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Occupational Therapy International, 10(4), 253-268, 2003 © Whurr Publishers Ltd 253

Concepts in occupational therapy

in relation to the ICF

LENA HAGLUND Department of Neuroscience and Locomotion, Section of

Occupational Therapy and Section of Psychiatry, Faculty of Health
Sciences, Linköping University, Sweden
CHRIS HENRIKSSON Department of Neuroscience and Locomotion,
Section of Occupational Therapy, Faculty of Health Sciences, Linköping
University, Sweden.

ABSTRACT: Occupational therapists need an acceptable terminology to describe a

client’s clinical performance. The language or terminology must be in harmony with
common language in the health care system but also reflect occupational therapists’
professional responsibility. The aim of this paper is to help clarify similarities and
differences between concepts in occupational therapy and the International Classifi-
cation of Functioning, Disability and Health (ICF). Two studies were completed in
which items in the International Classification of Impairments, Disabilities and
Handicaps (ICIDH-2) were compared with concepts from the Swedish version of the
assessment of Motor and Process Skills (AMPS) and the Assessment of Communi-
cation and Interaction Skills (ACIS-S). An expert panel of occupational therapists
served as raters and 33 clients with learning disabilities and mental health problems
were assessed. The result showed that 12 (60%) of the skills items from the ACIS-S
were found to be equivalent to items in then ICIDH-2. In total, 41% (n = 23) of the
items in the AMPS or ACIS-S have a correlation higher then 0.60 with the ICIDH-2.
The classification can serve as a useful tool for occupational therapists and supports
communication between professions, but is not sufficient as a professional language for
occupational therapists. Further research is indicated to examine how the ICF can be
applied in occupational therapy and its implications on clinical practice.

Key words: International Classification of Functioning, Disability and Health

(ICF), occupational therapy terminology, Assessment of Motor and Process
Skills (AMPS), Assessment of Communication and Interactions Skills
(ACIS-S)
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254 Haglund and Henriksson

Introduction

Occupation has always been a central concept in occupational therapy. The

concept denotes intentional actions performed by a human being. It also has a
close relation to doing. In the most recent version of the International Classifi-
cation of Functioning, Disability and Health, (ICF; WHO, 2001) human
functioning is one of the central concepts, which rehabilitation professions
can very easily adopt and understand (Grimby, 2001; McLaughlin Gray, 2001).
The development of the international classification started in 1973 when the
WHO commissioned Philip Wood to identify a classification system, which
resulted in the publication ‘Impairments, Disabilities and Handicaps’ (WHO,
1980). After years of discussion and revision the document was accepted by
the WHO in 1993 under the name of International Classification of Impair-
ments, Disabilities and Handicaps (ICIDH). This document has been further
revised, and the final draft, adopted by the World Health Organization
(WHO) in spring 2001, is the International Classification of Functioning,
Disability and Health (ICF). Since its first publication the ICIDH/ICF has
been used as a statistical, research and clinical tool, in planning and designing
social policy, and for educational purposes (WHO, 2001). The overall aim is to
provide a unified language to describe healthy human functioning and health-
related states, outcomes and determinants, which can be used worldwide by
health and social service professions. The classification is related to health
conditions and is not disease- or aetiology-specific.
The latest version of the ICF addresses body, individual and societal levels.
The information is organized in two parts: Functioning and Disability, and
Contextual Factors. The first part, Functioning and Disability, has two compo-
nents: (1) Body Functions and Structures, and (2) Activities and
Participation. The second part, Contextual Factors, is also divided into two
components: (1) Environmental Factors, and (2) Personal Factors. All compo-
nents except Personal Factors are divided into domains. Body Functions and
Structures, for example has two domains: body functions, which covers physio-
logical and psychological function of the body systems, and body structures,
which refers to body organs and limbs. Body Functions are divided into
chapters such as mental functions, sensory functions and pain, and voice and
speech functions. Each domain is divided into categories and subcategories,
the units of classification. Thus the mental functions domain is divided into
categories such as global mental functions and specific mental functions,
which in turn are divided into subcategories such as consciousness functions,
orientation functions, intellectual functions, and temperament and personality
functions. The subcategories are sometimes further divided into lower levels.
The classification is excellent for communicating resources and limitations
in an individual’s ability to manage actions, activities and participation in
everyday life. The classification can be easily understood and applied at more
or less detailed levels depending on the need to study or understand activity.
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Concepts in occupational therapy 255

The primary aim of the classification is to identify health-related abilities,

and limitations or restrictions in daily life situations. The ICF can be
combined with other classification systems when different aspects or levels
need to be described. The purpose of this study is to demonstrate how the
vocabulary of ICF can be used together with additional occupational therapy
terminology when an individual’s limitations need to be further analysed by
the occupational therapist. The component activities and participation does
not distinguish between what can be described as single actions and what are
more demanding and complicated activities, for example, lifting versus
furnishing a place to live. All domains in the activities and participation
component have activities at many levels of complexity. Some are demanding
as they require complicated and co-ordinated efforts involving many different
functions and structures. The ICF classification is structured on categories of
functions, activities or participation rather than on the complexity of actions.
All items within the domains can be further explained by using a generic
quantified scale where 0 means ‘no problem’, 1 ‘mild problem’, 2 ‘moderate
problem’, 3 ‘severe problem’ and 4 ‘complete problem’. There are two
additional qualifiers for ‘unspecified’ and ‘not applicable’.
The aim of this paper is to contribute to the discussion and to clarify
similarities and differences with respect to certain concepts in occupational
therapy and the ICF. In an article, McLaughlin Gray (2001) presents an
overview of the ICIDH-2 and states that future research projects related to the
classification and to categories and concepts in occupational therapy are
needed to increase the profession’s understanding. She also notes that when
the ICIDH-2 is introduced to occupational therapists, many of them respond,
‘This is occupational therapy language’ or ‘This is what we are measuring’.
The terminology used in occupational therapy and in the ICF is very often
the same, but do the words have the same meaning, or does a concept in
occupational therapy have an underlying assumption that the ICF classifi-
cation does not reflect? If the categories and concepts are related to each other,
how will this influence the development of occupational therapy in the future?
And if they are not related how will that affect communication? Can one
profession have its own interpretation of a concept, and not share the interpre-
tation with other professions in the health care system? Is ICF a result of
normal, ordinary language used in society, and have occupational therapists
developed a special connotation concerning certain concepts, which may raise
language barriers between professions? If so, is it only occupational therapists
that have these problems?
We will start our discussion about the relationship between categories
in ICF and occupational therapy by clarifying the meaning of some
existing theoretical concepts in occupational therapy and applying them in
the light of ICF.
The ICF classification has numerous categories, many of which cover
functions and activities that occupational therapists use for describing
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256 Haglund and Henriksson

functions and disabilities in clients’ everyday lives. It is important that we

study the classification system and learn how to use it in everyday clinical
work. The ICF provides a systematic and specific language as well as a rating
system that can benefit both professional growth and clients. By using a
detailed classification we can observe, document and grade activities and
participation more distinctly. However, the ICF classification is sometimes
not sufficient for detailed analyses at a level required for deeper under-
standing of a client’s performance. When seeking knowledge, additional
specific terminology is required in order to understand not only what can and
cannot be managed to various degrees, but also why it cannot be managed
and how a limitation can be compensated for or treated. For example, an
occupational therapist may need to analyse an occupation at a more detailed
level in order to observe, describe and understand why a client has diffi-
culties in performing tasks and roles as satisfactorily as prior to an accident or
an illness. Concepts for naming different aspects of an activity presented by
Haglund and Henriksson (1995), building on Nordenfelt (1987), may be
combined with the ICF and can be a useful tool for reaching a deeper under-
standing of why certain difficulties are present. The concepts in the article
were action, single action, generated action, action sequences, operations,
simultaneous actions and activity.
An action is an intentional, goal-directed movement. A single action
cannot be divided into further actions; it is the lowest level of performance. A
single action is the smallest functional unit that can be seen and analysed at an
individual level. Any further attempt to break the action of a movement into
smaller parts would mean that the action perspective would be replaced by a
body function and structure perspective. For example, we can observe if the
individual can lift an object, but cannot observe muscle strength. Muscle
strength has to be measured separately.
A single action can generate other actions, a generated action. Such an
action, once started, cannot usually be stopped or interrupted. For example, ‘by
pressing the button she opened the door’ is an example of a generated action.
This concept is useful, as occupational therapists often try to find ways to
compensate for a limitation in function by technical innovations, such as
when pressing a button the lift helps the person to reach an upright position.
By using a generated action, less demand is made on the actor.
An action sequence is a number of consecutive actions and can be
composed of single actions, generated actions and a combination of the two.
The actions are carried out in a specific temporal order and are more or less
automated. A more well-known task can be performed through a longer
action sequence than a less well-known task as more control is needed to
manage the latter. Examples of this can be seen when learning to ride a
bicycle, or finding the way to a new address. At first different movements
have to be performed separately, monitored carefully and performed with
more or less concentration. When a person knows how to ride a bicycle or
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Concepts in occupational therapy 257

knows the way to a new address performance becomes automatic and the
person can concentrate on other things.
An action with a certain goal can be carried out in many different ways
depending on the contextual factors. The way the action is performed may be
varied through modification of some of the movements of the action. The
action is thus performed slightly differently through the use of modifications,
which are called operations. Operations are variations in the way an action is
performed. They have no goals of their own but are adaptations made in the
actions to perform them more easily, more efficiently, or in a personally
preferred fashion.
Simultaneous actions contain several actions and action sequences
performed at the same time. The last concept described in the article was
activity, defined as a cluster of actions with an overriding conscious goal. The
action terminology can sometimes be useful as a supplement to the ICF termi-
nology when there is a gap in the terminology in ICF in the domain, body
functions. In Chapter 7 of ICF, in the section on body functions, neuromuscu-
loskeletal and movement-related functions are described and in Chapter 4 of
the section on activities and participation, activities are described. The
functions of joints, bones and muscles can certainly hinder movement and
thus activity, if there are impairments, but there may also be activity diffi-
culties without any observable limitations in the neuro-musculoskeletal and
movement-related functions mentioned in Chapter 7.
Furthermore, in Chapter 2 on general tasks and demands, in the activity
and participation section, there are items to categorize undertaking a simple
task or complex task, independently or in a group. However, if the classifi-
cation is used in clinical settings, it is sometimes also necessary to be able to
describe what is observed in the performance at a more detailed level.

Application of an action terminology in a therapeutic situation

Let us exemplify the action concepts in relation to two cases: A woman aged
39, with a husband and two children aged 15 and 11, is assessed. She has only
slight difficulties in self-care activities, for example, with washing her hair. For
the time being she is unable to work and in domestic activities she has severe
difficulties managing her household tasks. We can note that in all the fields of
domestic activities there are some to severe difficulties. Nothing is a complete
inability, but there are obvious difficulties in performing tasks such as getting
lunch ready in time or in organizing her work. We may observe the woman in
action and interview her, or use a diary to monitor daily activity patterns. We
may conclude that even though she can manage most of the different tasks,
she has great difficulties in performing to a satisfactory level.
In ICF terms we can further classify and communicate what we find. The
limitations we observe are found in the chapter on domestic life. If we proceed
to the second category we note that this woman has problems with household
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258 Haglund and Henriksson

tasks. Further subcategories cover preparing simple or complex meals, doing

housework such as washing and drying clothes and cleaning living area. Since
the woman has difficulties in carrying out these tasks, we find in Chapter 2,
under general tasks and demands, there are further terms and qualifiers for
describing the limitations. The problems can be described in terms such as
completing multiple tasks, completing daily routines and handling crises. The
ICF classification has thus a terminology that can communicate more detailed
information than ‘problems in household activities’.
However, when we want to understand why she has problems, we may need
to use a different and more detailed analysis. If we use the action terminology
presented above, we find that she can perform the single actions involved in
most tasks, but the actions are performed with effort, and she seems to be aware
of every movement she has to perform. The actions are not performed
routinely, but carefully and with attention. Action sequences are few and
usually one single action follows the next. Described in words, ‘First I take a
potato, then I peel it, I then take a knife and cut the potatoes in portions, put
them in a saucepan, pour on water, put it on the stove and turn up the heat. I
then get the frying pan…’, etc. The task is made up of single actions, where the
actor has to concentrate and expend effort on almost every step of the perfor-
mance (Figure I, see Pattern A).
A person would normally perform household tasks in action sequences
where a decision is made to prepare the potatoes for dinner and proceeds more
or less automatically with all the actions without hesitation and with little
concentration on the task (Figure I, see Pattern B). People who work with
habitual skills in their own well-known environment often have several simul-
taneous ongoing actions and action sequences. At the same time as the
potatoes are prepared a person may be listening to the radio, receiving a
telephone call, frying the meatballs and talking to the children about their day
(Figure I, see Pattern C).
Through operations the action is adapted to current circumstances and to
preferred routines. Operations, for example, are seen in the different ways a
person handles a peeler when peeling small or large potatoes or different
vegetables, the variations in the way different people support themselves when
doing a job, or the individual differences in handling objects or processes.
Moreover, the observed operations can give valuable information about condi-
tions such as pain, muscle weakness or stiffness.
In the household activities just discussed, the person had no obvious diffi-
culties, in ICF terminology, in orientation, motivation, energy and drive, or
memory. Neither had she any difficulties in mobility of joints, stability or
muscle power function. However, she did have problems performing tasks and
major life activities, in this particular case due to continuous muscular pain. By
using the action terminology we can see that she performs her tasks mainly in
single actions and can also hypothesize that she has limitations, in ICF termi-
nology, in attention functions, perhaps in dividing attention or sustaining
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Concepts in occupational therapy 259

Pattern A 1
Single actions 2
3
4
5
6
7
8

i
ii
iii
iv
v

Pattern B 12345678 = prepare potatoes for dinner

Action sequence i ii iii iv v vi = fry the meatballs
ABCDEF = supervise a 2-year-old child playing in
the kitchen

Pattern C 12345678
Simultaneous actions i ii iii iv v vi
ABCDEF

FIGURE 1: Actions terminology in relation to performing tasks. The figure shows how perfor-
mance of a task can be conceptualised in its different parts. Pattern A is performed totally by
single actions, whereas action sequences are used in pattern B. Pattern C indicates how single
and actions sequence are used simultaneously.

attention. This woman has chronic pain and we know from many studies that
pain interferes both with muscular function and cognitive function. By using
the action terminology this can be observed and documented. The ICF can be
used in conjunction with further special terminology without problems.
Another person might have limitations after a stroke. This person also has
difficulties in performing general tasks and demands. He has problems in
undertaking a single task, but also in many mobility categories. In order to
observe and describe in ICF terminology what difficulties the person has, the
occupational therapist could investigate the actions of the person. The perfor-
mance may show that mainly single actions are used and that this may be due
to difficulties in fine hand use, co-ordination of voluntary movements or to
Chapter 1 mental functions in organisation and planning, problem solving,
energy and drive functions, or motivation.
In addition to ICF, other terminology and instruments used in occupational
therapy or in related knowledge domains can be used to describe what is
observed. Instruments such as the Assessment of Motor and Process Skills
(AMPS; Fisher, 1997; 1999) may be applied for evaluating the different motor
and process skills necessary for managing activities satisfactorily. Further, the
Assessment of Communication and Interaction Skills (ACIS; Haglund and
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260 Haglund and Henriksson

Kjellberg, 1998) may offer a structured method of evaluating communication

and relational skills. Both these instruments are based on a theoretical model
that will help the therapist to interpret the results in such a way that imple-
mentation of suitable treatment may be offered. However, in addition to these
and other instruments the action terminology for analysing activities in
actions, action sequences, and operations may be helpful to understand and
describe what is disrupting the flow of the activity pattern.

Empirical studies

Methods

In order to investigate how different assessments in occupational therapy are

related to the ICIDH-2, (Swedish version) two different empirical studies were
performed in which the items in the ICIDH-2 were compared with concepts
from the Swedish versions of the instruments, AMPS and ACIS-S.
Both instruments are based on the model of human occupation
(Kielhofner, 1995). The model offers an understanding of the nature of
human occupation. It emphasizes the understanding of ‘how, when, and why
humans engage in occupation’. It presents thoughts about motivation and
choice of participation in different occupations and how these are organized
into routines and habits. The performance of occupations requires skills
which are observable. The model also emphasizes and discusses how different
aspects of the environment influence occupation. The different skills, which
are operational concepts in relation to the model, are motor, process, commu-
nication and interactions skills.
AMPS is frequently used in both practice and research in occupational
therapy (Fisher, 1997; 1999). It evaluates observable motor and process skills,
based on a four-point rating scale. The instrument covers 36 items in total; 16
items related to motor skills and 20 to process skills. The items are well defined
in the manual. The client is observed when performing two or three well-
known activities. The activities are standardized and described in a manual. In
order to use AMPS properly the occupational therapist first has to attend a
training course. In the present study the Swedish translation of AMPS,
Editions 2 and 3 have been used.
The ACIS and the ACIS-S, which has been used in this study, are still
under development (Kjellberg et al., 2003). The instrument covers commu-
nication and interaction skills, and has a four-point rating scale with 20
items related to three domains: physicality (6 items); information exchange
(9 items); and relations (5 items). The client is observed during activities
performed together with others. For both instruments a score of 4 means ‘no
problems’, 3 ‘questionable problems’, 2 ‘interferes with performance’, and a
score of 1 is used when the skills are so deficient as to cause an
‘unacceptable result’.
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Concepts in occupational therapy 261

Study I

An expert panel identified which categories in the dimension Activity,

ICIHD-2 (Swedish version), were related to concepts in the AMPS and the
ACIS-S. The expert panel consisted of six occupational therapists, all with
good knowledge of the model of human occupation and skilled in using the
AMPS and ASIC-S. The ICIDH-2 was introduced at a meeting where the aim
of the study was presented. The experts received a copy of the Activity
dimension of ICIDH-2 (Swedish version) and were asked to fill out, in the
right margin, which concepts from AMPS or ACIS-S they understood to
mean the same thing as the ICIDH-2 categories. They performed this task over
a two-week period and were requested to have no contact with each other. All
relationships identified by the individual occupational therapist between the
categories in ICIDH-2 and the two instruments are included in the results
presented in this article.

Study II

Subjects
In total 33 clients with learning disabilities or mental health problems were
assessed using ( 1) the Activity dimension of ICIHD-2 (Swedish version), (2)
AMPS, and (3) ACIS-S.
Nine clients were assessed with ICIDH-2, ACIS-S and AMPS, 11 with
the ICIDH-2 and AMPS, and 13 with ICIDH-2 and ACIS-S (Table 1). Each
client was rated only once with ICIDH-2.
Seventeen clients were rated with the AMPS in two or more situations
and three clients were rated in two situations with the ACIS-S. If the
ratings of a skill varied in the different situations, the lowest rating was

Table I. Number of clients rated with each assessment instrument (n = 33)

ICIDH-2 AMPS ACIS

(n) (n) (n)

Clients with 2 2 2
learning disabilities 11 – 11
8 8
Total 21 10 13

Clients with mental 7 7 7

health problems 2 – 2
3 3
Total 12 10 9

Overall total 33 20 22
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262 Haglund and Henriksson

used. The time between the ratings varied, but 67% had been performed
within a month.
The uniform qualifiers from ICIDH-2 which indicate degree of difficulty in
performing an activity states that a 0 means ‘no problem’ and 4 means
‘complete problem’. This scale was reversed in order to fit the two other
instruments.

Raters
Eleven occupational therapists served as raters. Three were the same as in the
expert panel. All raters who used AMPS had attended an AMPS course. All
raters who used the ACIS-S had been trained in the use of the instrument.
The aim of the study was presented at a meeting where ICIHD-2 was intro-
duced and reversal of the uniform qualifiers was discussed.

Analysis
In order to calculate the correlation between the ratings for the item from
ICIDH-2 and the different instruments (AMPS and ACIS-S) identified by the
expert panel, Spearman rank-order correlation coefficient was used.

Results

Study I

The results showed that 12 (60%) of the skills items from the ACIS-S were
found to be equivalent to items in ICIDH-2, and the majority of the skills
items appear more than once (Table 2). Only three concepts (Gazes,
Manoeuvres, and Contacts) correlated with only one category each in ICIDH-
2. For the concept Conforms, six categories from ICIDH-2 were given.
Regarding the AMPS, 17 (49%) of the skills items correlated with items
in ICIDH-2. Eight concepts in AMPS correlated with only one category in
ICIDH-2, and no concepts in the AMPS correlated with more than two
categories in ICIDH-2. Only six categories from ICIHD-2 appeared twice.

Study II
The correlation coefficients between the ratings in ICIDH-2 and AMPS and
ACIS-S are shown in Table 2. In total, 41% (n = 23) of the items in the
AMPS or ACIS-S have a correlation higher than 0.60 with ICIDH-2. Looking
separately at the instruments, more of AMPS items than ACIS-S items have a
high correlation with ICIDH-2; 54% for the AMPS and 30% for the ACIS-S.
The lowest correlation with ICIDH-2 is also found in the ACIS-S. Two items
(Gestures and Sustains) have a correlation coefficient of only 0.20.
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Concepts in occupational therapy 263

Table 2. Correlation coefficients between ratings on items in ICIDH-2 and concepts from
AMPS and ACIS-S. Where ICIDH-2 items fit more than one concept, bold text is used for
the strongest correlation. When two correlations are equally strong one is marked in square
brackets.

ICIDH-2 Activities ACIS (Spearman) AMPS (Spearman)

a1100 Watching activity Gazes (0.24)

a1150 Paying attention Attends (0.23)
Notices (0.38)
a145 Problem solving activities Benefits (0.22)
a220 Activities of understanding
non-verbal messages Respects (0.63)
a2200 Understanding body gestures Manoeuvres (0.33)
Gestures (0.09)
a2300 Producing spoken messages
with literal meaning Speaks (0.89)
a2301 Producing spoken messages
with implied meaning Speaks (0.85)
a2400 Producing body gestures Gestures (0.12)
a2500 Initiating a conversation Engages (0.75)
a2501 Maintaining a conversation Sustains (0.58)
a2502 Shaping and directing
conversation Relates (0.43)
a2503 Terminating a conversation Relates (0.39)
a2504 Conversation activities with Engages (0.36)
many people Sustains (0.52)
a3203 Shifting the weight of the body Stabilizes (0.57)
a3400 Lifting Lifts (0.66)
a3401 Carrying in the hands Transports (0.69)
a3402 Carrying in the arms Transports (0.61)
a3405 Putting down Calibrates (0.81)
a360 Activities of fine hand use Manipulates (0.86)
a3600 Picking up [Lifts (0.66)]
a3601 Grasping Grips (0.77)
a370 Activities of hand and arm use Co-ordinates (0.73)
a3700 Pulling Moves (0.84)
a3701 Pushing Moves (0.74)
a3702 Turning or twisting Manipulates (0.74)
a410 Walking activities Walks (0.87)
a7100 Showing respect and warmth Conforms (0.60)
a7102 Showing tolerance in Conforms (0.60)
relationships Respects (0.38)
a7104 Responding to social cues Conforms (0.55)
a7105 Using appropriate physical
contact Contacts (0.25)
a7200 Maintaining social space Conforms (0.50)
a7201 Regulating emotions and
impulses for interactions Expresses (0.55)
(Table continues)
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264 Haglund and Henriksson

(Table 2 continued)

a7205 Interacting according to Conforms (0.60)

a7202 Regulating verbal aggression Expresses (0.27)
social rules and conventions Respects (0.44)
a7206 Interacting appropriately to Conforms (0.70)
own social position Respects (0.53)
a730 Activities of initiating
interaction Engages (0.48)
a7400 Activities of maintaining short
term interaction Sustains (0.41)
a7401 Activities of maintaining long
term interaction Sustains (-0.03)
a8100 Initiating a task Initiates (0.50)
a8101 Organising time and
material for a task Sequences (0.41)
a8102 Carrying out a task at
appropriate pace Continues (0.47)
a8103 Completing a task Terminates (0.39)
a8105 Performing a task in
a group Collaborates (0.66)
a8150 Initiating multiple tasks Initiates (0.51)
a8151 Organising time and
material for multiple tasks Sequences (0.33)
a8152 Carrying out multiple
tasks at appropriate pace Continues (0.65)
a 8153 Completing multiple tasks Terminates (0.63)
a8155 Performing multiple
tasks in a group Collaborates (0.42)
a8250 Sustaining physical
requirements for task performance Paces (0.27)
a8251 Sustaining psychological
requirements for task performance Paces (0.29)

Discussion

The empirical study was based on ICIDH-2, but in the following discussion we
will refer to the ICF since the difference between the two versions in respect of
the studied categories of the classification is marginal.
Certain concepts in the ACIS-S or AMPS were found to be related to more
than one category in the ICF, such as Conforms, Respects and Continues. How
should this be interpreted? One reason could be that the ICF is more specific
and thus more detailed, and that the concepts mentioned cannot be described
by using just one category in the ICF. Another reason could be that ACIS-S is
under development and has not yet found its optimal format. However,
research has shown that the instrument has sufficient validity and reliability
(Kjellberg et al., 2003) and that the concepts should be well defined.
The concepts in ASIC-S seem to be more specific than the terms of the ICF.
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Concepts in occupational therapy 265

On the other hand, some terms in the ICF related to the area of communication
and interaction do not appear in ACIS-S. Can the reason be that the other
categories of the ICF cannot be observed by the therapist in daily activities?
ACIS-S is based on observation of the performance of activities. Furthermore,
the ICF classification also covers categories that cannot always be observed
and thus are not included in ACIS-S. However, the categories are included in
the ICF because they can be assessed using, for example, tests or other specific
instruments developed and used by other professions and based on their
theoretical foundations.
The items of AMPS seem to correspond more directly to individual
categories in the ICF. There were never more than two categories from the ICF
related to one concept in AMPS (Table 2). Does this reflect the fact that it is
easier to observe and assess motor and process skills than communication skills
when the client is performing an activity? Historically, these kinds of skills
have more or less always been assessed in health care. It may be easier to define
concrete words such as ‘moves’, ‘lifts’ and ‘grips’ in comparison to more
abstract words such as ‘attends’ and ‘relates’. Is there an overlap between the
different categories of the ICF from an occupational therapist’s point of view?
The lack of a given definition may have resulted in the occupational therapists
using their own definitions of the concepts, which resulted in the expert thera-
pists using different words from AMPS and ACIS-S in order to explain the
ICF concept. Another interpretation could be that the occupational thera-
pists’ terminology is less specific because less specificity is needed or possible
for them to assess. The more specific categories concern other professions, and
are more related to their particular fields, for example speech therapists or
psychologists. On the other hand, when one ICF category is described in two
or more ACIS-S or AMPS items, does this indicate that occupational thera-
pists need a more specialized terminology? Do they need more than one
category to describe exactly what they mean?
One conclusion of the present study could be that in order to base the
assessment on the theoretical foundations central to the profession and the
profession’s domains of concern, occupational therapists need their own assess-
ments such as AMPS and ACIS-S. The profession-specific assessments cannot
be replaced by using the ICF classification. The profession-specific assess-
ments, the occupational therapy knowledge and terminology should be used as
complements to the ICF. However, it is important to realize that the ICF is a
terminology designed to be used for communication between different profes-
sions and at different levels of investigation and understanding. Occupational
therapists should use the terminology of the classification whenever it is
adequate for their level of assessment and intervention.
As the ICF is most likely going to become the common language, occupa-
tional therapists should be well acquainted with the categories that pertain to
their special area of practice. It is important to note that the ICF might lack
certain categories to describe what occupational therapists need to communicate
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266 Haglund and Henriksson

to clients and colleagues in everyday practice. It may not be possible to obtain

the exact connotations of the different ICF categories. Moreover, when it is
necessary to use additional terminology, every effort should be made to carefully
define the concepts in relation to the ICF categories. If occupational therapists
disregard the ICF classification and develop their own concepts, or if they use
previous terminology without considering the ICF categories they may be
isolating their profession instead of building bridges and enriching the common
terminology in health care. On the other hand, the ICF classification should not
be accepted without reflection. The terminology that has been developed in the
field of occupational therapy over recent decades must be considered, otherwise
occupational therapists are likely to lose their specialized professional language
and thereby also the specialized knowledge that has been developed in the field.
One limitation in this study may be the use of the uniform qualifiers. There is
no theoretical base for the qualifiers; criteria for each grade have to be developed,
and research has to be performed. However, Grimby (2001) states that it is
important to investigate how different instruments relate to the ICF. The main
reason for this is that the uniform qualifiers have not yet been properly studied.
The empirical part of the present study can be discussed from the point of
validity. Content validity is the representativeness of the concept. Does the
item cover the aspect of the measured attribute? To test validity is important
when developing new concepts, an aspect that is often not given enough
attention. If the ICF classification is to be used to identify the client’s need of
intervention, it must be capable of doing so accurately.
The assessment of validity involves evaluation against some kind of
standard criterion. Content validity is a prerequisite for empirical validity. The
content of the item has to be adequate, otherwise it is difficult to establish
empirical validity. The first study presented in this article, using an expert
panel, can be viewed as a content validity study.
The correlations between the ICF and AMPS and ACIS-S were identified
in the second study. A criterion validity test requires a ‘true’ instrument to
serve as ‘gold standard’. The aim is to identify how well the instrument under
study is correlated to an existing instrument that has previously been tested
for validity and which measures the attribute being studied. It can be
questioned whether the two instruments, AMPS and ACIS-S, used in this
study have a standard that permits such a comparison. We will argue that
both instruments have such a standard. Research and practical use of the
instruments have shown that the concepts represent relevant aspects of
functioning. ACIS has been studied in the USA and Great Britain, providing
evidence that ACIS has a valid rating scale with a discriminative power for
different levels of communication and interaction skills (Salamy, 1993;
Forsyth et al., 1999). Kjellberg et al. (2003) conclude that ACIS-S has ‘good
measurement qualities. There is evidence for internal, construct and person,
response validity of the ACIS-S.’
The reliability and validity of AMPS have been shown in many studies and
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Concepts in occupational therapy 267

AMPS has been standardized on more than 46,000 subjects internationally

(Fisher, 2001). It has been ‘used widely in clinical practice and research for the
past two decades’ (Kottorp et al., 2003).
Furthermore, does this study present an acceptable level of correlation? A
correlation coefficient of 0.50 is often considered acceptable (Landis and Koch,
1977); thus it can be argued that the correlation between many of the concepts
and the categories is quite insufficient. One reason for the poor correlation could
be that the categories of the ICF were first matched to the concepts in the two
instruments by the expert panel. These results were later used in calculating the
correlation between the ICF and the instruments. This means that if the expert
panel did not succeed in combining concepts from the two instruments with the
items of ICF with the same meaning, this would later influence the results of the
correlation test. ACIS-S and AMPS include many concepts that cannot be
identified by one category of the ICF, and, on the other hand, the ICF also has
many categories that were not identified in the other two instruments.
Another limitation in this study was that the time between the different
ratings varied. However, 67% of the ratings were performed within a month.
Since the population in this study consisted of clients with chronic disease,
such as learning disabilities or schizophrenia and affective disorders, it can be
argued that the time between the ratings should only marginally influence the
differences in the ratings from ICF and the other instruments.
One more limitation can be that ICIDH-2 was used in the empirical studies
and that discussions are based on ICF. The study has investigated how occupa-
tional therapists understand the concepts in ICIDH-2. The understanding of
the concepts may be different when using ICF since the two components,
activity and participation, have been made into one component. These
changes may influence the understanding of the categories even though these
are defined in the same way as in the earlier version.
In this study the understanding of the concepts of AMPS, ACIS-S and
ICIDH-2 has been investigated. All concepts in AMPS and ACIS-S are
observable skills but the concepts in the activity section of ICIDH-2 are not
presented as skills but as observable behaviours.
The aim of this paper was to start a discussion about the relation between
the ICF and occupational therapy by clarifying the meaning of some existing
theoretical concepts in occupational therapy and applying them in the light of
categories of the ICF. We hope this discussion will continue as we have raised
many question that have not been answered in this paper. Hopefully further
research will find some answers and raise new unexpected questions.

Conclusion

The ICF classification can serve as a useful tool for occupational therapists and
support communication between professions, but it is not sufficient as a profes-
sional language for occupational therapists. The results of this study indicate
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268 Haglund and Henriksson

that, in addition to the ICF, occupational therapists also need their own termi-
nology to describe a client’s capacity in a way that guides intervention. Further
studies will show to what extent the ICF can be used in different fields of
occupational therapy.

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Address correspondence to Lena Haglund, Department of Neuroscience and Locomotion,

Section of Occupational Therapy, Faculty of Health Sciences, Linköping University, 581 85
Linköping, Sweden. Tel: +4613227825, Fax: +4613227819. Email: Lena.Haglund@psy.liu.se