Advances in Speech Language Pathology

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Using the ICF within speech-language pathology:

Application to developmental language
impairment

Karla Nadine Washington

To cite this article: Karla Nadine Washington (2007) Using the ICF within speech-language
pathology: Application to developmental language impairment, Advances in Speech Language
Pathology, 9:3, 242-255, DOI: 10.1080/14417040701261525

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Advances in Speech–Language Pathology, September 2007; 9(3): 242 – 255

Using the ICF within speech-language pathology: Application

to developmental language impairment

KARLA NADINE WASHINGTON

University of Western Ontario, Canada

Abstract
The conceptual framework proposed by the World Health Organization (WHO), the International Classification of
Functioning, Disability, and Health, (ICF), provides a multidimensional approach to the investigation of various com-
munication disorders, including developmental language impairments. The comprehensive view of health and common
language offered by the ICF framework is useful for guiding clinical and research practices within speech-language
pathology. Some sub-specialities (e.g., aphasia and traumatic brain injury (TBI)) have already begun to use the ICF
framework to guide assessment and treatment practices. However, its application for children with specific language
impairment (SLI), a type of developmental language impairment and one of the most common communication disorders in
preschool and school-age children, is somewhat limited. The purpose of this paper is two-fold: (1) to emphasize the
usefulness of the ICF framework as a tool for describing SLI and (2) to illustrate how consideration of the ICF framework
may be helpful in the management and evaluation of outcomes for children with SLI.

Keywords: International Classification of Functioning, Disability and Health (ICF), specific language impairment,
speech-language pathology, children, service delivery, participation, outcome measures.

Ultimately, a shift in the paradigm for speech-

Introduction
Professionals within speech-language pathology have
provided intervention services for a growing number
of individuals with communication disorders for over
75 years. The primary focus of this healthcare pro-
fession has always been to normalize or maximize
communication potential and in turn quality of life
(QOL). To facilitate the attainment of this goal, a
number of conceptual frameworks and classification
systems have been used to guide research and
intervention practices. Like many other healthcare
disciplines, the medical model was the primary
service delivery system used in the field. Services
based on this model resulted in speech-language
pathologists (S-LPs) focusing on a client’s level of
impairment without considering co-occurring levels
of functioning and disability (Threats & Worrall,
2004; Washington & Warr-Leeper, 2006a). Given
the broad nature of the field, it was clear that the
medically-driven model of speech-language services
inadequately addressed the comprehensive and inter-
related nature of communication disorders. As a
result of this limitation, it was necessary to employ a
new, more behavioural, approach to intervention.
language services from a biomedical to a more social
and synergistic view of health and health condition
ensued and has encouraged S-LPs to modify their
focus (Threats, 2006; Threats 2007; Threats &
Worrall, 2004; Worrall, 2006).
To date, S-LPs have endeavoured to evaluate and
provide intervention using a more holistic and non-
hierarchical approach (McLeod, 2006; Threats,
2006; Worrall, 2006). One framework, the Interna-
tional Classification of Functioning, Disability and
Health (ICF), proposed by the World Health
Organization (WHO) is being implemented gradu-
ally (McLeod, 2004; 2006; Simeonsson, 2003;
Threats, 2006; Threats & Worrall, 2004). This
conceptual framework classifies health condition
using a more integrated approach for all people with
a health condition and not just people with dis-
abilities (Threats & Worrall, 2004; Worrall, 2006).
As a result, it considers the dynamic interaction
amongst a number of factors that potentially
contribute to an individual’s health status (WHO,
2001). The ICF’s comprehensive view of health and
healthcare status, as well as the common language
that it offers clinicians to not only describe but also

Correspondence: Karla Nadine Washington, University of Western Ontario, Elborn College, 1201 Western Road, London, Ontario, Canada N6G 1H1.
Tel: þ1 519 6612111 ext. 88119. Fax: þ1 519 850 2369. E-mail: knwashin@uwo.ca
ISSN 1441-7049 print/ISSN 1742-9528 online ª The Speech Pathology Association of Australia Limited
Published by Informa UK Ltd.
DOI: 10.1080/14417040701261525

discuss functioning and disability, is an appropriate
platform from which to base and guide clinical and
research practices (McLeod, 2006; Threats, 2006;
Threats & Worrall, 2004).
Growing popularity for the application of the ICF
in health care fields is evident from the number of
professional associations that have embraced it. The
American Speech-Language-Hearing Association
(ASHA) has adopted the ICF as the framework for
its Scope of Practice (Threats, 2003, 2006) and
leading health agencies in Australia and Canada are
considering it (Bickenbach, 2003; Threats &
Worrall, 2004). Application of the ICF has also
been utilized in the education of future researchers
and professionals in the Rehabilitation Sciences
(Threats, 2006). Use of the ICF framework has
certain practical applications in speech-language
pathology including: (a) describing the role of the
clinician; (b) demonstrating the value of the rehabi-
litative discipline; (c) specifying outcomes and costs
of services for third-party payers; and (d) describing
the impact of rehabilitation on clients’ QOL (Eadie,
2003; Threats, 2006). To date, research in a number
of sub-specialties for adults (e.g., aphasia and trau-
matic brain injury (TBI)) has suggested that adop-
ting the ICF framework may be beneficial in guiding
assessment and treatment practices (Threats, 2006,
2007). The application of the ICF to clinical
categories for children, such as specific language
impairment, SLI, however has been somewhat
limited. Decreased application of the ICF may be
attributed to its failure to adequately cover all the
important developmental aspects, particularly in
the birth to five populations. This limitation has
been addressed in a version of the ICF called the ICF
for Children and Youth (ICF-CY). The ICF-CY
has additional categories and domains that appro-
priately address important issues for children and
youth (Lollar & Simeonsson, 2006; McLeod, 2006).
The ICF-CY will be published in 2007 and has 200
new codes that are not in the current version of the
ICF (see Lollar & Simeonsson, 2006 and McLeod,
2006, for a discussion). The ICF in its current
state will be reviewed in the present paper given
its successful application within communication
disorders as well as the time frame for release of
the ICF-CY.
The primary purpose of this paper is to describe
the usefulness of the ICF as a framework for des-
cribing SLI. To this end, the origin of the ICF will be
outlined followed by a description of its classifi-
cation system as it relates to SLI. First, an introduc-
tion to SLI, including areas of impairment and
potential factors affecting language abilities will
also be reviewed. Second, a brief illustration of
how the ICF can be applied to SLI, facilitating
service delivery, assessment, and treatment practices
will be discussed. Finally, a need for an orien-
tation to and measurement of participation will be
highlighted.
The ICF and language impairment 243
The ICF: Origin, concept, and paradigm shift
In 1980, the WHO developed an original frame-
work for healthcare provision called the International
Classification of Impairments, Disabilities and Handi-
caps (ICIDH). The purpose of this framework was to
provide a means for researchers and clinicians to
understand and classify the consequences of diseases
as well as the impact of those diseases on an indi-
vidual’s life (WHO, 1980). The basic premise of
the ICIDH was that impairment existed within the
person, caused directly by some disease or trauma.
This impairment in turn created a disability or
restriction of activities resulting in a handicap or
limitation that affected an individual’s ability to
participate fully in life (WHO, 1980). Essentially,
impairment led to disability, which led to handicap.
The underlying assumption of such a biomedical
focus was that any health problem found its
genesis in impairment, without consideration of
co-occurring levels of functioning and disability.
Treatment for health problems in turn had a one-to-
one relationship with the cause resulting in a
search for the cure of the disease (Threats & Worrall,
2004).
This classification scheme has been criticized for
the type of language used as well as its failure to
consider variables operating outside of the individual
that potentially affect his/her life (Threats & Worrall,
2004). A change in the terminology and underlying
conceptual framework (i.e., biomedical) was neces-
sary to not only account for the myriad of variables
affecting a person’s health, but to also address the
lack of unification and synergy that existed in such a
unidirectional framework. To provide a more com-
prehensive view of health and health status, the
WHO proposed a new, more holistic framework that
considered the influence of contextual variables
including societal attitudes, environmental con-
straints, and factors unique to each person, such as
motivation or type of personality, that impacted
health status (WHO, 2001).
In contrast to the ICIDH, the ICF, an end result
of unpublished beta-versions (e.g., ICIDH-2), used a
bio-psycho-social approach to the classification of
health states. The use of such an integrated approach
not only permits the inclusion of biological factors,
but also incorporates influential contextual variables
such as personal and environmental factors that
impact a person’s level of health functioning.
The theoretical framework supporting the ICF
willingly combines the medical and social views of
health to accommodate for the existence of disability
without a co-occurring impairment. As a result,
variables that occur within and/or outside the
person are considered when classifying health state
(WHO, 2001).
Within the WHO, health is described as more than
just the absence of disease or infirmity but is instead
a complete state of physical, mental, and social
244 K. N. Washington

well-being (WHO, 1948). This view of health, which
is incorporated within the ICF, ultimately acknowl-
edges the dynamic interaction that exists between
varied levels of functioning, resulting in a more
complete representation of a person’s health status.
This newly revised framework provides the structural
support for WHO’s recently proposed classification
system, The International Classification of Functioning,
Disability, and Health (ICF). This tool provides a
more holistic view of health by including health-
related states that have been ignored, but that are
now included due to the significant impact they have
on a person’s ability to attain life fulfilment. It
appears that the ICF has linked seemingly disparate
areas of health functioning into a coherent whole.
The classification system that results from this
framework is one that incorporates three inter-
related levels of daily functioning including, Body
Functions and Structures, Activities and Participa-
tion, and of course Contextual Factors (ICF com-
ponents are denoted using capitalization throughout
the remainder of this paper to distinguish these
items from their everyday use). Conceptually, it
is evident that a shift from a unidirectional to a
multi-directional classification scheme has occurred,
encouraging a multidimensional approach to health
care.
The ICF has four levels of classification beginning
with two parts, Functioning and Disability (Part 1)
and Contextual Factors (Part 2), each with its own
set of corresponding components, domains, and
categories. Within this framework, there is a generic
coding system used for the classification of health
conditions. Codes within this classification scheme
are modified using one or more qualifiers to highlight
the nature or extent of the health condition. All codes
are first identified using a universal qualifier that
ranges from ‘‘0’’, indicating no problem, to ‘‘4’’,
indicating a complete problem. Definitions of terms
used within the ICF, along with an illustration of
interactions between ICF components, are detailed
in Table I and Figure 1, respectively. The com-
ponents and corresponding domains of the ICF
are detailed in Table II. The author has listed
the most applicable codes to be considered for the
child with specific language impairment in the
Appendix.
Part 1, Functioning and Disability, consists of two
components. The first component within Part 1 is
Body Functions (e.g., language, cognition, and
short-term memory) and Structures (e.g., the frontal
or temporal lobes), designated by the roman letters b
and s respectively. Two qualifiers are used to modify
the extent or magnitude of the impairments of the
system for Body Structures, while only one qualifier
is used for Body Functions. The ICF therefore has
levels of codes and qualifiers that are used to care-
fully describe health status. For example, b can be
amended first by adding 1440 to specify short-term
memory (i.e., b1440) and then further expanded by
appending .2 to indicate a moderate impairment
(i.e., b1440.2). Activities and Participation, the
second component within Part 1 designated by the
roman letter d, describes the functional aspects of an
individual, including areas such as learning to read
(d140), learning to write (d145), solving problems
(d175), and starting a conversation (d3500). The
qualifiers, capacity (i.e., the ability to do a behaviour
in a standard setting such as a clinic room) and
performance (i.e., the ability to do a behaviour in
your own environment) are used as descriptors for
Activities and Participation. Part 2, Contextual
Factors, designated by the roman letter e, includes
two aspects: (a) Environmental Factors, which can
be coded as either a facilitator or a barrier (e.g.,
support from immediate family [e310] or a speech-
language pathologist [e355]); and (b) Personal
Factors (e.g., sex, level of motivation). The addition

Table I. A description of the components, domains, and constructs of the ICF.

Component
Body Functions and Structures
Activities and Participation
Contextual Factors
Description
Body functions are the physiological functions of body systems (including psychological
functions).
Body structures are anatomical parts of the body such as organs, limbs and their components.
Impairments are the problems in body function or structure such as a significant deviation or loss
(a negative aspect).
Activity is the execution of a task or action by an individual.
Activity limitations are difficulties an individual may have executing activities (a negative
aspect).
Participation is involvement in a life situation.
Participation restrictions are problems an individual may experience in involvement in life
situations.
Environmental factors make up the physical, social, and attitudinal environment in which
people live and conduct their lives.
Personal factors are the particular background of an individual that are not part of a health
condition or health states. These factors may include gender, age, other health conditions,
upbringing, and coping styles.

Note: Definitions from the International Classification of Functioning, Disability, and Health (ICF; p. 10) by the World Health Organization
(WHO), 2001, Geneva, Switzerland: Author. Copyright 2001 by the WHO. Reprinted with Permission.
 The ICF and language impairment 245

Figure 1. Current interactions between the components of the International Classification of Functioning, Disability, and Health, ICF. Note.
From the ICF (p. 18) by the World Health Organization (WHO), 2001, Geneva, Switzerland: Author. Copyright 2001 by the WHO.
Reprinted with Permission.

Table II. A list of components and domains within the ICF. of these factors was a direct result of continued
Component Domain interest in understanding the influential nature of
components beyond Functioning and Disability that
Body 1. Mental functions
affect a person’s life.
Functions 2. Sensory functions and pain
3. Voice and speech functions According to Simmons-Mackie (2004), the ICF
4. Functions of the cardiovascular, may be the most appropriate framework to use when
haematological, immunological, and working with children. It encourages movement
respiratory systems away from a primary focus on Impairment toward
5. Functions of the digestive, metabolic,
the inclusion of Contextual Factors that modify
and endocrine systems
6. Genitourinary and reproductive functions Body Functions and Structures and Activities and
7. Neuromuscular and movement-related Participation. Further, the ICF is a more encom-
functions passing framework that considers the interdepen-
8. Functions of the skin and related structures dence amongst the various domains of health that
Body 1. Structures of the nervous system affect children, including those with SLI. Given the
Structures 2. The eye, ear, and related structures ICF’s expanded definition of health, which illustrates
3. Structures involved in voice and speech how decreases at any level (e.g., Activities and
4. Structures of the cardiovascular,
immunological, and respiratory systems Participation) can lead to a disorder such as SLI, it
5. Structures related to the digestive, is reasonable that this developmental language
metabolic and endocrine systems impairment is considered another child health con-
6. Structures related to the genitourinary and dition in need of further exploration.
reproductive systems
7. Structures related to movement
8. Skin and related structures Language acquisition and development
Activities and 1. Learning and applying knowledge
Investigation into the language acquisition process of
Participation 2. General tasks and demands
3. Communication typical language learning children is important for
4. Mobility understanding the mechanisms underlying the sys-
5. Self-care tem breakdown and possible treatment for children
6. Domestic life with SLI. Research findings gathered over the years
7. Interpersonal interactions and relationships
have generated numerous theories explaining lan-
8. Major life areas
9. Community, social and civic life guage acquisition and development. To date, pro-
posed theories include innate determination, the
Environmental 1. Products and technology
Factors 2. Natural environment and human-made Nativist Perspective; the sole influence of the
changes to environment environment, the Environmentalist Account; and
3. Support and relationships the interaction of biology, the environment, and
4. Attitudes information processing, the Interactionist Position
5. Services, systems and policies (see Paul, 2001; Piaget, 1952; Vygotsky, 1962, for
Note: Personal Factors are excluded from this table as they are not a detailed discussion of these theories). It is assu-
specified in the current version of the ICF. med that language learning is a multidimensional
246 K. N. Washington
phenomenon dependent upon cognitive, social,
linguistic, and biological interplays. While no over-
arching theory for language development exists, it is
agreeably a highly complex process unique to each
child. The synthesis offered by the integrated
approach of the Interactionist Position may offer
some reconciliation between theories that best facili-
tate our understanding of the multifaceted nature of
language development.
The identification of SLI
The language learning process occurs as a result of
numerous inter-related factors that facilitate the
comprehension and ultimate production of lin-
guistic structures. Since the road to learning
language is as complex as has been described, the
process of unravelling how or why the system breaks
down is equally complex. While the cause of SLI is
not fully understood, it is described as a type of
developmental language impairment, more com-
mon in boys than in girls, that is characterized by
a child’s persistent difficulty in acquiring age-
appropriate language skills despite having normal
IQ (Ahmed, Lombardino, & Leonard, 2001; Snyder,
Dabasinskas, & O’Connor, 2002).
The term SLI is used when developmental lan-
guage impairments exist in the absence of any known
difficulties in other areas such as biological or
emotional functioning. SLI is therefore considered
exclusionary in nature, affecting approximately 7%
of children.
Typically, children with SLI demonstrate varying
degrees of language difficulty resulting in an assort-
ment of profiles and suggested subtypes (Bishop,
2004; Van Daal, Verhoeven, & van Balkom, 2004).
The most commonly observed difficulties are in
language form, affecting syntax, morphology, and
phonology; while language comprehension and prag-
matics are generally intact (Leonard, 1997). It has
been commonly accepted that children with SLI are
not necessarily deviant in their language develop-
ment; instead they are limited in their capacity for
language learning. Hence, they are considered a
heterogeneous group who are less adept at learning,
producing, and at times acquiring language at a
normal rate and by an expected age (Bishop, 2004;
Leonard, 1997). It is agreed that SLI is a result of
some compromise in the development of specific
language skills. For the most part, these language
skills are considered to be higher cognitive deficits
that affect the use of complex linguistic structures,
literacy acquisition, including decoding and compre-
hension, problem solving abilities, and mature lexical
development (Ahmed et al., 2001; Bishop, 2004).
Potential mechanisms underlying SLI
While the aetiology of SLI remains somewhat
unanswered, a number of child language researchers
(e.g., Baddeley, 2003; Bishop, 1992; Ellis Weismer,
Evans, & Hesketh, 1999; Kail, 1994; Montgomery,
2002; Tallal, 1988; Washington & Warr-Leeper,
2006b) have proposed a variety of working hypoth-
eses accounting for deficit mechanisms affecting
language abilities including: (a) inefficient use of
limited space within verbal working memory; (b)
inability to automate the learning process, affecting
speed of processing; and (c) auditory perceptual or
temporal processing difficulties. Like most other
theories attempting to explain the occurrence of SLI,
each of the aforementioned hypotheses is for the
most part exploratory with no one account being
ultimately definitive or universally applicable to all
children labelled as SLI. However, it has been
suggested that because language learning is multi-
dimensional, the use of comprehensive frameworks
are most suited to deciphering such a pheno-
menon (Simmons-Mackie, 2004; Washington &
Warr-Leeper, 2006a).
The application of the ICF to SLI in children
The application of the ICF to SLI is essential as its
framework permits a more comprehensive examina-
tion of this health condition. The inclusion of
multiple areas of functioning within the ICF creates
a necessary pathway for linking language deficits to
broader life skills. Due to its consideration of
contextual variables, the ICF is considered an
ethologically valid framework that best depicts
the holistic nature of communication disorders
(Threats & Worrall, 2004). Use of this framework
in speech-language pathology can broaden the
clinician’s understanding of communication disor-
ders in children and ultimately increase the breadth
of assessment and treatment practices used in the
field (McLeod, 2006; McLeod & Bleile, 2004;
Simeonsson, 2003). Given the prevalence of SLI
amongst children (i.e., 7%) as well as the associated
long-term negative impacts (e.g., poor academic,
vocational, social and life achievement), it would be
beneficial that this framework be used to address this
phenomenon.
The following sections detail components of the
ICF as they relate to SLI in preschool and school-age
children. As a consequence of describing each of
these sections, it may appear that the ICF is unidirec-
tional and discrete; however, it is important to note
that this is not the case.
SLI—function and disability: An examination of
body functions and structures
When SLI was identified over 70 years ago it was
defined by a collection of characteristic behaviours
shared by children who appeared to have difficulties
in language comprehension and expression. Since its
identification, numerous investigations of neuro-
logical, anatomical, and genetic associations for the

occurrence of SLI have been completed (Ahmed
et al., 2001; Bishop, Laws, Adams, & Norbury,
2006; Bishop, North, & Donlan, 1995; Bishop,
Price, Dale, & Plomin, 2003; Lane, Foundas, &
Leonard, 2001; Plante, Swisher, & Vance, 1989;
Rice, Haney, & Wexler, 1998). With the advent of
neuroimaging technologies within the medical field
(i.e., magnetic resonance imaging, MRI, and func-
tional magnetic resonance imaging, fMRI), contin-
ued investigation of the neurobiological correlates of
language have been examined.
Researchers posit that given the neurobiological
function of language, it is reasonable that most
language impairments reflect deficits in some biolo-
gical mechanisms (Ahmed et al., 2001; Bishop,
2004; Plante, 1991). To date, several medical
explanations for language deficits have been con-
sidered (Hugdahl, Gundersen, Brekke, & Thomsen,
2004; Lane et al., 2001). Typically, the impact of soft
neurological signs in brain neuroanatomy has been
investigated, including: (a) unusual brain morphol-
ogy, namely reduced lateralization or atypical asym-
metry, (b) decreased brain activities in language
dominant regions, and (c) genetically-based lan-
guage deficits. It is important to note that these areas
are implicated generally and are not necessarily
causally related as some normally developing chil-
dren can demonstrate these medical signs (Ahmed
et al., 2001; Foundas, Leonard, Gilmore, Fennel, &
Heilman, 1996).
Neuroanatomical correlates of language
structures and functioning
Studies examining the neuroanatomical status of
children with SLI have found that specific regions
within the perisylvian regions of the language domi-
nant hemisphere are at times anatomically atypical
(Ahmed et al., 2001; Gauger, Lombardino, &
Leonard, 1997; Plante, 1991; Trauner, Wulfeck,
Tallal, & Hesselink, 2000). The two, most impli-
cated brain regions are the pars triangularis (PTS), a
core constitution of Broca’s area, and the planum
temporale (PTM), a subcomponent of Wernicke’s
area. Normal asymmetry dictates that these regions
are larger in the left than in the right hemisphere to
accommodate for the production and comprehen-
sion of language, respectively. However, some MRI
twin and singleton studies (e.g., Ellis Weismer,
Plante, Jones, & Tomblin, 2005; Gauger et al.,
1997; Plante et al., 1989) have found that language
structures in the right and left perisylvian region are
symmetrical or that the right is larger than the left in
children with SLI. The distribution of these perisyl-
vian asymmetries for SLI participants is significantly
different than for age-matched controls.
Current research has expanded to include inves-
tigations of functional neuroanatomy using fMRI
technologies to provide information on possible
differences in brain activation in children with SLI.
The ICF and language impairment 247
Results of these investigations suggest that indivi-
duals with SLI show reduced activation in language
dominant brain areas (e.g., inferior frontal gyrus and
the middle and superior temporal gyri) during
speech and language tasks as compared to control
participants (Ellis Weismer et al., 2005; Hugdahl
et al., 2004). Researchers have speculated that
decreased activities within these brain regions
suggest that children with SLI may have developed
a reliance on less functional methods of processing
and producing information, resulting in an ineffi-
cient use of brain networks.
Genetically-based language correlates
Over the past decade, growing recognition for the
role of genetics in the existence of language impair-
ments in children has been noted (Bishop et al.,
2003; Hudghal et al., 2004). Major advances in
understanding the aetiology of SLI have led to
speculations about the important role of heritability
in causing this language impairment (Ahmed et al.,
2001; Bishop et al., 2003, 2006; Rice et al., 1998;
Trauner et al., 2000). Twin studies completed on
both monozygotic (MZ) and dizygotic (DZ) twins
have found substantially higher concordance for
SLI in MZ versus DZ twins with .45 or higher
heritability estimates (Bishop et al., 1995, 2003,
2006). The variability of these estimates is reportedly
different across the literature depending on the
definition or criteria used to identify SLI (Bishop
et al., 2003; Watkin, Dronkers, & Vargha-Khadem,
2002).
Prospective studies conducted on the occurrence
of SLI found a familial linkage between parents and
siblings who were identified as language-impaired
and children with SLI in both nuclear and extended
families (Lai, Fisher, Hurst, Vargha-Khadem, &
Monaco, 2001; Spitz, Talla, Flax, & Benaish,
1997). While fathers of children with SLI reportedly
have a higher rate of both speech and language
impairments, it is more likely that children will have
language deficits if their mothers had these deficits as
children (Plante, 1991; Rice et al. 1998). To date, a
point mutation of a gene on chromosomes 7, 16, or
19 has been identified in affected family members
(Watkins et al., 2002). Caution in classifying these
findings as genes specific to SLI, particularly for
chromosome 7, is noted given that the phenotype in
the affected family members is reportedly severe with
considerable impairments in syntax, phonological
processing, and orofacial praxis (Watkins et al.,
2002). Other research work has also identified the
deletion of the FOXP2 gene on the 7q31 locus as a
potential cause of speech-language impairments (Lai
et al., 2001). Further investigation into genetic
causes of SLI is continuing in order to determine if
duplication of region 7q11.23 might be a second
locus of speech-language impairment. The familial
tendency for the occurrence and seemingly biological
248 K. N. Washington
transmission of language impairment gives credence
to the notion that there is a genetic basis for SLI.
It is evident that regions of the language dominant
hemisphere can be significantly different in children
with SLI in terms of their size, shape, and activation
as compared to normally developing children.
Further, the role of a biologically transmittable factor
in SLI is reasonable because children who have
parents and siblings with some type of developmental
language impairment are at a greater risk for develo-
ping language difficulties.
Psychological processes
Researchers have suggested that impairments in
higher order mental functions exist that potentially
result in SLI (Hill, 2001; Lahey & Bloom, 1994).
They hypothesize that children with SLI have
difficulties allocating resources, forming mental
models for varied constructs, while they simulta-
neously processing information, and thus are unable
to attend to salient information. As a result, there are
increased burdens on resources, decreased formation
of mental models to facilitate learning, and inade-
quate, weak, or deficient processing. Typically, the
processing of information from the environment is
fast-acting and for the most part error-free. When
processing information, children construct ideas
(i.e., mental models) for interpretation and expres-
sion by integrating information from the present
context with information accessed from long-term
memory. These mental models are essentially short-
cuts in the information processing cycle that expedite
language learning. The fluid nature of these models
makes them subject to change as new information is
added to the system. The complementary Piagetian
processes of assimilation and accommodation, ne-
cessary for the integration of information, come into
play to facilitate these changes. The older the child
becomes, the more complex the mental model and
the more adept s/he must be in formulating and
using concepts.
Limitations in the automation of language skills
(e.g., word retrieval or decoding) in children with
SLI may lead to decreased capacities to construct
mental models thereby overusing well-needed re-
sources (Lahey & Bloom, 1994; Snyder et al., 2002;
Washington & Warr-Leeper, 2006a). Ultimately, the
child’s inability to maintain a balance between
available resources and task demands results in an
overload of the system leading to inefficient use of
limited spaces in verbal working memory, affecting
speed of processing (Ellis Weismer et al., 2005; Gill
et al., 2003; Kail, 1994; Lahey & Bloom, 1994).
Children with SLI are at a significant disadvantage
because they are unable to make the routine for
learning more automatic thereby: (a) decreasing
attention to salient features; (b) increasing memory
load and burden on resources; and (c) decreasing
mental models for language structures and further
growth. In the end, these children expend resources
struggling with language knowledge and are thus
unable to produce sufficient mental models or keep
them active, making the language learning pro-
cess more tedious and difficult (Washington &
Warr-Leeper, 2006a).
Function and disability: An examination
of activities and participation
The Activities and Participation components of the
ICF describe an individual’s ability to execute a task
in everyday life situations (WHO, 2001). To date,
there remains a continued debate regarding differ-
entiating the Activities and Participation domains
within the ICF (Threats & Worrall, 2004). To
accommodate for varying preferences, the ICF has
listed four options to be used when interpreting these
components (WHO, 2001; Threats & Worrall,
2004). While Option 4 has been identified as the
most popular choice due to its use of overlapping
Activities/Participation domains, for the purposes of
this paper, Option 1, which has distinct domains for
these components, will be used. The author has
chosen this option because it permits an examination
of how impairment or functioning in either domain
can positively or negatively influence the other.
The need for Activities and Participation compo-
nents to describe the impacts of communication
disorders has been reported in the literature (Eadie
et al., 2006; McLeod, 2004; 2006; McLeod & Bleile,
2004; Simmons-Mackie, 2004; Threats, 2003;
Threats & Worrall, 2004). Researchers examining
Activities and Participation for children with com-
munication disorders suggest that the wide range of
negative consequences associated with this disorder
necessitate its use (McLeod, 2004, 2006; Simmons-
Mackie, 2004). These consequences include, but are
not limited to: (a) low grades, weak oral and written
skills, social failure and an inability to adapt to and
learn the language of the classroom (Gertner, Rice, &
Hadley, 1994; Lewis, Freebairn, & Taylor, 2000);
(b) withdrawal from peer interaction (Fujiki,
Brinton, Isaacson, & Summers, 2001); and (c)
demonstration of social and behavioural problems
(Hart, Fujuki, Brinton, & Hart, 2004). Combined,
these deficits can decrease the probability of the
development of socially productive relationships
(Washington & Warr-Leeper, 2006a). It is therefore
essential that S-LPs include Activities and Participa-
tion ratings (e.g., using anecdotal observations and
teacher/parent/student questionnaires or interviews)
along with standardized test scores to determine level
of language functioning, nature/impact of the im-
pairment, and services needed to improve current
language level. These ratings could broaden the
criteria used for accessing, terminating, or continu-
ing speech-language services within schools, result-
ing in appropriate use of resources that helps to
improve the QOL experienced by children with SLI.

While it is known that a child with SLI can exp-
erience deficits in Body Functions and Structures
and psychological processes, the potential effects of
these deficits on a child’s functioning in everyday
situations is not always explored. The relationship
between biological functioning, social competence,
and language proficiency is both reciprocal and
interdependent. Atypical neuoranatomy, genetic
anomalies, and weak psychological processes can
limit a child’s ability to learn critical language skills
(e.g., production, comprehension, and socialization)
that are essential to full participation. Ultimately,
children with SLI can be excluded from social
activities and potentially become rejected and iso-
lated. These exclusions decrease opportunities for
exposure to language and practice in learning social
scripts and conventions, further exacerbating an
existing problem or potentially creating new ones.
Continued exposure to language learning opportu-
nities is important as they facilitate the on-going
expansion of critical language skills. The value of
well-developed language skills in children with SLI is
manifest in strong interpersonal skills and social
competence, positive parent-child attachments and
interactions, and positive school experiences (Liiva &
Cleave, 2005). Good language skills are therefore
important as they facilitate the formation and
maintenance of friendships, which is one of the most
basic human needs.
Taken together, impairments within Body Func-
tions and Structures can negatively affect language
skills and application of those skills. To date, a
growing number of clinicians and researchers are
making the necessary links among biology, language
tasks, and the larger social and academic context of
communication. The interdependent relationship
between Functioning and Disability and Contextual
Factors illustrated within the ICF framework can
therefore be applied to SLI to gain a greater under-
standing of the nature of this disorder. This relation-
ship will be further elaborated in following sections
of this paper.
Contextual factors: Role of personal and
environmental factors on performance
The nature of language learning necessitates inter-
play between a child’s innate constitution (i.e.,
Personal Factors), and environmental situation
(i.e., Environmental Factors). Personal Factors are
not detailed within the ICF, but are included given
their core role in health functioning. In its descrip-
tion, the ICF maintains that Personal Factors are not
the result of a health condition, but may contribute
to it (WHO, 2001). These factors can be changeable
(e.g., level of motivation) or unchangeable (e.g., age,
sex) acting together to affect Functioning. Personal
Factors can directly influence a child’s ability to
comprehend and/or produce language, as they are
undoubtedly associated with level of language
The ICF and language impairment 249
functioning. For example, a more motivated client
may perform better in treatment than a client who is
less motivated. Consideration of Personal Factors
can inform clinical decision making as clinicians and
researchers examine characteristics of clients that
may affect their performance. Favourable modifica-
tion of client characteristics (e.g., improving coping
styles, decreasing frustration) is the hallmark of good
clinical management. Clinicians are able to deter-
mine the client characteristics in need of modifica-
tion through observations made in assessment
sessions and/or in the early stages of treatment. For
example, if a client has a low tolerance for struggle in
treatment, the clinician will ensure success through
highly scaffolded learning and gradual shaping of
required responses. Application of this type of
knowledge is beneficial in speech-language pathology
as it guides management of the language problem,
the client’s behaviour, and his/her ability to function
effectively.
Environmental Factors are more clearly delineated
within the ICF. These factors are defined as the
‘‘physical, social, and attitudinal environment in
which people live and conduct their lives. These
factors are external to individuals and can have a
positive or negative influence on the individual’s per-
formance as a member of society, on the individual’s
capacity to execute actions or tasks, or on the
individual’s Body Function or Structure’’ (WHO,
2001, p. 16). From this definition, it is assumed that
Environmental Factors can be either facilitators of or
barriers to effective Functioning and possible creators
of barriers to Participation. The ICF organizes
physical, social, and attitudinal factors into two
different levels. Level one, individual, considers the
role of settings such as home, school, and work. Also
included is the impact of personal relationships with
peers, family members, and health care professionals.
Level two, societal, incorporates services, social
structures, regulations, formal and informal rules,
attitudes, and ideologies that have an impact on
individuals (WHO, 2001).
Aspects of a child’s individual and societal environ-
ment are crucial to his/her ability to communicate
and learn effectively. Within a child’s immediate
individual environment (e.g., home or school) any
number of factors can positively or negatively affect
the development of his/her language abilities. For
example, a decreased signal-to-noise ratio in the
home or classroom environment may create difficul-
ties for deciphering relevant stimuli (Nelson, 1985;
Snyder et al., 2002). In addition, lack of exposure to
enriched oral language and literacy experiences at
home can result in insufficient language stimulation
(Frijters, Barron, & Brunello, 2000; Justice & Ezell,
2000). Environmental facilitators include making
appropriate educational accommodations such as
engaging in shared reading activities at home that
help prepare children for future school success.
Within a child’s societal environment, there may be
250 K. N. Washington
insufficient funding from the government or laws
and implementation regulations that limit who
may or may not access speech-language services
(Washington, Warr-Leeper, & Luke, 2005). A child
may also experience difficulties obtaining transporta-
tion to and from services or restrictions in the amount
of service available that potentially hinders his/her
progress (Washington et al., 2005). Further, a lack of
understanding about SLI, attitudes, reactions, and
beliefs of individuals or groups (e.g., friends, family,
teachers, and healthcare professionals) can exa-
cerbate a language problem by creating a societal
environment that is not conducive to inclusion
(Washington & Warr-Leeper, 2006a). Support from
any aspect of the child’s societal environment (e.g.,
providing services in the home or daycare, increasing
awareness of SLI through parent/teacher workshops)
can create circumstances that are encouraging
continued language growth.
Contextual Factors play crucial roles in the
language learning process by interacting with Body
Functions and Structures and Activities and
Participation to create circumstances that may
positively or negatively influence a child’s develop-
ment of language (Washington & Warr-Leeper,
2006a). The ICF describes Personal Factors in a
more rudimentary fashion given their variable
nature. The influence of these factors is, however,
considered crucial when working within children as
they have the potential to positively or negatively
influence treatment outcomes. Researchers investi-
gating the impact of Personal Factors such as age,
IQ, and sex report that these variables can be
predictive of performance and therefore warrant
continued exploration (Washington & Warr-Leeper,
2006a).
While the ICF does not directly illustrate the link
between Environmental and Personal Factors, the
author believes that they strongly affect each other in
a synergistic relationship. For example, decreased
involvement in classroom-based or social activities,
caused by certain personality traits, potentially makes
it difficult for children to learn in school or to
establish and maintain friendships. Lack of support
from family members, friends, or support services,
may further intensify and even create problems
within the child by decreasing opportunities for
practice in and exposure to language. Given that
language learning is a multi-dimensional pheno-
menon, it is believed that difficulties in language
development can be influenced by many unique and
inter-related factors that act together (Washington &
Warr-Leeper, 2006a). Therefore, the interdepen-
dence of the various components within and between
Parts 1 and 2 of the ICF framework is useful for
understanding the phenomena of SLI in preschool
children.
An expansion of the interaction between Function-
ing and Disability and Contextual Factors for
the child with SLI is presented in Figure 2. This
depiction of the ICF provides a description of
pathways of interaction. The two-headed, dotted-line
arrows between Body Functions and Structures and
Activities and Participation represent mutual influ-
ences. For example, increasing a child’s capacity for
communication (e.g., increasing oral language skills)
with treatment could positively influence Function-
ing of impaired brain structures (e.g., PTM or PTR).
As a result, areas of the brain that typically experience
hypoactivation during the completion of language
tasks may react differently after treatment. Increases
in Activities could also lead to more Participation,
thereby improving the opportunities for application
of learned skills. Improved Participation further
strengthens functions of impaired brain structures
through exposure to well-needed interactions with
family and peers. Specifically, improving a child’s
receptive and expressive language abilities by helping
them to: (a) sequence morphemes and phonemes
together into more complex and coherent utterances,
and (b) process and store information as well as to
decipher sounds, signs, and symbols necessary for
reading and following along in the classroom, could
facilitate inclusion in everyday conversational and
play situations important for the development of
cognitive skills. Overall improvements in func-
tioning of Body Structures and Activities and
Participation could enhance relationships with others
in the environment resulting in more stimulation of
language development from significant others and
more motivation to attempt communication.
Furthermore, support from family members, toler-
ance and acceptance by peers, and access to
well-needed speech-language and school services
could positively affect coping styles and level of
motivation further strengthening Functioning and
decreasing Disability.
Implications for the application of the ICF
for children with SLI
Previous sections of this paper detail the need for the
ICF due to its overarching framework and immedi-
ately useful application. Use of this framework as a
clinical tool in speech-language pathology is encour-
aged, as it could assist in: (a) deciphering the nature
of SLI; (b) increasing comprehension of the impact
of Body Functions and Structures, Activities and
Participation, and Contextual Factors on language
competence for children with SLI; (c) increasing the
breadth of assessments tools and outcome measures
used; (d) selecting a wider-range of goals in and
approaches to treatment; (e) expanding notions of
what constitutes service to include such activities as
health promotion and prevention; (f) broadening
what constitutes improvement in language function;
and (g) helping to demonstrate the usefulness of
speech-language services for functioning in various
life areas. Moreover, the various components within
the ICF framework support the need for the myriad
 The ICF and language impairment 251

Figure 2. Interconnections among areas of the International Classification of Functioning, Disability and Health, ICF as they relate to SLI. The
dotted lines represent the interaction between Part 1 and Part 2 of the ICF and between the components of the ICF. Impairments in Body
Functions and Structures, Activity-limitations, and Participation-restrictions are depicted in Part 1. Potential areas of influence within and
outside the child with SLI are denoted in Part 2. From ICF (p. 18) by the World Health Organization (WHO), 2001, Geneva, Switzerland:
Author. Copyright 2001 by WHO. Adapted with Permission.

of services used within speech-language pathology
and can assist in the identification of other areas that
need to be addressed.
As the field of speech-language pathology evolves,
services provided should continue to address all
components of the ICF framework. To date, services
within Part 1 include advances in medical technology
that permit more detailed examination of brain
structures and activations as well as genetics to
better understand how language is potentially
acquired, produced, and understood. Treatment of
language deficits can therefore be focused to better
improve language functioning, Activities (e.g., the
ability to comprehend, converse, read) and Partici-
pation (e.g., following directions in the classroom,
talking with classmates to solve a problem, gaining
information from reading) in everyday life. Services
within Part 2 include the provision of information
and training for significant others on how to best
facilitate language in normally developing and
disordered children. Additionally, direct services to
children in their natural environment (e.g., the
daycare or school) or indirect service, such as
mediated language stimulation through daycare
providers, ultimately address Environmental and
Personal Factors while targeting Functioning and
Disability.
Evaluation of the effectiveness of services provided
is common practice, acting as a guide to continuous
improvement in the field. During the process of
evaluation, outcomes of services at different levels
are typically measured, focusing primarily on Activ-
ities. The next most appropriate step being pursued
in speech-language pathology is the expansion of
252 K. N. Washington
measures examining Participation (Eadie et al.,
2006). According to Threats (2003, p. 2), ‘‘the
ultimate therapeutic outcome is not what happens in
the clinic; it is post-therapy communication func-
tioning of the person’’. Essentially, the question of
whether a child is able to apply and/or generalize
learned skills beyond the level of the clinic or
laboratory allowing for Participation in the main-
stream should be addressed. While the inadequate
number of instruments exclusively evaluating
Participation outcomes has been addressed for adults
with communication disorders (Eadie et al., 2006),
their necessity for use with children is less empha-
sized. Of the small number of tools available for
measuring outcomes in children with language
impairments, few solely address Participation. The
development and implementation of tools examining
Participation outcomes is an important step toward
improving the identifiable everyday effects of speech-
language services for preschool and school-age
children. To date, researchers at Bloorview Kids’
Rehab (formerly Bloorview Children’s Centre)
located in the province of Ontario, Canada, have
begun beta testing on a measure of Participation.
This measure is an expansion of the earlier measures
evaluating the everyday impact of speech and
language services. In addition, the Ontario Preschool
Speech and Language Initiative, a provincially-
funded programme providing early intervention
services to preschool children between birth and six
years of age with speech and language disorders,
has already begun to evaluate children’s Participation
outcomes. Given that there is an on going para-
digm shift from focus on Impairment to Activities
and Participation not only in health care but
also in speech-language pathology, use of measures
that are reflective of the current philosophy is
warranted.
Conclusions and future directions
The integrated approach offered by the ICF may
be used as a heuristic for understanding the
multifactorial nature of language development and
disorders. The ICF permits a comprehensive con-
ceptualization of language functioning that guides
our assessment, treatment, and ultimately our
measures of outcomes leading to further modifica-
tion of services thereby fostering best practices in the
area of SLI. While the illustration depicted in
Figure 2 is currently a conceptual expansion of the
ICF, it can be empirically tested through investiga-
tions of outcomes at different levels. As mentioned
earlier, research work evaluating Participation out-
comes for children with speech and language
disorders has already begun. Since the ICF also
highlights Contextual Factors in need of considera-
tion, the next step should be the evaluation of their
impact on a child’s responsiveness to and outcome in
treatment. Valid and reliable qualitative measures
such as parent and/or teacher interviews and ques-
tionnaires can be used to determine these effects.
Further, insights from the ICF-CY can be used for
assessment, goal selection, and treatment of children
with communication disorders, including those with
SLI.
The need for evidence to guide clinical and
research practices is critical and has begun to
increase within speech-language pathology (Threats,
2003). Adoption of the ICF framework is therefore
encouraged as it can be used to guide future research
investigations. Given that there is an increase in the
need for accountability of services provided, use of
the ICF framework is considered timely (Threats,
2003). In the end, adoption of the ICF is beneficial
not only for clinicians and researchers but also for
clients and their families.
The comprehensive nature of the ICF framework
provides a more complete investigation of the nature
and potential areas of influence on SLI in preschool
and school-age children. Adopting this framework
has many practical advantages but its use in everyday
settings will take time. Researchers and clinicians
wishing to apply this framework within SLI may
require on going support from other colleagues and
administrative personnel to facilitate its implementa-
tion. Ultimately, use of the ICF framework within
speech-language pathology encourages a broader
approach to services that is reflective of the varied
needs of children with SLI.
Acknowledgements
The author of this paper gratefully acknowledges the
unrelenting support of her supervisor, Dr. Genese
Warr-Leeper, an exceptional clinician, researcher,
and advocate in the area of child language disorders.
The author also acknowledges the guidance and
editorial assistance of Nancy Thomas-Stonnel,
Bloorview Kids Rehab; Comprehensive Committee
members from the University of Western Ontario,
Drs. Doreen Bartlett and Ruth Martin; and the
funding support of the Canadian Language and
Literacy Research Network (CLLRnet). Further
appreciation is sent to family members for their
continued support during the completion of this
document.
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Appendix 1
ICF codes considered relevant to the child with SLI
ICF Code Application to the Child with SLI
Part 1: Functioning and Disability
B. Body Functions
b1 Mental Functions Difficulty processing information, formulating mental models, producing
b117 Intellectual Functions complex and coherent sentences, and automating the language-learning
b126 Temperament and personality functions process, despite having a normal IQ
b139 Global mental functions, other specified and
unspecified
b140 Attention functions
b144 Memory functions
b160 Thought functions
b164 Higher-level cognitive functions
b167 Mental functions of language
S. Body Structures
s1 Structures of the nervous system Asymmetries and hypoactivation within the frontal and temporal lobes (e.g.,
s110 Structure of brain the pars triangularis in Broca’s Area, the planum temporale in Wernicke’s
s199 Structure of nervous system Area, the middle and superior temporal gyri)
D. Activities and Participation
d1 Learning and applying knowledge
d110 Watching Difficulties decoding written material essential to reading; have low grades,
d115 Listening weak oral language skills, social failure, difficulty adapting to and learning
d120 Other purposeful sensing the language of the classroom. Decreased ability to solve problems given
d130 Copying the complex language skills required.
d135 Rehearsing
d140 Learning to read
d145 Learning to write
d160 Focusing attention
d163 Thinking
d166 Reading
d170 Writing
d177 Solving problems
d3 Communicating-receiving
d310 Communicating with – receiving spoken messages Difficulty participating in a conversation due to inability to understand verbal
d315 Communicating with – receiving nonverbal and non-verbal aspects of communication, resulting in decreased
messages discussions with others.

(continued)
 The ICF and language impairment 255

Appendix 1 (Continued)
ICF Code Application to the Child with SLI
d325 Communicating with – receiving written
messages
d350 Conversation
d355 Discussion
d7 Interpersonal interactions and relationships Difficulties appropriately initiating interactions with others, tend to be
d710 Basic interpersonal interactions excluded from social activities resulting in decreased opportunities for
d720 Complex interpersonal interactions formulating socially productive relationships.
d730 Relating with strangers
d740 Formal relationships
d750 Informal social relationships
d760 Family relationships

Part 2: Contextual Factors

E. Environmental Factors
e3 Support and relationships and e310 Immediate Amount of support from family members, peers, teachers S-LPs. If
family insufficient, can create an environment that is not conducive to learning
e315 Extended family or attempts to learn.
e325 Acquaintances, peer colleagues, neighbours and
community members
e330 People in positions of authority
e355 Health professionals

e4 Attitudes Attitudes may create circumstances that decrease or increase inclusion into
e410 Individual attitudes of immediate family members everyday academic and social situations necessary for further language and
e415 Individual attitudes of extended family members cognitive growth.
e420 Individual attitudes of friends
e425 Individual attitudes of acquaintances, peers,
colleagues, neighbours, and community members
e430 Individual attitudes of people in positions of
authority
e450 Individual attitudes of health professional
e460 Societal attitudes
e5 Services, systems and policies Level of funding from the government or implementation regulations may
e580 Health services, systems and policies limit or enhance who may or may not access speech-language services.
e585 Education and training services, systems and
policies

Note: The codes used in the appendix represent broad categories essential to language functioning, but the list is not necessarily exhaustive.
The reader is referred to the WHO (2001) for a full list of codes and sub-codes along with their definitions and inclusions/exclusions.
Readers interested in a list of codes relevant to communication disorders in children should see McLeod (2006) and Simeonsson (2003).