The ICF Activities and Participation related to speech-languagepathology

ROBYN O’HALLORAN1 & BRIGETTE LARKINS1,2

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

New Zealand

AbstractIncreasingly speech-language pathologists are considering the effects of a client’s communication and/or swallowingdisability on the client’s day to day life. The activities and life situations that make up a person’s everyday life are described inthe Activities and Participation component of the World Health Organization’s International Classification of Functioning,Disability and Health (ICF). This paper describes the Activities and Participation component of the ICF and howcommunication is currently represented in this component. This paper then explores the current debate between theconcepts of activities and participation and how this can continue to inform and develop our understanding ofcommunication activity and communication participation into the future.

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

Introduction

Many influences may direct a speech-language

pathologist to consider the effects of a client’s

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 clinician’s 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

people’s everyday lives (Frattali, 2000). The ad-

vances in medical technology added to the ageing

population have resulted in increased demand and

costs for the healthcare sector. In response, third

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 client’s life

(Byng, Cairns, & Duchan, 2002; Worrall, 2000).

From a theoretical viewpoint, a person’s 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 Organization’s

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 person’s everyday activities and life

situations. It then discusses some of the problems

with the Activities and Participation component of

Correspondence: Robyn O’Halloran, Communication Disability Centre, The University of Queensland, St Lucia, 4072, Queensland, Australia.

E-mail: s374859@student.uq.edu.au

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

ISSN 1754-9507 print/ISSN 1754-9515 online ª The Speech Pathology Association of Australia Limited

Published by Informa UK Ltd.

DOI: 10.1080/14417040701772620

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the ICF, in particular the alternative ways in which

activities and participation have been proposed to

relate to each other. The final section of this paper

draws on the discussion of the relationship between

activities and participation to further clarify the

concepts of communication activity and commu-

nication participation as they relate to the assessment

and management of adults with acquired commu-

nication disabilities.

The Activities and Participation component

of the ICF

The Activities and Participation component of the

ICF describes the complete range of human func-

tioning from both an individual and a societal

perspective (WHO, 2001). The individual perspec-

tive is expressed through the concept of activity

which is defined as ‘‘the execution of a task or action

by an individual’’ (p. 10, WHO, 2001). The societal

perspective is expressed through the concept of

participation and is defined as ‘‘involvement in a life

situation’’ (p. 10, WHO, 2001). These two perspec-

tives of functioning and disability make up the ICF

Activities and Participation component.

The Activities and Participation component con-

sists of a single list of nine chapters or domains.

These are ‘‘Learning and applying knowledge’’ (d1);

‘‘General tasks and demands’’ (d2); ‘‘Communica-

tion’’ (d3); ‘‘Mobility’’ (d4); ‘‘Self-care’’ (d5);

‘‘Domestic life’’ (d6); ‘‘Interpersonal interactions

and relationships’’ (d7); ‘‘Major life areas’’ (d8); and

‘‘Community, social and civic life’’ (d9). As with the

organizational structure of other parts of the ICF,

each domain in the Activities and Participation

component is described in further detail by first,

second, and sometimes third and fourth level items.

For example, the domain ‘‘Learning and applying

knowledge’’ (d1) consists of 21 first level items, such

as ‘‘Learning to calculate’’ (d150) and ‘‘Acquiring

skills’’ (d155). Some of these first level items are

described in further detail by second level items. For

example, ‘‘Acquiring skills’’ (d155) consists of the

second level items ‘‘Acquiring basic skills’’ (d1550)

and ‘‘Acquiring complex skills’’ (d1551). Finally, a

person’s level of functioning in each of the items

within these domains is made meaningful by two

qualifiers; ‘‘performance’’ and ‘‘capacity’’. The

performance qualifier describes what an individual

does in his or her current environment at a given

time, whereas the capacity qualifier describes an

individual’s highest probable level of functioning, in

a standardized or uniform environment at a given

time (WHO, 2001). The ICF describes an additional

third qualifier representing capacity with assistance

and a fourth qualifier representing performance

without assistance.

Of particular interest to speech-language patholo-

gists is how the Activities and Participation compo-

nent describes communication disability. The ways

in which the ICF currently conceptualize commu-

nication activities and participation is described in

the following section.

Communication in the Activities and

Participation component

Chapter 3 of the Activities and Participation compo-

nent is ‘‘Communication’’ and is one of the nine

chapters in this component. It describes commu-

nication activities and participation at the broad three

digit level in terms of ‘‘Communicating – receiving’’

(d310 – d329); ‘‘Communicating – producing’’

(d330 – d349); and ‘‘Conversation and use of com-

munication devices and techniques’’ (d350 – d369).

‘‘Communication – receiving’’ and ‘‘Communica-

tion – producing’’ are described in further details in

terms of the type of message the person is receiving

or producing, that is, whether it is non-verbal or

verbal and in terms of the modality the person uses to

communicate such as through body gestures and

drawings. ‘‘Conversation and use of communication

devices and techniques’’ is described in further detail

by differentiating conversations from discussions and

in terms of the number of people involved.

However, communication activity and participa-

tion is also part of many other activities and

participation domains. For example, within the

‘‘Learning and applying knowledge’’ (d1) domain

are the items: ‘‘Reading’’ (d166), ‘‘Writing’’ (d170)

and ‘‘Solving problems’’ (d175) which includes

resolving a dispute between two people. Similarly,

the ‘‘Domestic life’’ (d6) domain includes items such

as the ‘‘Acquisition of goods and services’’ (d620)

and ‘‘Assisting others’’ (d660) and not surprisingly

the ‘‘Interpersonal interactions and relationships’’

(d7) domain is replete with communication activities

such as showing ‘‘Respect and warmth in relation-

ships’’ (d7100), understanding ‘‘Social cues in

relationships’’ (d7104) and maintaining ‘‘Informal

relationships with friends’’ (d7500).

Therefore the Activities and Participation compo-

nent of the ICF describes communication activities

and participation in two different ways. Chapter 3 on

‘‘Communication’’ describes communication in

terms of the component parts of communication,

that is, the type of communication that is occurring

(e.g., receiving messages, producing messages, or

both, as in conversation), the communication mod-

ality employed (e.g., verbal or non-verbal) and the

number of people engaged in the communication.

These communication activities and participation are

not described in relation to the context of the

communication activity such as the place or purpose

of the communication. In contrast, communication

related activities included in other chapters of the

Activities and Participation component do describe

communication activities in relation to the context of

the communication. For example, the purpose of the

communication is explicit in the communication

ICF Activities and Participation 19

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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

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

these notions are used in different settings, in different

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 person’s 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 person’s 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.

20 R. O’Halloran & B. Larkins

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Another framework that views activities and

participation as a continuum is the Living with Apha-

sia: Framework for Outcome Measurement (A-FROM;

Kagan et al., 2007) The A-From identifies four

interrelated factors that have been proposed to

influence the overall experience of living with aphasia.

These factors are ‘‘the severity of the aphasia’’,

‘‘participation in life situations’’, ‘‘communication

and language environment’’ and ‘‘personal identity,

attitudes and feelings’’. These factors are similar to

the ICF components Body Functions and Structures,

Activity and Participation, Environmental Factors

and Personal Factors respectively. Of particular

interest is that the ‘‘Participation in life situations’’

factor consists of ‘‘communication activities’’, ‘‘com-

munication and conversation’’, ‘‘roles and responsi-

bilities and relationships’’. That is, this model also

suggests that communication activities are an integral

part of participation in life situations (Kagan et al.,

2007). Both these models suggest that activity is part

of participation, therefore these models imply that a

person’s level of communication activity is related to

his/her level of communication participation.

The Australian Institute of Health and Welfare

(AIHW) has also considered the relationship be-

tween the ICF concepts of activities and participa-

tion, by reflecting on the factors that differentiate

activities and participation. In contrast to the

perspective above, in a 2003 publication, the AIHW

suggested that activities and participation were

different on six criteria.

These were:

1. ‘‘Activities focus on the person’s individual

functioning, while Participation emphasises

the person’s involvement in society.

2. Activity is completely externally observable.

Participation refers to the ‘lived experience of

the person’.

3. Activity can relate to a ‘test’ environment

(although it can also relate to a real environ-

ment), with or without equipment. Participa-

tion is essentially ‘confounded’ with the

environment, i.e., the concept has little mean-

ing without consideration of the physical and

social environment, and it cannot be ‘as-

sessed’ in a ‘test’ environment.

4. ‘Involvement in society’ relates in particular to

social roles. This highlights the confounding

of Participation with that part of the environ-

ment that shapes expected roles and societal

norms.

5. Activity is fine grained, whereas Participation

is broad brushed.

6. Activity is about action or process, Participa-

tion relates to the overall goal of actions or sets

of actions’’ (AIHW, 2003, pp. 35 – 36).

Recently the AIHW has differentiated the concepts

of activities and participation further, by proposing

that activities and participation are different in

relation to their norms, qualifiers and how activities

are chosen and participation is determined as

described in Table I. Whiteneck (2006) has also

considered the differences between the ICF view of

activities and participation and has also proposed

that they are different. He proposed 11 differentiat-

ing criteria which are listed in Table II.

It is of note that some of the criteria used by the

AIHW (AIHW, 2003, 2007) and Whiteneck (2006)

accommodate the perspective of the first view

presented in this section, in that some of their

criteria also conceptualize activities and participation

as being at different ends of the same continuum.

They state variously that activities are simple whereas

participation is complex; activities are less dependent

on environment whereas participation is more

dependent on environment (Whiteneck, 2006);

activities are fine grained whereas participation is

broad brushed (AIHW, 2003).

Other criteria suggest however that activities and

participation are qualitatively different and perhaps

represent two distinctly different constructs, for

example, the AIHW propose that activity describes

activities whereas participation involves choice and

judgements (AIHW, 2007). Similarly, activity is

Table I. The differences between activities and participation in the

context of a health condition (AIHW, 2007).

Activities Participation

At the level of the individual In the context of the person’s

life

Norm—a person without

disablement

Norm—a person without

disablement in the same

society, culture or sub

culture

Qualifiers—difficulty and

assistance

Qualifiers—extent and

satisfaction

Describes activities Involves choices and

judgements

Level of chosen activity

determined by factors

arising within the person

Extent of participation in a

chosen area determined by

factors arising outside the

person

Table II. The ICF concepts of Activity and Participation

differentiated by Whiteneck (2006).

Activity Participation

Individual level Societal level

Performed alone Performed with others

Simple Complex

Related to impairment Related to quality of life

Less environment dependent More environment dependent

Medical model of disability Social model of disability

Focus of rehabilitation Focus of consumers

Assessed in hospital Assessed in community

Clinician assessment Self or proxy report

Not always possible Always theoretically possible

Task Social role

ICF Activities and Participation 21

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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 person’s 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 person’s ability within the clinic

setting and the performance qualifiers are measures

of the person’s 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 individual’s 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 individual’s

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 Whiteneck’s (2006)

position where activities are measured by the

clinician whereas participation is measured by self-

report or proxy.

Describing the differences between a person’s

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 person’s ability in the

clinic room there is the risk that clinicians may either

assume that a person’s 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

22 R. O’Halloran & B. Larkins

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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; O’Halloran, 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 person’s 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

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 person’s 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 person’s communication activity

performance describes a person’s 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 individual’s

ability to execute a task or action. The ICF states that

a person’s optimal ability is determined in a

standardized or uniform environment (WHO,

2001). This suggests that a person’s 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 person’s ability to carry

out communication activities is to a large extent

dependent on his/her communicative environment,

then a person’s 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 person’s 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 person’s communica-

tion activity limitation would be described in terms

of the second qualifier ‘‘capacity without assistance’’.

In contrast, a clinician seeking to understand a

person’s 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-

son’s 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

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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 person’s optimal ability

to communicate, or ‘‘capacity with assistance’’, in a

facilitative communicative environment is the In-

patient Functional Communication Interview (IFCI;

O’Halloran, 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 person’s 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; O’Halloran

et al., 2007). Further descriptive detail about the

communication behaviours included information

about the person’s 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 person’s 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 person’s

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 people’s

social networks and the range and frequency of their

social activities (Cruice, Worrall, & Hickson, 2005)

and the change in a person’s 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 person’s 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

24 R. O’Halloran & B. Larkins

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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

person’s 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 person’s 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.

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