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Title: International Classification of Function, Disability and Health (ICF)


1
International Classification of Function,
Disability and Health (ICF)
  • Dr Ger Craddock

2
World Health Organization Classification
Assessment Surveys Terminology Group
  • ICF

WHO Family of International Classifications
www.who.int/classification/icf
3
International Classification of Functioning,
Disability and Health
3
3
4
ICF Applications
  • Health sector
  • Social security
  • Education sector
  • Labour sector
  • Economics development sector
  • Legislation law
  • Other .

4
5
Definitions
Impairment Loss or abnormality in body structure or function (including mental function)
Activity Limitations Difficulties individual may have in executing activities in terms of quantity or quality
Participation Restrictions Problems an individual may experience in involvement in life situations
Facilitators Barriers Environmental factors may be a facilitator for one person barrier for another
5
6
ICF Components
  • Body functions Physiological functions of body
    systems
  • Body Structures Structural or anatomical parts of
    the body
  • Activities Execution of a task or action by an
    individual (individual perspective)
  • Participation Persons involvement in a life
    situation (societal perspective)
  • Environmental Factors All aspects of the external
    world that impact on the persons functioning

6
7
ICF Structure
  • Two parts
  • 1. Functioning and Disability
  • a) Body functions and structures
  • b) Activities and Participation
  • 2. Contextual Factors
  • a) Environmental factor
  • b) Personal factors

7
8
Family of Who Classifications
  • ICF belongs to the WHO family of international
    classifications, the best known member of which
    is the ICD-10 (the International Statistical
    Classification of Diseases and Related Health
    Problems). ICD-10 gives users an etiological
    framework for the classification, by diagnosis,
    of diseases, disorders and other health
    conditions.

9
WHO Family
  • By contrast, ICF classifies functioning and
    disability associated with health conditions. The
    ICD-10 and ICF are complementary.
  • Encouraged to use them together to create a
    broader and more meaningful picture of the
    experience of health of individuals and
    populations.
  • In short, ICD-10 is mainly used to classify
    causes of death, but ICF classifies health.

10
International Classification of Function,
Disability and Health (ICF)
  • Originally ICIDH (international Classification of
    Impairments, disabilities and Handicaps 1980) now
    ICF (International Classification of Function,
    disability and health 2001)
  • Classification was conceived as means to evaluate
    the effectiveness of health care processes

11
International Classification of Function,
Disability and Health (ICF)
  • Classification envisioned for three uses
  • Statistics on the consequences of disease
  • Statistics on use of health services
  • Conditions classified according to categories

12
Why ICF?
  • There is also an increased recognition among
    policy makers and service agencies that
    reductions in the incidence and severity of
    disability in a population can be brought about
    by
  • 1)enhancing the functional capacity of the person
    and
  • 2) by improving performance by modifying features
    of the social and physical environment.
  • To analyze the impact of these different
    interventions, we need a way of classifying
    domains of areas of life as well as the
    environmental factors that improve performance.
  • ICF allows us to record this information.

13
THE MODEL OF ICF
  • The medical model views disability as a feature
    of the person, directly caused by disease, trauma
    or other health condition, which requires medical
    care provided in the form of individual treatment
    by professionals. Disability, in this model,
    calls for medical or other treatment or
    intervention, to 'correct' the problem with the
    individual

14
The ICF Model
  • The social model of disability, on the other
    hand, sees disability as a socially created
    problem and not at all an attribute of an
    individual. On the social model, disability
    demands a political response, since the problem
    is created by an unaccommodating physical
    environment brought about by attitudes and other
    features of the social environment.

15
The ICF Model
  • On their own, neither model is adequate, although
    both are partially valid.
  • Disability is a complex phenomena that is both a
    problem at the level of a person's body, and a
    complex and primarily social phenomena.
    Disability is an interaction between features of
    the person and features of the overall context in
    which the person lives, but some aspects of
    disability are almost entirely internal to the
    person, while another aspect is almost entirely
    external.
  • Summary Both medical and social responses are
    appropriate to the problems associated with
    disability we cannot wholly reject either kind
    of intervention.

16
The ICF Model
  • A better model of disability,? synthesize what is
    true in the medical and social models, without
    making the mistake each makes in reducing the
    whole, complex notion of disability to one of its
    aspects.
  • This model of disability is called the
    biopsychosocial model.
  • ICF is based on this model, an integration of
    medical and social. This provides a coherent view
    of different perspectives of health biological,
    individual and social.

17
International Classification of Function,
Disability and Health (ICF)
  • The ICF was given a mandate to develop a global
    common language in the field of health and
    disability. The overall objective of the ICF was
    to develop an operational classification system
    on human functioning and disability that
  • Was applicable to every human being.
    (universality)
  • Addressed multiple dimensions regarding the
    person and environment (at body, person and
    society levels)
  • Was sensitive to International practices,
  • Was based on user needs
  • Was empirically based with field trials on
    applicability, reliability and utility.

18
Cultural Applicability
  • Conceptual and functional equivalence of
    Classification
  • Translatability
  • Usability
  • International Comparisons

19
Foundations of ICF
  • Human Functioning - not merely
    disability
  • Universal Model - not a minority
    model
  • Integrative Model - not merely medical
    or social
  • Interactive Model - not linear
    progressive
  • Parity - not
    etiological causality
  • Context - inclusive - not person alone
  • Cultural applicability - not western
    concepts ?
  • Operational - not theory
    driven alone
  • Life span coverage - not adult driven ?

20
The ICF
  • Uses neutral terms to identify function at the
    Body function, activity and participation level
    rather that impairment, disability and handicap

21
The ICF
  • The addition of the emphasis on the interaction
    of environmental features, both physical and
    social, adds an important context within which
    persons with disabilities can be evaluated
  • Increased emphasis on function i.e. does the
    intervention you propose maintain or improve
    function
  • Accordingly when measuring outcomes, the
    effectiveness of the intervention must be seen in
    the context of the users environments

22
Interaction of Concepts ICF 2001
Health Condition (disorder/disease)
23
ICF Components
Body Functions Structures
Activities Participation
Environmental Factors
Barriers Facilitators
Functions Structures
Capacity Performance
24
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25
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26
Disability
27
Functioning
28
  • Activity is the execution of a task or action by
    an individual.
  • It represents the individual perspective of
    functioning.
  • Participation is involvement in a life situation.
  • It represents the societal perspective of
    functioning.

29
Body structures and functions
  • The ICF includes 4 dimensions
  • Impairments at a body level
  • Activities at the person level (formerly
    disability)
  • Participation at the social level (formerly
    handicap)
  • Contextual factors which list physical
    environment factors, such social environment
    factors, laws, attitudes
  • Interaction of the environmental factors with the
    3 levels result in functioning that is either
    positive or negative

30
Activities
  • Activities are performance of person-level tasks
    or activities undertaken by the person
  • Domains of activity are communication, movement,
    self care, interpersonal and performing the
    simple to complex tasks involved in major life
    activities
  • Activities are the observable and reportable
    performance of actions of individuals in the
    context of their culture

31
Participation
  • Participation is defined as individuals
    involvement in life situations in relation to
    health conditions, body functions and structures,
    activities and contextual factors
  • A key term is Involvement means inclusion of the
    individual in life activities in the context of
    how and where they live

32
Participation
  • The classification of participation restriction
    is assessed on desired participation of the
    individuals life activities within society
  • It is measured by placing the observed
    involvement in a life activity in 1- 9
    participation domains that include personal
    maintenance, mobility, exchange of information,
    social relationships, home life and assistance to
    others, education, work and employment, economic
    life, community, social and civic life

33
Participation
  • Participation is qualified by the degree of
    restriction experienced
  • For example, if mobility outside the home is
    moderately restricted as a function of the lack
    of the availability of accessible transport, then
    the participation code (p) would be assigned as
    follows chapter 2 (participation in mobility)
    under the 2nd level heading (230) titled
    Participation in mobility outside the home and
    other buildings and restriction qualifier of
    moderate (2) resulting in the full code of p230.2

34
ICF Mechanisms for Documenting Disability Status
  • .0 No Barrier
  • .1 Mild Barrier
  • .2 Moderate Barrier
  • .3 Severe Barrier
  • .4 Complete Barrier
  • Environment
  • 0 No Facilitator
  • 1 Mild Facilitator
  • 2 Moderate Facilitator
  • 3 Severe Facilitator
  • 4 Complete Facilitator

PSI LDSIG 16/04/2010
35
Contextual Factors
  • Environment
  • Products
  • Milieu
  • Institutions
  • Social Norms
  • Culture
  • Built-environment
  • Political factors
  • Nature
  • Person
  • gender
  • age
  • other health conditions
  • coping style
  • social background
  • education
  • profession
  • past experience
  • character style

36
Structure
ICF
Classification
Part 1 Functioning and Disability
Part 2 Contextual Factors
Parts
Activities and Participation
Body Functions and Structures
Personal Factors
Environmental Factors
Components
Constructs/ qualifiers
Change in Body Structures
Capacity
Performance
Facilitator/ Barrier
Change in Body Functions
Domains and categories at different levels
Item levels 1st 2nd 3rd 4th
Item levels 1st 2nd 3rd 4th
Item levels 1st 2nd 3rd 4th
Item levels 1st 2nd 3rd 4th
Item levels 1st 2nd 3rd 4th
37
THE DOMAINS OF ICF
  • The domains of ICF are arranged in a hierarchy
    (Chapter, second, third and fourth level
    domains), which is reflected in the codinge.g.

38
The Qualifiers
  • The list of domains in ICF becomes a
    classification when qualifiers are used.
    Qualifiers record the presence and severity of a
    problem in functioning at the body, person and
    societal levels.

39
For body function and structure, the primary
qualifier
  • The primary qualifier indicates the presence of
    an impairment (5 point Scale)
  • no impairment,
  • mild,
  • moderate,
  • Severe
  • Complete

40
Activity and Participation domains,2 Qualifiers
  • The Performance qualifier describes what an
    individual does in his or her current
    environment. Since the current environment always
    includes the overall societal context,
    performance can also be understood as
    "involvement in a life situation" or "the lived
    experience" of people in their actual context.
    (The 'current environment' will be understood to
    include assistive devices or personal assistance,
    whenever the individual actually uses them to
    perform actions or tasks.)

41
Activity and Participation domains,2 Qualifiers
  • The Capacity qualifier describes an individuals
    ability to execute a task or an action. This
    indicates the highest level of functioning of a
    person in a given domain at a given moment.

42
ICF Mechanisms for Documenting Disability Status
  • Functioning
  • Structures
  • Activity
  • Participation
  • 0 No Problem
  • 1 Mild Problem
  • 2 Moderate Problem
  • 3 Severe Problem
  • 4 Complete Problem

Capacity What a person can do without
assistance Performance What a person can
actually do
43
Capacity and Performance Data
  • Having access to both performance and capacity
    data enables ICF user to determine the 'gap'
    between capacity and performance.

44
Capacity and Performance Data?
  • If capacity is less than performance, then the
    person's current environment has disabled/enabled
    him or her to perform better??

45
Capacity And Performance Answer
  • the environment has facilitated performance.

46
Capacity And Performance?
  • If capacity is greater than performance??

47
Capacity And Performance Answer
  • Some aspect of the environment is a barrier to
    performance.

48
Questions re Defining Capacity?Mobility
(1) In your present state of health, how much
difficulty do you have walking long distances
(such as a kilometer or more) without
assistance? (2) How does this compare with
someone, just like yourself only without your
health condition? (Or "than you had before you
developed your health problem or had the
accident?)
49
Questions defining Performance?mobility
(1) In your present surroundings, how much of a
problem do you actually have in walking long
distances (such as a kilometer or more)? (2) Is
this problem walking made worse, or better, by
your actual surroundings? (3) Is your capacity to
walk long distances without assistance more or
less than what you actually do in your present
surroundings?
50
Questions Defining CapacityMajor Life Areas
(1) In your present state of health, how much
difficulty do you have getting done all the work
you need to do for your job, without
assistance? (2) How does this compare with
someone, just like yourself only without your
health condition? (Or "than you had before you
developed your health problem or had the
accident?)
51
Defining questions Re PerformanceMajor Life
Areas
(1) In your present surroundings, how much of a
problem do you actually have getting done all the
work you need to do for your job? (2) Is this
problem fulfilling your job requirements made
worse, or better, by the way the work environment
is set up or the specially adapted tools you
use? (3) Is your capacity to do your job, without
assistance, more or less than what you actually
do in your present surroundings?
52
Use of the qualifiers
53
Use of the qualifiers
54
Use of the qualifiers
55
Use of the qualifiers
56
Activity
  • For example, inability to walk and use of a
    wheelchair for mobility would be classified as
    follows chapter 4 (Activities of moving around
    under the level 2 heading of walking activities
    (410) level of difficulty qualifier (4) and
    assistance qualifier (1) for a resulting code of
    a410.41

57
Mapping ICF to an assessment forms - eligibility
for benefits
  • What, if any, movement difficulty is there?

    ICF b7302.2 (moderate impairment of one side
    of body)
  • To what extent can you perform personal care?
  • ICF d5702.1 (mild impairment maintaining
    ones health)
  • Do you require assistance to move from place to
    place inside your home/school/place of work?
  • ICF d4601.0 (no problem moving around within
    buildings other than home)

57
58
the complete list of chapters in the ICF
59
the complete list of chapters in the ICF
60
the complete list of chapters in the ICF
61
 
Examples of disabilities that may be associated
with the three levels of functioning linked to a
health condition.
62
The levels of disability linked to three
different levels of intervention.
63
The levels of disability linked to three
different levels of intervention.
Activity Limitation
? ? ?
? ? ?
64
The levels of disability linked to three
different levels of intervention.
65
The levels of disability linked to three
different levels of intervention.
Participation Restriction
? ? ?
? ? ?
66
The levels of disability linked to three
different levels of intervention.
67
ICF in policy making
  • assessment of population health
  • impact of disability
  • economic
  • social
  • evidence-base for policy makers on different
    policy interventions
  • responsiveness of services
  • efficiency
  • performance assessment

68
Function (Task Specific)
Function
69
ICF in clinical practice management
  • Needs assessment
  • Outcome assessment
  • Utilization patterns
  • Comparison of different interventions
  • Consumer satisfaction
  • Service performance
  • outcomes
  • cost-effectiveness
  • Electronic records
  • Clinical terminology

70
Characteristics of a Good Assessment of Need
(AON)
  • The ICF provides a useful framework to support
    AONs that are
  • Person centred
  • Needs Driven
  • Biopsychosocial
  • Age appropriate
  • Multi-disciplinary

PSI LDSIG 16/04/2010
71
Suggested Framework for Assistive Technology
Assessment
  • Identify Functional Limitation
  • Identify Impairments that cause functional
    limitation
  • Work with rehabilitation specialists to address
    impairment level issues.
  • Maximize function by collaborating with
    rehabilitation specialist to create assistive
    technology solutions which take into account
    individual impairments.

72
Joseph Pre-assessment
Example (including ICF components and
International Standards Organisation (ISO) 9999
(AT) products)
Joseph is a 22-year-old male who received a T-12
incomplete spinal cord injury body functions and
structures (b) from a diving accident 4 years ago
After rehabilitation, he returned to his parents
home and both his mother and father worked hard
to meet his physical needs. During the past 3
years, however, he has had a difficult time
recognising and accepting the changes in his
lifestyle he must make emotional functions (b1)
and personal factors, identity. As a result,
Joseph frequently feels angry and depressed (b1,
temperament and personality) and often prefers to
be alone (d7, interpersonal interactions).
At first family and friends would stop by to
visit, but his withdrawal, anger and depression
led to strained interactions and eventually the
visits became rare occurrences (d7, e3 and e4).
73
Joseph Assessment
At Time Point 2, 3 years post-injury, Joseph
learned about the existence of a wheelchair
basketball team in his city that was looking for
an additional player.
Joseph is fortunate that he lives in a large
enough city that has the facilities and resources
to foster a wheelchair basketball team e5
Joseph uses a lightweight manual wheelchair
(e1,ISO 9999 class 12.22.03, bimanual wheel
driven wheelchairs), but to play on the team
required that Joseph have an additional
specialised wheelchair, that is a sport
wheelchair (e1, ISO 9999 class 12.22.03).
His physician recommended an assessment at a
local AT centre that focussed on his preferences
as well as needs (b7, d4, d7, d9, personal
factors), the purpose and environments of
wheelchair use (d9, e2) and desirable product
features and add-ons such as special tires and a
means for transporting himself and his wheelchair
(ISO 9999 class 12).
74
Joseph post assessment
The outcome of the comprehensive assessment was
the selection of a wheelchair among multiple
choices that Joseph could afford, was a good
match with his needs and preferences, and that
performed well for him as a wheelchair basketball
player 2830. Joseph enjoyed playing on the
team, and the team valued Josephs contribution
(e3 and e4). Joseph interacted with other
individuals, some who become closer friends than
others (d7). The addition of Joseph affected
the group identity as a whole as well as each
individual (e3 and e4,personal factors). As a
group they performed very well and won a regional
championship. Now,almost 4 years post-injury,
Joseph is finding he is less depressed and angry
(b1) and greatly looks forward to being with his
teammates not only on the basketball court but
socially as well d7. He is now thinking of
returning to university and wants to explore
additional ATs to save time and energy.
75
In Summary ICF
  • ICF describes all aspects of health in terms of
    health domains
  • ICF is integration of the medical and social
    models biopsychosocial approach
  • ICF is designed in a hierarchical scheme based on
    commonly understood principles and language
  • The ICF facilitates collaboration and
    communication amongst system supports
  • ICF describes situations for functioning and its
    restrictions and provides a framework to organise
    this information

75
76
In SummaryThe New Approach ICF
  • The ICF is an active system, it is constantly
    changing
  • The ICF understands that disability is the
    interaction between a person and their
    environment
  • The ICF provides an assessment tool and a means
    to classify data collection using simple, common
    language and forms

76
77
End With another case study
78
Johns Profile
  • Intellectual Functioning Average
  • Age 12 .5 years
  • Gender Male
  • Address Dublin 11
  • Medical Diagnosis ADHD
  • (ICD 10 Code F90.0/ DSM IV 314.1)
  • Family Status Father Information Technologist
  • Mother Dental Secretary
  • Educational Status First Year Secondary
  • Reason for Referral
  • Assessment of Need as a result of class
    disruption and aggressive behaviour during
    recreation. Bedwetting is also reported by his
    parents as an issue. GP has identified ADHD as
    the most likely cause.

PSI LDSIG 16/04/2010
79
Johns Behaviour Profile
  • John has difficulty
  • Paying attention to details
  • Sustaining attention
  • Listening to stories and instruction
  • Finishing tasks
  • Organising himself
  • Keeping track of his belongings
  • John
  • Blurts out answers before a question is finished
  • Doesnt wait his turn
  • Interrupts and intrudes upon others
  • Fidgets
  • Is unable to stay seated
  • Has difficulty engaging in leisure activities
    quietly

PSI LDSIG 16/04/2010
80
John Learning Strengths
  • Articulate
  • Artistic
  • Popular with school friends
  • Interested in sports
  • Supports in place for him already e.g. OT and
    Tuition
  • Willing to participate
  • Good relationship with his mother
  • Support and interest from home
  • Reflective ability
  • Good Auditory Discrimination
  • Good Expressive language
  • Ability to understand directions when presented
    clearly
  • Can interpret body language

81
Johns Activity and Participation Profile
  • Has difficulty in settling down to listen to
    stories or instructions
  • Has yet to acquire introductory word decoding
    skills
  • His formation of letter shapes is very immature
  • Has not exhibited the ability solve simple
    problems when presented orally
  • Has moderate difficulty in organising himself to
    carry out anything other than simple task
  • Has no difficulty in communicating through speech
    and gesture
  • Is constantly in motion, fidgeting and moving
    around

PSI LDSIG 16/04/2010
82
Johns Activity and Participation Profile
  • Has difficulty relating to his father without
    getting angry.
  • The relationship with his mother is close but
    dependent
  • Can react aggressively even to friendly
    approaches from other children
  • Finds it very difficult to respond appropriately
    to correction or control from teachers
  • In the school yard he often gets into fights and
    has no close friends
  • Has been unable to adapt to formal education and
    is failing in school work
  • Is not very good at physical activities and has
    developed no interests sports or other pursuits

83
An analysis of Johns Environment
  • His father has given him a number electronic toys
    and gadgets including a electronic spelling tutor
    all of which he refuses to use
  • His mother works flexi-time in order to be
    available to him when problems arise.
  • His father is well meaning but often absent from
    the home on business trips
  • His parent have recently identified an OT who has
    begun to work with him using Sensory Integration
    techniques
  • His teacher is frustrated and has yet to find a
    way to manage his behaviour in class. He is on
    The waiting list for the Learning Support Teacher
    but is unlikely to receive help in the current
    school year

84
An analysis of Johns Environment
  • His mother is frustrated and fears that she may
    have to give up work in order to cope with his
    problems
  • His father is distant emotionally and tends to
    underplay the problems as something he will grow
    out of
  • He has no close friends
  • Is currently receiving no SEN support
  • Apart from the GP and the occasional visits to
    the OT his parents are paying for privately he is
    receiving no health or social care intervention

85
Johns Learning Needs
  • Needs support to organise and manage personal
    possessions
  • Needs to deal with authority better
  • Needs a review of what he has been doing in
    learning support to identify what works and what
    needs to change
  • Needs to get agreement on using alternative
    format for presenting his academic work
  • Extend his ability to communicate emotionally
  • Needs to be encouraged to attend and stay in
    school
  • Need to feel better about himself and be more
    confident about communicating with others

86
Johns Learning Needs
  • Needs to related better to his father
  • He needs to start using assistive technology
  • Needs to work cooperatively with his class mates
  • Eyes and ears need to be checked
  • Family may need to work to improve relationships
  • Appropriate programme to facilitate transfer to
    secondary school

87
Johns ICF Profile Johns ICF Profile Johns ICF Profile Johns ICF Profile
Area of Functioning ICF Code ICF Rating Description of Need
Intellectual b117 0 Intelligence assessed within average range
Regulation of behavior b127.4 3 Has great difficulty adapting behaviour appropriately to classroom context
Impulse control b1304.3 2 Has difficulty resisting sudden urges to do things
Short term memory b1440 2 Moderate impairment in tests of STM
Attention b1460 2 Both parents and teachers report moderate difficulties in maintaining attention
Orientation b1141/b1148 2 Has difficulties with temporal and spatial orientation
Emotional b152 2 Emotional responses are inappropriate and he has difficulty regulating them
Visual Perception b1561 2 Had difficulty with all tests involving visual perception
Motor coordination b760/b7601 2 2 Fine motor coordination and finger dexterity difficulties have been identified
88
Activity /Participation ICF Code Capacity Performance
Listening d115 2 2 Has difficulty in settling down to listen to stories or instructions
Learning to read d140 2 3 Has yet to acquire introductory word decoding skills
Learning to write d145 2 3 His formation of letter shapes is very immature
Solving problems d175 2 3 Has not exhibited the ability solve simple problems when presented orally
Multiple Tasks d220 2 3 Has moderate difficulty in organising himself to carry out anything other than simple task
Communication d310-d349 0 0 Has no difficulty in communicating through speech and gesture
Maintaining a sitting position d4153.3 3 3 Is constantly in motion, fidgeting and moving around
Family Relationships d720 0 3 Has difficulty relating to his father without getting angry.
Family Relationships d720 0 2 The relationship with his mother is close but dependent
Regulating behaviors within interactions d7202.2 0 3 Can react aggressively even to friendly approaches from other children
Authority d740 0 3 Finds it very difficult to respond appropriately to correction or control from teachers
Peers d7600 0 2 In the school yard he often gets into fights and has no close friends
School d820 2 3 Has been unable to adapt to formal education and is failing in school work
Recreation Leisure d9201 1 3 Is not very good at physical activities and has developed no interests sports or other pursuits
89
Environmental Analysis ICF Code ICF Rating
Products Technology e1
Products for personal use in education e130 0 His father has given him a number electronic toys and gadgets including a electronic spelling tutor all of which he refuses to use
Supports e3
Immediate Family e310 2 His mother works flexi-time in order to be available to him when problems arise.
Immediate Family e310 0 His father is well meaning but often absent from the home on business trips
Health professionals e355 0 His parent have recently identified an OT who has begun to work with him using Sensory Integration techniques
Other professionals (Teachers) e360 0 His teacher is frustrated and has yet to find a way to manage his behaviour in class. He is on the waiting list for the Learning Support Teacher but is unlikely to receive help in the current school year
Attitudes e4
Immediate Family e410 -2 His mother is frustrated and fears that she may have to give up work in order to cope with his problems
Immediate Family e410 -2 His father is distant emotionally and tends to underplay the problems as something he will grow out of
Friends e420 0 He has no close friends
Services Systems e5
SEN Support e5860 0 Is currently receiving no SEN support
Health Services e5800 0 Apart from the GP and the occasional visits to the OT his parents are paying for privately he is receiving no health or social care intervention
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