Conceptual challenges of the construct ‘functioning and disabilities’ in the person-centered framework


  • Luis Salvador-Carulla University of Cadiz; and Spanish Association for Research on Healthy Ageing (AECES)
  • Javier E. Saavedra
  • Mencia Ruiz



Assessment instruments, disability, functioning, ICF, person-centered care, person-centered integrative diagnosis


The publication of the International Classification of Functioning (ICF), the approval of the UN Convention on the Rights of Persons with Disabilities and the release of the 2011 World Report on Disability are cornerstones in the process of developing a functioning and disability (F&D) perspective in the care systems in the World. However, the significant advances on the conceptualisation of functioning and disabilities -mainly derived from the ICF model- have not produced an international consensus on the definition of this construct and different approaches persist even within the ICF framework. Reasons for dissent are, among others, holistic versus practical approaches to human functioning, universal versus health-related perspectives and assessment of individuals versus assessment of target groups (e.g. specific diseases or age groups). Different models of F&D are described as well as their related assessment instruments. In order to improve the definition of F&D, a clear distinction between the supra-domains ‘activity/participation’ and ‘inclusion/citizenship’ may be needed. Within this context, person-centered medicine and the related Person-centered Integrated Diagnosis (PID) model may provide a new perspective on this topic as it incorporates F&D into a broader frame where F&D domains can be differentiated from the health condition, the experiences of health and the determinants of health.

Author Biography

Luis Salvador-Carulla, University of Cadiz; and Spanish Association for Research on Healthy Ageing (AECES)

Dr Luis Salvador-Carulla is professor of Psychiatry at the University of Cadiz (Spain). He has been member of the Advisory Board on disability and dependency of the regional government of Catalonia (Spain) and he is member of the advisory committee of the national strategy on Mental Health at the Ministry of Health and Social Policy. His field of interest is integrated support decision systems and policy in long-term care. He is honour member of the World Psychiatry Association and secretary of its section “Classification, Diagnostic assessment and Nomenclature”. He is also President of the PSICOST research association, and the Spanish Association on Scientific Research on Healthy Aging (AECES), as well as Vice-president of the Spanish Society of Epidemiological Psychiatry (SEEP). Dr. Salvador-Carulla has intensively participated in the development of international research networks in the fields mentioned as well as in social inclusion, person centered medicine, healthy ageing and bridging and knowledge transfer between the fields of disability and ageing. He has also collaborated with the European Commission (EC) and the World Health Organisation  (WHO) as external advisor. He coordinated the European Commission project eDESDE-LTC for the development of an European coding system for long term care, and he participates now on the EC project Refinement for analysing financing, quality and effectiveness of mental health systems in Europe. He chairs the WHO working group on the classification of intellectual disabilities at chapter V of the International Classification of Diseases (ICD-11).


World Health Organisation.(2001).International Classification of Functioning, Disabilityand Health (ICF). Geneva: WHO.

United Nations.(2006). Convention on the Rights of Persons with Disabilities. Geneva, United Nations. ( disabilities-convention.htm, accessed 17 February 2012).

World Health Organisation and The World Bank. (2011). World Report on Disability. Geneva: World Health Organisation.

World Health Organization. (2002–2004). World Health Survey, Geneva (, accessed 18 February 2012)

The Global Burden of Disease. (2004). Update. Geneva: World Health Organization, 2008a. (, accessed 2 February 2012).

Salvador-Carulla, L. & García-Gutierrez, C. (2011).The WHO construct of health-related functioning (HrF) and its implications for health policy. BMC Public Health 11(Supplement 4) S9.

Salvador-Carulla, L. & Gasca, V.I. (2010).The role of functional disability in psychiatric classification. Life Span and Disability 13 (1) 7-28.

Salvador-Carulla, L. & Gasca, V.I. (2010).Defining disability, functioning, autonomy and dependency in person-centered medicine and integrated care. International Journal of Integrated Care 10 (Supplement) e025.

Aristotle.(2001). “Nicomachean Ethics.”Classics of Moral and Political Theory.3rd ed. Trans. Terence Irwin. Ed. Michael L. Morgan. Indianapolis: Hackett Publishing Company.

Plato.(1992). Protagoras.Trans. Stanley Lombardo and Karen Bell. Indianapolis: Hackett Publishing Company.

Mont, D. (2007).Measuring health and disability. Lancet 369 (9573) 1658-1663.

Valderas, J.M. (2007).Measurement of health and disability.Lancet 370 (9586) 483-484.

Tesio, L. (2011).From codes to language: is the ICF a classification system or a dictionary? BMC Public Health 11 (Supplement 4) S2.

Wehmeyer, M.L., Buntinx, W.H., Lachapelle, Y., Luckasson, R.A., Schalock, R.L., Verdugo, M.A., Borthwick-Duffy, S., Bradley, V., Craig, E.M., Coulter, D.L., Gomez, S.C., Reeve, A., Shogren, K.A., Snell, M.E., Speat, S., Tasse, M.J., Thompson, J.R. & Yeager, M.H. (2008). The intellectual disability construct and its relation to human functioning. Journal of Intellectual & Developmental Disability, 46 (4) 311-318.

Power, M., Quinn, K. & Schmidt, S. (2005).WHOQOL-OLD Group. Development of the WHOQOL-old module. Quality of Life Research 14 (10) 2197-2214.

Power, M.J. & Green, A.M. (2010). WHOQOL-Dis Group. Development of the WHOQOL disabilites module. Quality of Life Research 19 (4) 571-584.

Garin, O., Ayuso-Mateos, J.L., Almansa, J., Nieto, M., Chatterji, S., Vilagut, G., Alonso, J., Cieza, A., Svetskova, O., Burger, H., Racca, V., Francescutti, C., Vieta, E., Kostanjsek, N., Raggi, A., Leonardi, M., Ferrer, M. & MHADIE consortium. (2010). Validation of the "World Health Organization Disability Assessment Schedule, WHODAS-2" in patients with chronic diseases. Health and Quality of Life Outcomes 8, 51.

Kostanjsek, N. (2011).Use of The International Classification of Functioning, Disability and Health (ICF) as a conceptual framework and common language for disability statistics and health information systems. BMC Public Health 11 (Supplement 4) S3.

Coenen, M., Cieza, A., Freeman, J., Khan, F., Miller D., Weise, A., Kesselring, J. & Members of the Consensus Conference. (2011).The development of ICF Core Sets for multiple sclerosis: results of the International Consensus Conference. Journal of Neurology 258 (8) 1477-1488.

Vieta, E., Cieza, A., Stucki, G., Chatterji, S., Nieto, M., Sánchez-Moreno, J., Jaeger, J., Grunze, H. &Ayuso-Mateos, J.L. (2007). Developing core sets for persons with bipolar disorder based on the International Classification of Functioning, Disability and Health. Bipolar Disorder 9 (1-2) 16-24.

Grill, E., Müller, M., Quittan, M., Strobl, R., Kostanjsek, N. & Stucki, G. (2011).Brief ICF Core Set for patients in geriatric post-acute rehabilitation facilities. Journal of Rehabilitation Medicine 43 (2) 139-144.

Leonardi, M., Bickenbach, J., Ustun, T.B., Kostanjsek, N., Chatterji, S. & MHADIE Consortium. (2006).The definition of disability: what is in a name? Lancet 368 (9543) 1219-1221.

Pessina, A. (Ed). (2010). Ethical recommendations for the use of ICF- draft 10/10/2010 for FDRG Members’ Revision. Milan: Bioethics Centre of the Catholic University of Milan.

Leonardi, M., Ayuso-Mateos, J.L., Hollenweger, J., Pessina, A. & Bickenbach, J.E. (2012). Multidisciplinary Research and Training Network on Health and Disability in Europe: The MURINET Project. American Journal of Physical Medicine & Rehabilitation 91 (13 Supplement 1 )S1-4.

Ochoa, S., Salvador-Carulla, L., Vilalta, M., Gibert, K. & Haro, J.M. (2012).Use of functioning-disability, and dependency for case-mix and subtyping of schizophrenia. European Journal of Psychiatry 26 (1) 1-12.

Salvador-Carulla, L., Gibert, K. & Ochoa, S. (2010).Definition of “functional dependency”.Implications for health and social policy. AtenciónPrimaria 42 (6) 344-345.

Schalock, R.L., Borthwick-Duffy, S.A., Bradley, V.J., Buntinx, W.H.E., Coulter, D.L., Craig EM et al. (2010). Intellectual disability: Definition, classification, and systems of supports. Washington DC: American Association on Intellectual and Developmental Disorders.

Schalock, R.L. & Buntinx, W.H.E. (2010). Models of Disability, Quality of Life, and Individualized Supports: Implications for Professional Practice in Intellectual Disability. Journal of Policy and Practice in Intellectual Disabilities 7 (4) 283–294.

WPA IGDA Workgroup.(2003). IGDA.7.Standardized multi-axial diagnostic formulation. British Journal of Psychiatry 182 (Supplement 45) s52-s54.

Mezzich, J.E., Salloum, I.M., Cloninger, C.R., Salvador-Carulla, L., Kirmayer, L.J., Banzato,C.E., Wallcraft, J. & Botbol, M. (2010). Person-centred integrative diagnosis: conceptual bases and structural model. Canadian Journal of Psychiatry 55 (11) 701-708.

Alonso, F., Walsh, C.O., Salvador-Carulla, L. & eVITAL Group. (2010). Methodology for the development of a taxonomy and toolkit to evaluate health-related habits and lifestyle (eVITAL).BMC Research Notes 24, 83.

Cloninger, C.R. & Cloninger, K.M. (2011). Development of instruments and evaluative procedures on contributors to illness and health.International Journal of Person Centered Medicine 1 (3) 446–455.

World Health Organization. (2007). The International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY). Geneva: WHO.

Linden, M. & Baron, S. (2005). The “Mini-ICF-Rating for Mental Disorders (Mini-ICF-P)”.A short instrument for the assessment of disabilities in mental disorders.Rehabilitation 44 (3) 1444-1451.

Almansa, J., Ayuso-Mateos, J.L., Garin, O., Chatterji, S., Kostanjsek, N., Alonso, J., Valderas, J.M., Cieza, A., Raggi, A., Svestkova, O., Burger, H., Racca, V., Vieta, E., Leonardi, M., Ferrer, M. & MHADIE Consortium.(2011).The International Classification of Functioning, Disability and Health: development of capacity and performance scales. Journal of Clinical Epidemiology 64 (12) 1400-1411.

Cieza, A., Boldt, C., Ballert, C.S., Eriks-Hoogland, I., Bickenbach, J.E. &Stucki, G. (2011).

Setting up a cohort study on functioning: deciding what to measure. American Journal of Physical Medicine and Rehabilitation; 90 (11 Supplement 2) S17-28.

Post, M.W., de Witte, L.P., Reichrath, E., Verdonschot, M.M., Wijlhuizen, G.J. & Perenboom, R.J.(2008). Development and validation of IMPACT-S, an ICF-based questionnaire to measure activities and participation. Journal of Rehabilitation Medicine 40 (8) 620-627.

Anderson, K.D., Acuff, M.E., Arp, B.G., Backus, D., Chun, S., Fisher, K., Fjerstad, J.E., Graves, D.E., Greenwald, K., Groah, S.L., Harkema, S.J., Horton. J.A. 3rd., Huang, M.N., Jennings, M., Kelley, K.S., Kessler, S.M., Kirshblum, S., Koltenuk, S., Linke, M., Ljungberg, I., Nagy, J., Nicolini, L., Roach, M.J., Salles, S., Scelza, W.M., Read, M.S., Reeves R.K., Scott, M.D., Tansey, K.E., Theis, J.L., Tolfo, C.Z., Whitney, M., Williams, C.D., Winter, C.M. & Zanca, J.M. (2011). United States (US) multi-center study to assess the validity and reliability of the Spinal Cord Independence Measure (SCIM III). Spinal Cord 49 (8) 880-885.

Post, M.W., van der Zee, C.H., Hennink, J., Schafrat, C.G., Visser-Meily, J.M. & van Berlekom, S.B. (2012). Validity of the utrecht scale for evaluation of rehabilitation-participation. Disability and Rehabilitation 34 (6) 478-485.

van der Zee, C.H., Kap, A., Rambaran Mishre, R., Schouten, E.J. & Post, M.W. (2011).Responsiveness of four participation measures to changes during and after outpatient

rehabilitation. Journal of Rehabilitation Medicine 43 (11) 1003-1009.

Geyh, S., Peter, C., Müller, R., Bickenbach, J.E., Kostanjsek, N., Ustün, B.T., Stucki, G. & Cieza, A. (2011). The Personal Factors of the International Classification of Functioning, Disability and Health in the literature - a systematic review and content analysis. Disability and Rehabilitation 33 (13-14) 1089-1102.

Geyh, S., Müller, R., Peter, C., Bickenbach, J.E., Post, M.W., Stucki, G. & Cieza, A. (2011). Capturing the psychologic-personal perspective in spinal cord injury. American Journal of Physical Medicine and Rehabilitation 90 (11 Supplement 2) S79-96.

Power, M., Quinn, K., Schmidt, S. & WHOQOL-OLD Group. (2005). Development of the WHOQOL-old module.Quality of Life Research 14 (10) 2197-2214.

Power, M.J., Green, A.M. & WHOQOL-Dis Group.(2010). Development of the WHOQOL disabilites module. Quality of Life Research 19 (4) 571-584.

Janca, A., Kastrup, M., Katschnig, H., López-Ibor, J.J. Jr., Mezzich, J.E. & Sartorius, N. (1996). The World Health Organization Short Disability Assessment Schedule (WHO DAS-S): a tool for the assessment of difficulties in selected areas of functioning of patients with mental disorders. Social Psychiatry and PsychiatricEpidemiology 31 (6) 349-354.

Sección de Diagnóstico y Clasificación de la Asociación Psiquiátrica de América Latina. (2004).GuíaLatinoamericana de Diagnóstico Psiquiátrico. Guadalajara: Asociación Psiquiátrica de América Latina.

Instituto Nacional de Salud Mental. (2009). Confiabilidad y validez de los cuestionarios de salud mental de Lima y de la Selva Peruana. Anales de Salud Mental 25 (Supplement 1) 1-259.

Instituto Nacional de Salud Mental. (2008). Estudio Epidemiológico de Salud Mental en Lima Rural 2007. Informe General. Anales de Salud Mental 24 (1-2):1-247.

Saavedra, J.E., Cruz, V. & Mezzich, J.E. (2011).Person-centered Care and Economic Deprivation: an epidemiological view of positive mental health in a developing country. International Journal of Person Centered Medicine 1 (1) 62-75.

Mezzich, J.E., Cohen, N.L., Ruiperez, M.A., Banzato, C.E. & Zapata-Vega, M.I. (2011). The Multicultural Quality of Life Index: presentation and validation. Journal of Evaluation and Clinical Practice 17 (2) 357-364.

Schwartz, K.I., Zapata-Vega, M.I., Mezzich, J.E. & Mazzotti, G. (2006). Validation study of the Multicultural Quality of Life Index (MQLI) in a Peruvian sample. Revista Brasileira de Psiquiatria 28 (1) 24-28.

Schalock, R.L., Keith, K.D., Hoffman, K. & Karan, O.C. (1989). Quality of life: its measurement and use. Mental Retardation27(1) 25-31.

Wang, M., Schalock, R.L., Verdugo, M.A. & Jenaro, C. (2010). Examining the factor structure and hierarchical nature of the quality of life construct. American Journal on Intellectual and Developmental Disabilities 115 (3) 218-233.

Schalock, R.L., Brown, I., Brown, R., Cummins, R.A., Felce, D., Matikka, L. & Keith, K.D. (2002). Conceptualization, measurement, and application of quality of life for personswith intellectual disabilities: report of an international panel of experts. Mental Retardation 40 (6) 457-470.

Kostanjsek, N., Rubinelli, S., Escorpizo, R., Cieza, A., Kennedy, C., Selb, M., Stucki, G. & Üstün, T.B. (2011). Assessing the impact of health conditions using the ICF. Disability and Rehabilitation 33 (15-16) 1475-1482.





Fourth Geneva Conference on Person-centered Medicine: Person-centered integrative diagnosis (PID)