of 21 first level items, such ships (d7100), understanding Social cues in
as Learning to calculate (d150) and Acquiring relationships (d7104) and maintaining Informal
skills (d155). Some of these first level items are relationships with friends (d7500).
described in further detail by second level items. For Therefore the Activities and Participation compo-
example, Acquiring skills (d155) consists of the nent of the ICF describes communication activities
second level items Acquiring basic skills (d1550) and participation in two different ways. Chapter 3 on
and Acquiring complex skills (d1551). Finally, a Communication describes communication in
persons level of functioning in each of the items terms of the component parts of communication,
within these domains is made meaningful by two that is, the type of communication that is occurring
qualifiers; performance and capacity. The (e.g., receiving messages, producing messages, or
performance qualifier describes what an individual both, as in conversation), the communication mod-
does in his or her current environment at a given ality employed (e.g., verbal or non-verbal) and the
time, whereas the capacity qualifier describes an number of people engaged in the communication.
individuals highest probable level of functioning, in These communication activities and participation are
a standardized or uniform environment at a given not described in relation to the context of the
time (WHO, 2001). The ICF describes an additional communication activity such as the place or purpose
third qualifier representing capacity with assistance of the communication. In contrast, communication
and a fourth qualifier representing performance related activities included in other chapters of the
without assistance. Activities and Participation component do describe
Of particular interest to speech-language patholo- communication activities in relation to the context of
gists is how the Activities and Participation compo- the communication. For example, the purpose of the
nent describes communication disability. The ways communication is explicit in the communication
20 R. OHalloran & B. Larkins
related activities Resolving a dispute (d175) and
Shopping (d6200).
How best to describe communication activities
and participation is a difficult issue to resolve. Given
that communication is such an essential part of
everyday life it is not surprising that communication
activities are embedded within so many different
domains across the Activities and Participation
component. One solution may be to simply subsume
communication activities into the other domains.
However, this could result in communication being
buried within other activities and participation
domains and not getting the recognition it requires
as an essential aspect of human functioning. The
challenge will be to find ways to describe commu-
nication activities and participation in ways that
make it clear how essential they are across most
aspects of human functioning and interaction. For
example, for the codes dealing with intimate relation-
ships, which includes creating and maintaining
Romantic relationships (d7700) and Spousal these notions are used in different settings, in different
relationships (d7701), speech-language pathologists
could work with other professionals and researchers
to better understand how people who have commu-
nication disabilities create and maintain different
types of intimate relationships. In this way, commu-
nication activities and participation would not be
separate from other activities and participation but
recognized as integral to them. The relationships
among all the domains should be studied to come to
a better understanding of the complexity of human
interactions. Our ability to meet this challenge will be
greatly influenced by how the Activities and Partici-
pation component itself is understood. Therefore the
following section examines the concepts underpin-
ning activities and participation.
Activities and Participation concepts
As described above, the Activities and Participation
component consists of a single list of domains but
actually represents both the individual (Activities)
and societal (Participation) perspectives of function-
ing and disability. The reason the ICF does not have
separate Activity and Participation components is
because field trials of the beta-2 version of it found
no agreement among the active participants in the
development of the ICF as to which domains
reflected activities and which domains reflected
participation. As a result, WHO presents four
different possible interpretations of the Activities
and Participation component:
1. That the sets of codes are mutually exclusive.
That is, some sets of codes represent activities
and some represent participation.
2. That some of the sets of codes represent
activities, some represent participation, but
other domains represent both activities and
participation.
3. That all the specific and more detailed items
in the codes reflect activities and the general
overall headings represent participation. For
example, Moving around (d455) could be
participation but its more detailed subcategory
Crawling (d4550) could be listed as an
activity.
4. That all codes can be considered as activities
and as participation (WHO, 2001). An option
within this approach would be to consider the
capacity qualifiers as activity and the perfor-
mance qualifiers as participation.
Concerning this variety of options, the ICF states:
It is expected that with the continued use of the ICF and
the generation of empirical data, evidence will become
available as to which of the above options are preferred
by different users of the classification. Empirical
research will also lead to a clearer operationalization of
the notions of activities and participation. Data on how
countries and for different purposes can be generated
and will then inform further revisions to the scheme.
(WHO, 2001, p. 237).
There is consensus that the Activities and Participa-
tion component consists of two different perspec-
tives. One debate is around whether or not these two
perspectives represent two separate underlying con-
structs or reflect different ends of the same con-
tinuum. The first WHO framework of disability, the
International Classification of Impairment, Disability,
and Handicap (ICIDH) (WHO, 1980), conceptua-
lized the individual and societal perspectives of
functioning and disability as two separate constructs.
The perspective of the individual was referred to as
the disability and the perspective of society was
referred to as the handicap. As described above,
the revised ICF is less clear about the relationship
between these perspectives.
Since the publication of the ICF the relationship
between Activities and Participation has been con-
ceptualized in a number of different ways. These
perspectives are presented below. The first point of
view from speech-language pathology is that activ-
ities and participation are not distinctly different but
exist at different points along a continuum. The
continuum is the influence of contextual factors, that
is, environmental and personal factors (Davidson &
Worrall, 2000). This model conceptualizes Activ-
ities as a persons functioning across simple and
complex tasks and actions in a more restricting,
limiting context at one end of the continuum, for
example, reading a menu, whereas Participation
represents a persons functioning in unrestricted
contexts at the other end, for example, dining
out when a tourist in a foreign country
(Davidson & Worrall, 2000). In this view, the
concepts of Activity and Participation are
integrally related.
 ICF Activities and Participation 21

Another framework that views activities and that activities and participation are different in
participation as a continuum is the Living with Apha- relation to their norms, qualifiers and how activities
sia: Framework for Outcome Measurement (A-FROM; are chosen and participation is determined as
Kagan et al., 2007) The A-From identifies four described in Table I. Whiteneck (2006) has also
interrelated factors that have been proposed to considered the differences between the ICF view of
influence the overall experience of living with aphasia. activities and participation and has also proposed
These factors are the severity of the aphasia, that they are different. He proposed 11 differentiat-
participation in life situations, communication ing criteria which are listed in Table II.
and language environment and personal identity, It is of note that some of the criteria used by the
attitudes and feelings. These factors are similar to AIHW (AIHW, 2003, 2007) and Whiteneck (2006)
the ICF components Body Functions and Structures, accommodate the perspective of the first view
Activity and Participation, Environmental Factors presented in this section, in that some of their
and Personal Factors respectively. Of particular criteria also conceptualize activities and participation
interest is that the Participation in life situations as being at different ends of the same continuum.
factor consists of communication activities, com- They state variously that activities are simple whereas
munication and conversation, roles and responsi- participation is complex; activities are less dependent
bilities and relationships. That is, this model also on environment whereas participation is more
suggests that communication activities are an integral dependent on environment (Whiteneck, 2006);
part of participation in life situations (Kagan et al., activities are fine grained whereas participation is
2007). Both these models suggest that activity is part broad brushed (AIHW, 2003).
of participation, therefore these models imply that a Other criteria suggest however that activities and
persons level of communication activity is related to participation are qualitatively different and perhaps
his/her level of communication participation. represent two distinctly different constructs, for
The Australian Institute of Health and Welfare example, the AIHW propose that activity describes
(AIHW) has also considered the relationship be- activities whereas participation involves choice and
tween the ICF concepts of activities and participa- judgements (AIHW, 2007). Similarly, activity is
tion, by reflecting on the factors that differentiate
activities and participation. In contrast to the
perspective above, in a 2003 publication, the AIHW Table I. The differences between activities and participation in the
suggested that activities and participation were context of a health condition (AIHW, 2007).
different on six criteria.
Activities Participation
These were:
At the level of the individual In the context of the persons
1. Activities focus on the persons individual life
Norma person without Norma person without
functioning, while Participation emphasises
disablement disablement in the same
the persons involvement in society. society, culture or sub
2. Activity is completely externally observable. culture
Participation refers to the lived experience of Qualifiersdifficulty and Qualifiersextent and
the person. assistance satisfaction
Describes activities Involves choices and
3. Activity can relate to a test environment
judgements
(although it can also relate to a real environ- Level of chosen activity Extent of participation in a
ment), with or without equipment. Participa- determined by factors chosen area determined by
tion is essentially confounded with the arising within the person factors arising outside the
environment, i.e., the concept has little mean- person
ing without consideration of the physical and
social environment, and it cannot be as-
sessed in a test environment.
Table II. The ICF concepts of Activity and Participation
4. Involvement in society relates in particular to differentiated by Whiteneck (2006).
social roles. This highlights the confounding
of Participation with that part of the environ- Activity Participation
ment that shapes expected roles and societal Individual level Societal level
norms. Performed alone Performed with others
5. Activity is fine grained, whereas Participation Simple Complex
Related to impairment Related to quality of life
is broad brushed.
Less environment dependent More environment dependent
6. Activity is about action or process, Participa- Medical model of disability Social model of disability
tion relates to the overall goal of actions or sets Focus of rehabilitation Focus of consumers
of actions (AIHW, 2003, pp. 35 36). Assessed in hospital Assessed in community
Clinician assessment Self or proxy report
Not always possible Always theoretically possible
Recently the AIHW has differentiated the concepts
Task Social role
of activities and participation further, by proposing
22 R. OHalloran & B. Larkins
assessed by a clinician, whereas participation is
assessed by self or proxy report (Whiteneck, 2006).
If activity and participation are indeed separate
constructs then theoretically they are independent
of each other. Therefore, a persons ability to
perform everyday tasks and actions (even with
assistance) at the level of Activity could be
independent of his/her level of Participation in
everyday life situations.
A third, alternative view has been expressed in the
clinical manual being developed by the American
Psychological Association (APA) in collaboration
with the WHO, to assist healthcare professionals to
implement the ICF as a clinical tool. Currently in
development, the Procedural Manual and Guide to the
Standardized Application of the ICF: A Manual for
Health Professionals (American Psychological Asso-
ciation, World Health Organization, in press),
described in detail by Threats (2008), has chosen
the fourth option offered by the ICF and treats all
sets of categories as activities and participation. In
the prototype of the manual developed in 2003, they
argue that what is most critical for the clinical
application of the ICF is not whether an item within
a domain is identified as an activity or as participa-
tion but that the underlying constructs are fully
expressed through the descriptions of the domains
and the qualifiers (APA, 2003).
That is, instead of discussing the differences and
similarities between activities and participation and
then categorizing some domains as activities and/or
as participation, the core group developing the
Procedural Manual (APA, in press) has focused on
ways to describe the differences between what the
client does in the clinic room versus what the client
does in his/her own life (Reed et al., 2005). This
difference is expressed through the qualifiers, where
the two capacity qualifiers capacity without assis-
tance and capacity with assistance are considered
measures of the persons ability within the clinic
setting and the performance qualifiers are measures
of the persons real life experiences. For example, the
prototype guidelines in the Procedural Manual (APA,
in press) for rating the performance qualifier for the
code d330 Speaking states when determining
this qualifier, consider how the environment facil-
itates or impedes an individuals ability to speak,
taking into account unique demands encountered by
that individual, levels and types of support, socio-
cultural factors and laws, as well as the individuals
capacity to speak as determined through assessments
that target this areas (see capacity qualifiers) (p. II.
3 21). Therefore the Procedural Manual (APA, in
press) seeks to make a clear distinction between just
being able to speak (capacity) and the lived
experience in the act of speaking.
This distinction is similar to how the AIHW
(2003) differentiates activities and participation
where activities are described as externally observa-
ble and assessable in a test environment versus
participation which is described as the lived experi-
ence of the person and not assessable in a test
environment. It is also similar to Whitenecks (2006)
position where activities are measured by the
clinician whereas participation is measured by self-
report or proxy.
Describing the differences between a persons
ability in the clinic room compared with his/her
lived experience is one of the most important aspects
of the Activities and Participation component of the
ICF and this distinction has been effectively captured
in the development of the Procedural Manual (APA,
in press). However grouping activities and participa-
tion together is not unproblematic. Some codes in
some chapters, such as Family relationships
(d760) and Community life (d910) are overtly
participation in orientation and can not be measured
in the clinic setting. The Procedural Manual (APA, in
press) handles this situation by simply stating that
certain codes will not have possible or feasible
capacity codes and thus should be either left blank
or coded as not applicable, thereby acknowledging
that certain codes are participation in nature.
Secondly, the capacity qualifier has also been
developed to identify the highest probable level of
functioning that a person may reach in a given
domain at a given moment (WHO, 2001, p. 123).
By aligning capacity with a persons ability in the
clinic room there is the risk that clinicians may either
assume that a persons highest probable level of
functioning can always be revealed in the clinic
setting or alternatively, that this aspect of capacity
may be overlooked or lost.
Whether or not the Activities and Participation
component of the ICF is believed to represent one
underlying construct or two will have implications
for future developments of the ICF. If it is agreed
that the Activities and Participation component
represents two different constructs then future
versions of the ICF will separate Activities and
Participation components and each component will
have a separate set of domains, items and qualifiers.
If it is decided that the Activities and Participation
component represents the one construct, then future
versions of the ICF may still choose to represent the
individual and societal perspectives of functioning
and disability by separate domains, items and
qualifiers or may continue with the single list.
However, if the Activities and Participation compo-
nent continues to be represented by a single list of
domains, items and qualifiers, there is the risk that
this component will begin to be conceptualized and
clinically interpreted to mean one perspective. The
qualitatively different perspectives of functioning and
disability at the level of the individual and at the level
of society may become blurred and the potential
avenues for assessment and intervention may be-
come more limited as a result. The challenge for
speech-language pathologists is to debate what these
different perspectives mean for our clients, so that we

can continue to develop our understanding of
communication functioning and disability from both
activities and participation perspectives. The discus-
sion of activities and participation in general,
provides a platform upon which to specifically
explore the separate qualities of communication
activities and communication participation, and
these are described below.
Communication Activities
A review of functional communication assessments
and the Activities and Participation component of the
International Classification of Impairment, Disability
and Handicap beta draft (ICIDH-2), the preliminary
version to the ICF, was recently conducted by
Worrall and colleagues (Worrall, McCooey,
Davidson, Larkins, & Hickson, 2002). This article
reviewed the ICIDH-2, described three participant
observation studies of everyday communication and
summarized currently available measures of func-
tional communication. Whilst the observation stu-
dies have been reported in more detail elsewhere
(Davidson, Worrall, & Hickson, 2003; Larkins,
Worrall, & Hickson, 1999; OHalloran, Worrall, &
Hickson, 2007) they are discussed here in relation to
what they can tell us about the nature of commu-
nication activities. The three participant observation
studies described the everyday communication activ-
ities that occur in the lives of people with and without
aphasia, people with and without traumatic brain
injury (TBI) and people with and without commu-
nication disabilities who are patients in hospital.
These observation studies suggested that commu-
nication activities have some but not all of the
characteristics identified in the discussions about
activities described above. Some of the character-
istics of communication activities that are consistent
with general descriptions of activities are that the
communication activities were carried out by an
individual, they were externally observable by a
clinician and could be described in terms of actions.
In addition, it is possible that a persons capacity to
carry out most, if not all of these communication
activities, such as, explaining a problem, introducing
and giving instructions, could be assessed in a
standardized, uniform clinical environment.
However, these studies also indicated that com-
munication activities differ from an evolving under-
standing of the ICF definition of activities in some
important ways. Firstly, the communication activities
that were observed ranged from very simple such as
greeting, gaining his/her attention to very complex
such as explaining a problem, and selling. Secondly,
and not surprisingly these studies also found that
whilst some communication activities can be per-
formed alone such as watching television, doing
crosswords and studying, most communication
activities, by their very nature, involve others such
as asking for assistance, answering phone calls and
ICF Activities and Participation 23
telling personal details. Finally, given that many
communication activities were carried out with
others, the ability of a person to carry out a
communication activity is very dependent on the
communicative environment, such as the commu-
nication partner, rather than less so.
The ICF states that a persons ability to undertake
activities can be described in terms of his/her
performance and capacity. As described above, the
performance qualifier describes what an individual
does in his or her current environment (WHO,
2001). Therefore, a persons communication activity
performance describes a persons ability to carry out
communication activities in his/her current envi-
ronment. Communication measures such as the
American Speech-Language-Hearing Association
Functional Assessment of Communication Skills for
Adults (ASHA-FACS; Frattali, Thompson, Holland,
Wohl, & Ferketic, 1995) and the Communicative
Effectiveness Index (CETI; Lomas et al., 1989)
measure how well the person actually communicates
in everyday life and therefore most closely approx-
imate communication performance.
The capacity qualifier describes an individuals
ability to execute a task or action. The ICF states that
a persons optimal ability is determined in a
standardized or uniform environment (WHO,
2001). This suggests that a persons communication
capacity, that is his/her optimal ability to carry out
communication activities is revealed in a standar-
dized or uniform environment. However this pre-
sents a problem. Given that a persons ability to carry
out communication activities is to a large extent
dependent on his/her communicative environment,
then a persons optimal ability to carry out commu-
nication activities is unlikely to be revealed in a
standardized or uniform environment, rather it is
more likely to be revealed in a facilitative commu-
nicative environment (Kagan, 1995). Thus, the ICF
definition of capacity is more complex for speech-
language pathologists. A clinician seeking to under-
stand a persons communication activity capacity in a
standardized, uniform environment may administer a
measure such as the Communication Activities of Daily
Living (CADL-2; Holland, Frattali, & Fromm,
1998) in the clinic room. The persons communica-
tion activity limitation would be described in terms
of the second qualifier capacity without assistance.
In contrast, a clinician seeking to understand a
persons communicative capacity in terms of his/her
optimal communication ability would need to observe
the person communicating within an optimally
facilitative communicative environment. The per-
sons communication activity limitation capacity
would be described in terms of the third qualifier
capacity with assistance. In some cases, the
support needed by the person to communicate
optimally may not be available in the clinic and
the clinician would need to observe the person
communicating in this facilitative communicative
24 R. OHalloran & B. Larkins
environment. An example of an environment that
could not be re-created in a clinic room is a client
playing a card or board game with old friends. In
such a familiar well practiced setting with the usual
persons involved, the client could demonstrate
abilities that a clinician might be surprised to see.
One measure that describes a persons optimal ability
to communicate, or capacity with assistance, in a
facilitative communicative environment is the In-
patient Functional Communication Interview (IFCI;
OHalloran, Worrall, Toffolo, Code, & Hickson,
2004). This measure is designed so that the clinician
can try out different communication strategies, such
as using gesture, reducing syntactic complexity and/
or repetition during the administration of the inter-
view in order to optimize the persons ability to
communicate his/her healthcare needs when he/she is
a patient in hospital.
An additional issue is that when communication
behaviours are observed, they are described in very
different ways from those in the communication
domain in the Activities and Participation compo-
nent. As an example, the three observation studies
described previously, conceptualized communica-
tion activities primarily in terms of the purpose of
the communication activity. The purpose of the
communication activity was described in two differ-
ent ways, either in terms of the overall function of the
communication, that is whether the communication
was transactional, interactional or both (Davidson,
Worrall, & Hickson, 2003; Simmons-Mackie &
Damico, 1996) or alternatively in similar ways to
speech acts such as asking, telling, and describing
(Larkins, Worrall, & Hickson, 1999; OHalloran
et al., 2007). Further descriptive detail about the
communication behaviours included information
about the persons communication partner, the
duration of the communication, the setting and the
topic. Finally the type of communication behaviours
that were observed varied across people with
different types of communication impairment, peo-
ple from different cultural backgrounds and people
in different settings (Worrall et al., 2002).
It is important to note that these observation
studies were conducted with adults with and without
acquired communication disabilities. Observation
studies of the communication activities of children
and adults with different types of communication
disabilities will further develop our understanding of
the nature of authentic communication activities.
Communication Participation
Developments in the concept of communication
participation are consistent with the ICF concept of
participation where participation is closely aligned
with the social model of disability, focused on the
consumer, concerned with the persons social roles
and measured, where possible, by the individual him/
herself (Whiteneck, 2006).
The ICF concept of participation is perhaps best
embodied in aphasia by the social approach. The
social approach encourages clinicians to emphasize
the perspective of the person with aphasia, to
consider the social and personal consequences of
aphasia and to explore ways in which the persons
social and physical environment can be modified so
that he/she is more likely to experience successful
communicative interactions (Simmons-Mackie,
2000, 2001). Similarly, the Life Participation Ap-
proach to Aphasia describes ways to develop speech
pathology services that support individuals with
aphasia and others affected by aphasia in achieving
their immediate and longer term life goals (Chapey
et al., 2001). The needs and aspirations of the
individual with aphasia is central to the social
approach and the life participation approach and
this quality is also embedded within a revised
definition of functional communication as being
able to communicate competently, through your own
communication skills and those of others, and feeling
comfortable that you are representing who you are
(Byng, Pound, & Parr, 2000, p. 53).
Participation has also been defined in the research
literature in various ways. For example, healthcare
participation has been defined as how involved
people (with communication disabilities) are in
decisions about their healthcare. The barriers and
facilitators that people with different kinds of
communication disabilities and health and social
care staff experienced in health care decision making
were described through qualitative interviews (Byng,
Farrelly, Fitzgerald, Parr & Ross, 2005). Resident
participation in aged care facilities has also been
investigated. Resident participation was defined as
being involved in and consulted about matters that
range from day to day care to broad policy (Hickson,
Worrall, Wilson, Tilse, & Setterland, 2005). A range
of measures was used to describe residents activities
and participation, including clinician rated measures,
surveys, and questionnaires. The authors found that
the surveys and questionnaires that directly investi-
gated the residents opinions and experiences pro-
vided the most useful insights into resident
participation (Hickson et al., 2005). Social participa-
tion has also been measured by the extent of peoples
social networks and the range and frequency of their
social activities (Cruice, Worrall, & Hickson, 2005)
and the change in a persons conversation styles and
opportunities as measured on the Conversational
Analysis Profile for People with Aphasia (CAPPA;
Whitworth, Perkins, & Lesser, 1997) has also been
considered evidence of a persons life participation
(Ross, Winslow, Marchant, & Brumfitt, 2006).
Finally, a recent review of communication parti-
cipation measures also provides insights into the
concept of communication participation. In that
review, only measures that specifically targeted
communication functioning, described communica-
tion exchanges involving more than one person and

were rated by the person with the communication
disability were included (Eadie et al., 2006). Six
measures underwent full review. These included four
measures of voice as well as the ASHA Quality of
Communicative Life scale (Paul et al., 2004) and the
Burden of Stroke Scale (Doyle, McNeil, & Hula,
2003). The authors concluded that no existing
instrument adequately measured communicative
participation in its entirety.
The concept of communication activities shares
some characteristics of the ICF concept of activities,
in that they can be simple, observable and assessed in
a clinic situation and some characteristics of the ICF
concept of participation, in that they can also be
complex, dependent on the environment and are
usually performed with others. However the concept
of communication participation sits well within the
ICF concept of participation. This leads to the
question: Are the concepts of communication
activity and communication participation actually
distinct in any way? One way in which they appear to
be distinct is in how they are measured. Commu-
nication activities can be counted. Furthermore a
persons ability to undertake communication activ-
ities can be observed and described by a third person.
However communication participation seems ulti-
mately to be a subjective experience. Only people
themselves can say if they feel they can express who
they truly are in social interactions, how much they
enjoy and feel included in a social situation, how
much they feel listened to and involved in their
own healthcare or how much they are accepted
and valued where they live. Measures that identify
how meaningful and relevant the life situations are
for the person with a communication disability
and measures that describe the persons subjec-
tive experience communicating in these life situa-
tions seem key to understanding communication
participation.
Summary
This paper has explored the ICF concepts of
Activities and Participation with a particular empha-
sis on how these two concepts relate to each other
and how they have been operationalized in research
with adults with acquired communication disability.
Although the ICF presents Activities and Participa-
tion as a single component with a single list of
domains, the ICF states that the Activities and
Participation component represents two different
perspectives on functioning and disability. The
qualitative differences between Activities and Parti-
cipation are becoming clearer. The challenge for
speech-language pathologists is to engage in this
exploration. Not only will this assist the developers of
future versions of the ICF to more accurately
represent communication, but it will inform our
clinical efforts as we continue to support our clients
in having a say in their lives.
ICF Activities and Participation 25
References
Australian Institute of Health and Welfare (AIHW) (2003). ICF
Australian user guide. Version 1.0. Canberra: Australian Institute
of Health and Welfare.
Australian Institute of Health and Welfare (AIHW) (2007).
Personal communication: catherine.sykes@aihw.gov.au.
American Psychological Association, World Health Organization
(2003). International Classification of Functioning, Disability and
Health. Procedural Manual and Guide for a Standardized
Application of the ICF: A Manual for Health Professionals- Sample
and Prototype. Washington, DC: American Psychological
Association.
American Psychological Association, World Health Organization
(in press). International Classification of Functioning, Disability
and Health. Procedural Manual and Guide for a Standardized
Application of the ICF: A Manual for Health Professionals.
Washington, DC: American Psychological Association.
Byng, S., Cairns, D., & Duchan, J. (2002). Values in practice and
practising values. Journal of Communication Disorders, 35, 89
106.
Byng, S., Farrelly, S., Fitzgerald, L., Parr, S., & Ross, S. (2005).
Having a say: Promoting the participation of people who have
communication impairments in health care decision-making.
Retrieved from http://www.healthinpartnership.org/publications/
byng/byng-final.html on 14 November 2005.
Byng, S., Pound, C., & Parr, S. (2000). Living with aphasia: A
framework for therapy interventions. In I. Papathanasiou (Ed.),
Acquired neurogenic communication disorders: A clinical perspective
(pp. 49 75). London: Whurr Publishers.
Chapey, R., Duchan, J., Elman, R., Garcia, L., Kagan, A., Lyon,
J., & Simmons-Mackie, N. (2001). Life participation approach
to aphasia: A statement of values for the future. In R. Chapey
(Ed.), Language intervention strategies in aphasia and related
neurogenic disorders (4th ed.). Baltimore, MD: Lippincott,
Williams & Wilkins.
Cruice, M., Worrall, L., & Hickson, L. (2005). Personal factors,
communication and vision predict social participation in older
adults. Advances in Speech-Language Pathology, 7, 220 232.
Davidson, B., & Worrall, L. (2000). The assessment of activity
limitations in functional communication: Challenges and
choices. In L. Worrall & C. Frattali (Eds.), Neurogenic
communication disorders: A functional approach (pp. 19 34).
New York: Thieme.
Davidson, B., Worrall, L., & Hickson, L. (2003). Identifying the
communication activities of older people with aphasia:
Evidence from naturalistic observation. Aphasiology, 17,
243 264.
Doyle, P., McNeil, M., & Hula, W. (2003). The Burden of Stroke
Scale (BOSS): Validating patient-reported communication
difficulty and associated psychological distress in stroke
survivors. Aphasiology, 17, 291 304.
Eadie, T., Yorkston, K., Klasner, E., Dudgeon, B., Deitz, J.,
Baylor, C., Miller, R., & Amtmann, D. (2006). Measuring
communicative participation: A review of self-report instru-
ments in speech-language pathology. American Journal of
Speech-Language Pathology, 15, 307 320.
Frattali, C. (2000). Health care restructuring and its focus on
functional outcomes in the United States. In L. Worrall, &
C. Frattali (Eds.), Neurogenic communication disorders: A
functional approach (pp. 67 80). New York: Thieme.
Frattali, C., Thompson, C., Holland, A., Wohl, C., & Ferketic, M.
(1995). American Speech-Language-Hearing Association func-
tional assessment of communication skills for adults (ASHA
FACS). Rockville, MD: ASHA.
Hickson, L., Worrall, L., Wilson, J., Tilse, C., & Setterland, D.
(2005). Evaluating communication for resident participation in
an aged care facility. Advances in Speech-Language Pathology, 7,
245 257.
Holland, A., Frattali, C., & Fromm, D. (1998). Communication
activities of daily living (2nd ed.). Austin, TX:
Pro-Ed.
26 R. OHalloran & B. Larkins
Kagan, A. (1995). Revealing the competence of aphasic adults
through conversation: A challenge to health professionals.
Topics in Stroke Rehabilitation, 2, 15 28.
Kagan, A., Simmons-Mackie, N., Rowland, A., Huijbregts, M.,
Shumway, E., McEwen, S., Threats, T., & Sharp, S. (2007).
Counting what counts: A framework for capturing real-life
outcomes of aphasia intervention. Aphasiology, iFirst article.
Retrieved 14 May 2007, from http://www.informaworld.com/
10.1080/02687030701282595.
Larkins, B., Worrall, L., & Hickson, L. (1999). Everyday
communicative activities for individuals with traumatic brain
injury living in New Zealand. Asia-Pacific Journal of Speech
Language and Hearing, 4, 183 191.
Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., &
Zoghaib, C. (1989). The communicative effectiveness index:
Development and psychometric evaluation of a functional
communication measure for adult aphasia. Journal of Speech
and Hearing Disorders, 54, 113 124.
OHalloran, R., Worrall, L., & Hickson, L. (2007). Development
of a measure of communication activity for the acute hospital
setting: Part I. Rationale and preliminary findings. Journal of
Medical Speech-Language Pathology, 15, 39 50.
OHalloran, R., Worrall, L., Toffolo, D., Code, C., & Hickson, L.
(2004). Inpatient Functional Communication Interview. Oxon:
Speechmark.
Paul, D., Frattali, C., Holland, A., Thompson, C., Caperton, C.,
& Slater, S. (2004). The American Speech-Language-Hearing
Association Quality of Communication Life Scales (QCL):
Manual. Rockville, MD: American Speech-Language-Hearing
Association.
Reed, G., Lux, J., Bufka, L., Trask, C., Peterson, D., Stark, S.,
Threats, T. T., Jacobson, J. W., & Hawley, J. A. (2005).
Operationalizing the International Classification of Function-
ing, Disability and Health (ICF) in Clinical Settings. Rehabi-
litation Psychology, 50, 122 131.
Ross, A., Winslow, I., Marchant, P., & Brumfitt, S. (2006).
Evaluation of communication, life participation and psycholo-
gical well being in chronic aphasia: The influence of group
intervention. Aphasiology, 20, 427 448.
Simmons-Mackie, N. (2000). Social approaches to the manage-
ment of aphasia. In L. Worrall, & C. Frattali (Eds.), Neurogenic
communication disorders: A functional approach (pp. 162 187).
New York: Thieme.
Simmons-Mackie, N. (2001). Social approaches to aphasia inter-
vention. In R. Chapey (Ed.), Language intervention strategies in
aphasia and related neurogenic communication disorders (4th ed.,
pp. 246 268). Baltimore, MD: Lippincott, Williams & Wilkins.
Simmons-Mackie, N., & Damico, J. (1996). Accounting for
handicaps in aphasia: Communicative assessment from an
authentic social perspective. Disability and Rehabilitation, 18,
540 549.
Tarvydas, V., Peterson, D., & Michaelson, S. (2005). Clinical
decision-making and ethical issues in case management. In
F. Chan, M. Leahy, & J. Saunders (Eds.), Case management for
rehabilitation health professionals (2nd ed., pp. 144 175). Osage
Beach, MO: Aspen Professional Services.
Threats, T. T. (2008). Use of the ICF for clinical practice in
speech-language pathology. International Journal of Speech-
Language Pathology, 10, 50 60.
Whiteneck, G. (2006). Looking ahead: A critique of the
ICF with recommendations for environmental factors. North
American Collaborating Center (NACC) Conference. Living in
our environment: The promise of the ICF. Retrieved from http://
www.icfconference.com/prog_pres.html on 5 July 2007.
Whitworth, A., Perkins, L., & Lesser, R. (1997). Conversational
analysis profile for people with aphasia. London: Whurr
Publishers.
World Health Organization (WHO) (1980). International Classifi-
cation of Impairments, Disabilities, and Handicaps. Geneva:
World Health Organization.
World Health Organization (WHO) (2001). International Classifi-
cation of Functioning, Disability and Health. Geneva: World
Health Organization.
Worrall, L. (2000). The influence of professional values on the
functional communication approach in aphasia. In L. Worrall,
& C. Frattali (Eds.), Acquired neurogenic disorders: A functional
approach (pp. 191 205). New York: Thieme.
Worrall, L., McCooey, R., Davidson, B., Larkins, B., & Hickson,
L. (2002). The validity of functional assessments of commu-
nication and the Activity/ Participation components of the
ICIDH-2: do they reflect what really happens in real-life?
Journal of Communication Disorders, 35, 107 137.
Ylvisaker, M., Jacobs, H., & Feeney, T. (2003). Positive
supports for people who experience behavioural and cogni-
tive disability after brain injury. Journal of Head Trauma, 18,
7 32.
Ylvisaker, M., Szekeres, S., & Feeney, T. (2001). Communication
disorders associated with traumatic brain injury. In R. Chapey
(Ed.), Language intervention strategies in adult aphasia (4th ed.,
pp. 745 808). Baltimore, MD: Lippincott, Williams &
Wilkins.