The International Classification of Impairments, Disabilities,
and Handicaps (ICIDH) is the leading standard for defining 
disabilities and related terminology.  The official document--
included below in electronic form--was published in 1980 by the 
World Health Organization.  Subsequent drafts have been the 
subject of much discussion, testing, and evaluation.  The next 
official version is expected some time in 1998.  Consistent 
world-wide definitions in this area would significantly benefit 
scientific data, policy analysis, and product design affecting 
people with disabilities.

Jamal Mazrui
National Council on Disability
Email: 74444.1076@compuserve.com

----------

                     FOREWORD TO THE 1993 REPRINT

 The International Classification of Impairments, Disabilities, 
and Handicaps (ICIDH), developed in the 1970s, was issued by WHO 
in 1980 as a tool for the classification of the consequences of 
disease (as well as of injuries and other disorders) and of their 
implications for the life of individuals. It now exists in 13 
languages1 and further language versions are in preparation; more 
than 15 000 copies of the English and French versions and over 10 
000 copies in other languages have been distributed. The 
bibliography maintained by the WHO Collaborating Centre on ICIDH 
in the Netherlands lists over 1000 references to the ICIDH. 
Published comments on the ICIDH include such remarks as: "[The 
ICIDH] concepts provide the key to rational management of chronic 
diseases"; at the same time, however, concern has been expressed 
that the ICIDH does not state clearly enough the role of social 
and physical environment in the process of handicap, and that it 
might be construed as encouraging "the medicalization of 
disablement". The term is "disablement" is used here to encompass 
the full range of impairment, disability, and handicap.)

 The ICIDH belongs to the "family" of classifications developed 
by WHO for application to various aspects of health and disease. 
The best established is the International Statistical 
Classification of Diseases, Injuries, and Causes of Death (ICD), 
the Ninth Revision of which (ICD-9) was issued shortly before the 
publication of the ICIDH. The first volume of the Tenth Revision 
of the ICD (ICD-10), published in June 1992, includes various 
changes, for instance in the area of mental and behavioural 
disorders, which will have to be taken into account in a revised 
ICIDH.

 The dissemination and application of the ICIDH, as well as the 
advocacy role of organizations and bodies devoted to the problems 
of people with disabilities, have been accompanied by important 
changes in the way impairments, disabilities and handicaps, and 
the various problems that may arise in each of these three areas 
are perceived and addressed. The listing of the classification 
items has allowed a better description and facilitated the 
assessment of people with disabilities and of their situation 
within a given physical and social environment.

 This foreword is intended to clarify certain aspects of the 1980 
introduction which have been the subject of much discussion, and 
to indicate some of the issues to be addressed in a forthcoming 
revision. It also offers an opportunity to provide information on 
the range of uses of the ICIDH and on the developments that have 
occurred as a result of its publication. In other respects, the 
manual is essentially unchanged and includes the original 
introduction.

 Two Collaborating Centres for the ICIDH have been established, 
in France (Centre technique national d'Etudes et de Recherches 
sur les Handicaps et les Inadaptations) and in the Netherlands 
(Standing Committee for Classifications and Terminology). 
Together with other WHO Collaborating Centres for Health-related 
Classifications, notably those in Uppsala, Sweden for the Nordic 


  1A list of translations is available on request from 
Strengthening of Epidemiological and Statistical Services 
(SES/HST), World Health Organization, 1211 Geneva 27, 
Switzerland.


                                      i 







countries and at the National Center for Health Statistics, 
Hyattsville, MD, USA for North America, with groups such as the 
Canadian Society for the ICIDH and the R‚seau pour l'Etude de 
l'Esp‚rance de Vie en Sant‚/International Network on the Study of 
Healthy Life Expectancy (REVES), and with intergovernmental 
Organizations such as the Statistical Division of the United 
Nations Department of Social and Economic Development, and the 
Council of Europe, these Centres have formed a technical network 
which has been in operation since 1987. The Council of Europe has 
established a committee of Experts for the Application of the WHO 
International Classification of Impairments, Disabilities, and 
Handicaps, which brings together representatives of 14 countries, 
plus five observers. This Committee has examined specific 
applications of the ICIDH in rehabilitation work, surveys, and 
the collection of statistics, in the study of mental retardation, 
the assessment of vocational capacity, the assessment of 
technical enabling devices, and the application of the concept of 
handicap. The Real Patronato de Prevenci¢n y de Atenci¢n a 
Personas con Minusval¡a in Madrid has undertaken a survey of the 
use of the ICIDH in Spanish-speaking countries.




Current applications of the ICIDH


 The ICIDH is intended to offer a conceptual framework for 
information; the framework is relevant to the long-term 
consequences of disease, injuries or disorders, and applicable 
both to personal health care, including early identification and 
prevention, and to the mitigation of environmental and societal 
barriers. It is also relevant to the study of health care 
systems, in terms both of evaluation and of policy formulation. 
The concepts of the ICIDH have elicited much philosophical 
interest, and its applications have covered activities in social 
security, the design of population surveys at local, national and 
international levels, and other areas, such as the assessment of 
working capacities, demography, community needs assessment, town 
planning, and architecture. Although the ICIDH is inherently a 
health-related classification, future documentation and 
development will need to reflect a broader spectrum of 
applications and users.

 A primary application of the ICIDH has been to describe the 
circumstances of individuals with disabilities across a wide 
range of settings. The ICIDH has been directly applied to the 
care of individuals in diagnosis and treatment, evaluation of 
treatment results, assessment for work, and information. Reports 
on its use in personal health care have come from nurses, 
occupational therapists, physicians, physiotherapists and others 
working with a wide variety of persons, including elderly people, 
children and adolescents, and psychiatric patients, in many 
widely different countries, including Australia, the Netherlands, 
Pakistan, Spain, Venezuela, and Zimbabwe. The ICIDH is also used 
to assess patients in rehabilitation, in nursing homes, and in 
homes for the elderly; its use in these areas has facilitated 
communication between various categories of workers and 
coordination between different types of care.


                                     ii 











 At the institutional level the ICIDH has been used in order to 
assess the numbers and type of staff required, and to study 
discharge policies and the characteristics of health-care 
utilization. At the community level, it has helped in identifying 
the needs of people with disabilities and handicaps, identifying 
handicapping situations in the social and physical environment, 
and formulating the policy decisions necessary for improvements 
in everyday life, including modifications of the physical and 
social environment.

 In the areas of social security, occupational health, and 
employment, the ICIDH serves as an actual or potential basis for 
various assessments: for decisions on allowances, the orientation 
of individuals, and the nomenclature of handicaps, in France, for 
the assessment of working abilities in Germany and the 
Netherlands, and for access to institutional care and to enabling 
devices in Belgium (by the Flemish Fund for the Social 
Integration of Persons with a Handicap) and in Italy. Switzerland 
is investigating the use of the ICIDH in health insurance 
nomenclature.

 The framework of the ICIDH has been used successfully  by 
demographers, epidemiologists, health planners, policy-makers, 
and statisticians in disability surveys at national, regional and 
local levels in several countries, developed (inter alia 
Australia, Canada, Netherlands) or developing (inter alia 
Algeria, China, Fiji, Kuwait). Definitions used in the ICIDH have 
also served as a basis for surveys in the Netherlands, the United 
Kingdom, and most notably Spain, and for analysis of survey 
results. The statistical tools developed by the Statistical 
Division of the United Nations Department of Social and Economic 
Development for the international monitoring of population and 
household censuses, surveys, and administrative systems include 
an  International Disability Statistics Database (DISTAT), which 
uses a framework based on the ICIDH; DISTAT covers national 
statistics from over 95 countries both in machine-readable form 
and as a printed Compendium on Disability. The concepts and 
definitions of the ICIDH have similarly been used in REVES to 
determine various types of demographic indicators of Healthy Life 
Expectancy (impairment-free, disability- free, or handicap-free 
life expectancy) for a range of developing and developed 
countries. The use of the ICIDH in surveys has highlighted the 
relationships between impairment and disability and between 
disability and handicap; indeed, whether a survey is based on the 
concept of impairment or on that of disability can lead to marked 
differences in the resulting assessment of the population.

 At the conceptual and policy levels, the use of the ICIDH has 
changed the ways in which disabilities themselves, persons with 
disabilities, and the role of the physical and social environment 
in the development of handicap are considered. It has also 
changed some of the policy, planning and administrative reactions 
of governments, organizations, and individuals to these concepts. 
The action taken by France in the promotion of an adapted version 
of the ICIDH for the collection of data on social services, and 
in the application of a  Nomenclature des handicaps based on the 
ICIDH, can be taken as one example (similar action is being 
considered in other countries); recent legislation in Italy is 
another. In Quebec, Canada, a systematic approach to policies on 
impairment, disability, and handicap is largely based on the 
ICIDH. Active interest in the ICIDH has recently been 
demonstrated in the USA, during and after the preparation of the 
Americans with Disabilities Act and in the publication of a major 
report on Disability in America. Even by those who do not 
necessarily accept it as the dominant framework, the ICIDH is 
widely recognized as an important standard for a conceptual 
framework in this field.



                                     iii 






Some problems identified in the use of the ICIDH


 An important task in the revision of the ICIDH will be to 
clarify the role and interrelationship of environmental factors 
in the definition and development of the different planes 
addressed by the ICIDH, most notably - but not exclusively - 
handicap. A report of the United Nations Commission on Human 
Rights for its Forty-third Session on Human Rights and Disability 
encouraged WHO to revise the ICIDH and to consider more 
specifically the role of the environment in the development of 
the handicap process. Much work has addressed conceptual 
developments for this topic, notably the proposals issued by the 
Canadian Society for the ICIDH on the development of the handicap 
process. The role of the social and physical environment is 
briefly addressed in the original introduction to the ICIDH (see 
p. 14):

  "  Handicap is more problematical. The structure of the 
      Handicap classification is radically different from all 
      other ICD-related classifications. The items are not 
      classified according to individuals or their attributes but 
      rather according to the circumstances in which people with 
      disabilities are likely to find themselves, circumstances 
      that can be expected to place such individuals at a 
      disadvantage in relation to their peers when viewed from 
      the norms of society."

This will require elaboration in the revised version. The 
Handicap classification is a classification of situations and not 
of individuals; the word "circumstances" is to be considered as 
referring not only to statistical aggregates of individuals, but 
also to characteristics of the physical and social environment. 
Indicators for both categories are also under development in the 
field of health promotion.

 The categories of impairment, disability and handicap remain 
robust; non- ICIDH-based models, embody similar concepts, 
although they may use different terms. A number of models of the 
consequences of disease which incorporate other factors, such as 
the physical and social environment, have been proposed in the 
scientific literature, and will be considered in the process of 
revision of the ICIDH, although they are still for the main part 
at the stage of theoretical development and empirical testing.

 In several instances, there is a degree of overlap between 
disability and handicap as regards functional limitations and 
activities of daily living. This overlap also occurs between 
impairment and disability, for instance as regards: intellectual 
impairments; the distinction between aural, ocular and language 
impairments and communication disabilities; incontinence; and 
physical independence. The problem of overlap will require 
further elaboration.

 The current model of the consequences of disease and its graphic 
representation (see p. 30) are effective in distinguishing 
between impairments, disabilities and handicaps as separate 
concepts, but do not provide adequate information on the 
relationship between these concepts. In particular, the arrows 
linking disease or disorder, impairment, disability and handicap 
have occasionally been interpreted as representing a causal model 
and an indication of change over time. This representation does 
not allow for movement from handicap and disability back to 
impairment, as facilitated by appropriate interventions, and has 
thus been taken to imply a unidirectional flow from impairment, 
to disability, to handicap. Furthermore, the graphic 
representation 


                                     iv




of the ICIDH framework does not adequately reflect the role of 
the social and physical environment in the handicap process. 
Although the original text states that the situation is more 
complex than a simple linear progression, this statement needs to 
be made more clearly - the arrows in the graphic presentation 
must be understood as meaning no more than "may lead to". These 
issues, as well as alternative graphic presentations, will be 
considered in the revision of the ICIDH.



Some proposed changes to the ICIDH



 The ICIDH has had a wider range of uses and of users than 
originally envisaged. Its value as a tool for policy-makers has 
been amply demonstrated, notably in Canada and France, and this 
aspect should be stressed and extended in an introductory section 
of the revised version. Similar considerations apply to other 
facets of its use. Several reports comment that the ICIDH is not 
difficult to use, and this is encouraging; in an effort to 
broaden the application of the classification, revision should 
tend towards simplification rather than towards the addition of 
further detail. Revision, particularly of the impairment 
classification, must also take into account the needs of users 
who are not health professionals. For example, the revised 
version should include alphabetical indexes in addition to the 
index that now exists for impairments only. Consideration should 
also be given to the problem of application in specific 
population groups (e.g., children, because their status changes 
rapidly), and more space should be given to the problems of 
measurement of severity; the guidance and rulings on this 
included in the current version will be reconsidered.

 In view of the concern about the way in which the definition of 
handicap is presented and understood, suggestions for revision 
include greater emphasis on presenting handicap as a description 
of the circumstances that individuals encounter as a result of 
the interaction between their impairments or disabilities and 
their physical and social environment. An important task in the 
revision of the ICIDH will be to improve the presentation of the 
way in which external factors affect the ICIDH components. The 
introduction must stress the importance of the environment, 
together with the role and interaction of individual 
characteristics and of physical and social factors.

 These factors, which are major components of the handicap 
process, should not be developed as an additional classification 
scheme within the ICIDH. Social and physical factors in the 
environment, and their relationship to impairment, disability, 
and handicap are strongly culture-bound. It is unlikely that a 
universally acceptable classification of these determinant 
factors is achievable at present, for the same reasons that 
preclude a universally accepted classification of the 
determinants of health. Nevertheless, classifications of 
environmental factors may prove useful in the analysis of 
national situations and in the development of solutions at the 
national level.



                                      v 











 The classifications developed in the area of mental health, 
whether for the entire population or for specific age groups, are 
based mainly on the ICD. The chapter on mental and behavioural 
disorders has been thoroughly updated in the Tenth Revision of 
the ICD, and the ICIDH will have to reflect these changes, as 
well as those embodied in other publications. The Council of 
Europe Committee of Experts has recently drawn up a report 
discussing the present use of the ICIDH in the study of mental 
retardation. Recognizing the ICIDH as an important step towards 
generally accepted criteria for legal definitions, the report of 
the United Nations Commission on Human Rights, mentioned earlier, 
encouraged WHO to revise the ICIDH, with special attention to the 
problems of impairments and disabilities related to mental 
health. Similar concerns also apply to the problems of cognitive 
function often associated with aging. Publication of the 
French-language version of the ICIDH in 1988 evoked particular 
interest among psychiatrists; as WHO Collaborating Centre for the 
ICIDH, the Centre technique national d'Etudes et de Recherches 
sur les Handicaps et les Inadaptations (CTNERHI) is devoting an 
important part of its activities to the applications of the ICIDH 
and its relation to other classifications in mental health. As a 
result of these developments, the area of mental health will be 
treated with particular care in the revision of the ICIDH.

 The revision process will also address detailed changes to items 
within the classification, and must take into account improved 
understanding of basic biological mechanisms, particularly as 
regards impairments. In some cases this will have implications 
for preferred terminology and will entail changes for terms that 
have become obsolete.

 The current version of the ICIDH contains definitions and 
examples that are highly culture-specific (e.g., references to 
"pouring tea") or that are inappropriately characterised 
according to sex. In addition, typographical and factual errors, 
and definitions no longer consistent with those in ICD-10 will be 
similarly remedied. A small number of these have been corrected 
in the present reprint.

 An "umbrella" term is needed to address the spectrum of 
experiences linked to impairment, disability, and handicap: the 
term "disablement" has been suggested, but is not universally 
accepted. In some languages there appears to be no unique 
suitable term. The official French-language version, for example, 
uses "handicap" as an umbrella term, stressing that it does not 
cover a monolithic reality, but is the result of different levels 
of experience; this version also uses a term signifying 
"disadvantage" for the third level of experience in the 
classification (as do the Italian, Japanese, and Portuguese 
versions). French-speaking Canadians, on the other hand, appear 
to prefer the word "handicap" for this third level and do not 
make use of an umbrella term. Agreement on the use of an existing 
term or on the use of a new term will require much thought and 
discussion during the revision of the ICIDH.

 Training and presentation materials for the ICIDH have been 
developed, notably in France by CTNERHI, and in Quebec, Canada 
(as a video presentation). In addition, the Real Patronato de 
Prevenci¢n y de Atenci¢n a Personas con Minusval¡a has supported 
the development of a computer-based program in Spanish. 
Identification and sharing of these and other experiences, and 
some standardization of approaches, will enhance their 
usefulness.

 The revision of the ICIDH will be based upon a review of reports 
and documents describing its use, and consultation with expert 
representatives from relevant disciplines. The opinions of 
international and nongovernmental organizations, including 
organizations of people with disabilities, which deal with 
different aspects of disability will continue to be sought and 
considered throughout the process of revision, and representation 
of experiences from countries in the various Regions of WHO will 
be ensured.

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                  THE CONSEQUENCES OF DISEASE

        This manual is concerned with improving information on 
the consequences of disease. Such an endeavour is dependent on 
appreciation of the nature of health-related experiences. It is 
necessary, therefore, to begin with an attempt to clarify these.

The response to illness

        In contemplating illness phenomena it is customary to 
invoke the concept of disease. This notion and its derivatives, 
such as the International Classification of Diseases (ICD), 
consider pathological phenomena as though they were unrelated to 
the individuals in whom they occur. Long-prevalent traditions in 
thought have fostered such separation, tending to make 
categorical distinctions between the natural and human worlds, 
between nonliving and living, and between body and mind. However, 
certain limitations in this approach are evident. By isolating 
thoughts of disease from consideration of the sufferer, the 
consequences tend to be neglected. These consequences - responses 
by the individual himself and by those to whom he relates or upon 
whom he depends - assume greater importance as the burden of 
illness alters. The problems may be illustrated by contrast 
between acute and chronic processes.

Acute and chronic illness

        In colloquial speech, "acute" tends to indicate something 
sharp or intense, whereas "chronic" implies severity in terms of 
being objectionable or very bad.  For this reason patients tend 
to be alarmed when they learn that the official nomenclature for 
their condition includes the latter term - e.g., chronic 
bronchitis. However, professional usage of the words remains 
closer to their etymology. Thus "acute" means "ending in a sharp 
point", implying a finite duration, which, classically, 
culminates in a crisis. On the other hand "chronic", which is 
derived from a word meaning "time", indicates "long continued". A
host of interrelated properties is associated with these 
contrasts in time scale, and these render unnecessary any precise 
formulation of the temporal boundary between acute and chronic 
processes.

        The characteristics of acute illness may be exemplified 
by acute infections.  Onset of the condition is frequently 
sudden. There may be almost total prostration, not least because 
rest is commonly regarded as facilitating recovery. Furthermore, 
there is the prospect of a limited period in this state.  These 
three features help to promote two important responses. First, 
suspension of everyday obligations comes about in such a way as 
to be acceptable both to the sufferer and to others. Secondly, 
the situation encourages unquestioning capitulation to 
professional advice. For the health professional the situation is 
also relatively straightforward. The interval between exposure to 
the putative dominant cause and development of the illness tends 
to be short, so that simple models of causality can account for 
disease occurrence. The high incidence of many acute conditions 
provides the professional with experience of a diversity of 
responses. Uncomplicated decisions are called for; either action 
is imperative or there is time for reflection on what forum of 
support might be appropriate. Most acute illnesses are 
self-limiting; some may be life-threatening, but the remainder, 
because of their finite duration, pose a minimal threat to the 
patient. These features encourage a paternalistic attitude by the 
professional, so that symptom relief is regarded largely as a 
means of tiding the patient over until the crisis has passed. 
Finally, the concentration of effort needed to treat acute 
conditions is not too difficult to justify; although primary 
prevention may offer a more economical solution, commitment of 
resources for secondary control by health services is at least 
time-limited. Thus, in policy terms, the options in regard to 
what can be accommodated within a given level of health service 
investment tend to be clear-cut, the choices being concerned with 
whether various acute health problems should be responded to at 
all.

        Chronic illness presents different challenges. The onset 
is usually insidious; there may be a gradual progression of 
symptoms, or more permanent problems may develop as the sequel to 
a number of acute episodes. Confidence and hopes are undermined; 
the experience is usually difficult to account if no end is in 
sight, and self-perception - the sense of identity - is assaulted 
by changes in the body and its functional performance. Activity 
restriction, though
at times severe , nevertheless usually falls short of total 
incapacity until very late in the course of the illness. 
Legitimation or acceptance by others can be more difficult when a 
degree of independent existence is possible, not least because 
obligations cannot be suspended indefinitely; some way of coming 
to terms with the altered situation therefore becomes necessary. 
Finally, the persistence of problems implicitly reveals 
limitations in the potency of medical treatment, so that 
professional advice is often accepted with less assurance. The 
health professional is confronted with complementary 
difficulties. The prevalence of chronic conditions may be high, 
but their incidence is relatively low; common experience 
therefore relates more to the range of problems unfolding in a 
limited number of patients. This has been one of the forces 
contributing to the development of medical specialization and the 
concentration of care in large institutions such as hospitals. 
Clinical decisions themselves are more problematic, the insidious 
progress of chronic disease making diagnosis more difficult; 
definitive conclusions often have to be deferred, yet action may 
be called for in the face of this uncertainty.

        Demands differ in other important aspects. Thus, the 
impact of the condition on the individual, though important, does 
not dominate the scene to the exclusion of all else. Clinical 
status has to be set against the background of life, moving, as 
it does, between home and work. Symptoms reflecting impairments 
and disabilities call for attempts at amelioration in their own 
right. Sensitivity is also taxed; virtually everyone experiences 
acute illness at some time , so that it is not too difficult to 
project oneself into the situation of the patient, but personal 
knowledge of chronic suffering is much less widespread. Finally, 
the multidimensional quality of problems encountered in people 
with chronic illness tends to promote needs-based appraisals, 
which carry with them potentially inflationary consequences for 
health and welfare services. Thus policy formulation is more 
difficult and more controversial; it is necessary to choose which 
to respond to from the diversity of problems presented by 
affected individuals.

A unifying framework

        The challenges for health care change as chronic illness 
comes to occupy a more dominant position. The sufferers 
themselves, the health
professionals concerned to help them, and the policy makers and 
planners seeking to adapt to the different needs that arise - 
each in his different way encounters difficulties in coming to 
terms with the consequences of disease. The confusion that all 
three groups share stems largely from the lack of a coherent 
scheme or conceptual framework against which to set such 
experiences.

        These limitations in understanding are an obstacle to 
improving relevant information, and this in turn inhibits 
progress towards more helpful responses.

Planes of experience

        The principal events in the development of illness are as 
follows:

        (i) Something abnormal occurs with the individual; this 
may be present at birth or acquired later. A chain of causal 
circumstances, the "etiology", gives rise to changes in the 
structure or functioning of the body, the "pathology". 
Pathological changes may or may not make themselves evident; when 
they do they are described as "manifestations", which, in medical 
parlance, are usually distinguished as "symptoms and signs". 
These features are the components of the medical model of 
disease, as indicated in the Introduction.
        (ii) Someone becomes aware of such an occurrence; in 
other words, the pathological state is exteriorized. Most often 
the individual himself becomes aware of disease manifestations, 
usually referred to as "clinical disease". However, it is also 
necessary to encompass two other types of experience.
        (a) Not infrequently, symptoms may develop that cannot 
        currently be
        linked to any underlying disease process. Something is 
        certainly  being exteriorized, even if it cannot be 
        accounted for. Most health professionals would attribute 
        such symptoms to a disturbance - as yet unidentified - of 
        some essential structure or process within the body 
        (b) In contrast, some deviation may be identified of 
        which the "patient" himself is unaware. Such pathology 
        without symptoms sometimes constitutes subclinical 
        disease, which is encountered with
        increasing frequency as screening programmes are 
        extended. Alternatively, a relative or someone else may 
        draw attention to disease manifestations.

        In behavioural terms, the individual has become or been 
made aware that he is unhealthy. His illness heralds recognition 
of impairments, abnormalities of body structure and appearance, 
and of organ or system function, resulting from any cause. 
Impairments represent disturbances at the organ level.

        (iii) The performance or behaviour of the individual may 
be altered as a result of this awareness, either consequentially 
or cognitively. Common activities may become restricted, and in 
this way the experience is objectified. Also relevant are 
psychological responses to the presence of disease, part of 
so-called illness behaviour, and sickness phenomena, the 
patterning of illness manifested as behaviour by the individual 
in response to the expectations others have of him when he is 
ill. These experiences represent disabilities, which reflect the 
consequences of impairments in terms of functional performance 
and activity by the individual. Disabilities represent 
disturbances at the level of the person.

        (iv) Either the awareness itself, or the altered 
behaviour or performance to which this gives rise, may place the 
individual at a disadvantage relative to others, thus socializing 
the experience. This plane reflects the response of society to 
the individual's experience, be this expressed in attitudes, such 
as the engendering of stigma, or in behaviour, which may include 
specific instruments such as legislation. These experiences 
represent handicap, the disadvantages resulting from impairment 
and disability. The explicit concern with the value attached to 
an individual's performance or status obviously makes this the 
most problematical plane of disease consequences.

        Each of the last three planes in this sequence - 
exteriorization, objectification, and socialization - now 
requires more detailed consideration. This will be followed by 
further examination of the interrelationships between the 
underlying concepts, supported by examples to highlight the 
distinctions.

Impairment

        In the context of health experience, an impairment is any 
        loss or abnormality of psychological, physiological, or 
        anatomical structure or function


        Two aspects of this definition need to be stressed. 
First, the term "impairment" is more inclusive than "disorder" in 
that it also covers losses; e.g., the loss of a leg is an 
impairment, but not a disorder. Secondly, in reaching agreement 
on terminology with other international agencies, it has been 
necessary to make certain modifications to the definitions 
included in a preliminary draft of this manual.[1] In this draft, 
functional limitations were regarded as being elements of 
disability, whereas they have now been assimilated with 
impairments; this alteration helps to resolve boundary 
distinctions that originally lacked clarity.

        Impairment represents deviation from some norm in the 
individual's biomedical status, and definition of its 
constituents is undertaken primarily by those qualified to judge 
physical and mental functioning according to generally accepted 
standards. Impairment is characterized by losses or abnormalities 
that may be temporary or permanent, and it includes the existence 
or occurrence of an anomaly, defect, or loss in a limb, organ, 
tissue, or other structure of the body, or a defect in a 
functional system or mechanism of the body , including the 
systems of mental function. Being concerned to describe identity 
at a particular point in time, impairment is  neutral in regard 
to a number of associated features, and this needs to be 
stressed. Thus impairment is not contingent upon etiology, how 
the state arose or developed;both ascribed and achieved status, 
such as genetic abnormality or the consequences of a road traffic 
accident, are included. Use of the term "impairment" does not 
necessarily indicate that disease is present or that the 
individual should be regarded as sick. Equally , the deviation 
from the norm does not need to be perceived by the impaired 
individual, as should be clear from what has been said above 
about exteriorization. On the same grounds, a concept of latent 
impairment constitutes a contradiction in terms - the individual 
exposed to or harbouring an extraneous etiological agent of 
disease is not impaired; impairment ensues only when the
agent has initiated a reaction by the body so that pathological 
processes develop.
Disability

        In the context of health experience, a disability is any 
        restriction or lack (resulting from an impairment) of 
        ability to perform an activity in the manner or within 
        the range considered normal for a human being

        In providing the link between impairment and handicap, it 
is fairly easy for the concept of disability to appear somewhat 
vague, variable, or arbitrary. As already noted, however, 
functional limitation is now regarded as an aspect of impairment, 
and this should resolve most of the difficulties. Impairment is 
concerned with individual functions of the parts of the body; as 
such it tends to be a somewhat idealistic notion, reflecting 
potential in absolute terms. Disability, on the other hand, is 
concerned with compound or integrated activities expected of the 
person or of the body as a whole, such as are represented by 
tasks, skills, and behaviours.

        Disability represents a departure from the norm in terms 
of performance of the individual , as opposed to that of the 
organ or mechanism. The concept is characterized by excesses or 
deficiencies of customarily expected behaviour or activity, and 
these may be temporary or permanent, reversible or irreversible, 
and progressive or regressive. The key feature relates to 
objectification. This is the process through which a functional 
limitation expresses itself as a reality in everyday life, the 
problem being made objective because the activities of the body 
are interfered with. In other words, disability takes form as the 
individual becomes aware of a change in his identity. Customary 
expectations embrace integrated functioning in physical, 
psychological, and social terms, and it is unrealistic to expect 
a neat separation between medical and social aspects of activity. 
For instance, physical incapacities and socially deviant 
behaviours equally transgress what is expected of the individual 
- the important differences between them concern the value that 
is attached to such deviations, and any sanctions that may be 
applied as a result; such valuations relate to the concept of 
handicap, rather that to that of disability.

        In attempting to apply the concept of disability, there 
is a need for caution in how the ideas are expressed. By 
concentrating on activities, disability
is concerned with what happens - the practical - in a relatively 
neutral way, rather than with the absolute or ideal and any 
judgements that may attach thereto. To say that someone has a 
disability is to preserve neutrality, nuances of interpretation 
in regard to his potential still being possible. However, 
statements phrased in terms of being rather than having tend to 
be more categorical and disadvantageous. Thus to say that someone 
is disabled, as if this were an adequate description of that 
individual, is to risk being dismissive and invoking stigma.

Handicap

        In the context of health experience, a handicap is a 
        disadvantage for a given individual, resulting from an 
        impairment or a disability, that limits or prevents the 
        fulfillment of a role that is normal (depending on age, 
        sex, and social and cultural factors) for that individual

        Three important features of this concept should be borne 
in mind:
(i) some value is attached to departure from a structural , 
functional , or performance norm, either by the individual 
himself or by his peers in a group to which he relates;
(ii) the valuation is dependent on cultural norms, so that a 
person may be handicapped in one group and not in another - time, 
place, status, and role are all contributory;
(iii) in the first instance, the valuation is usually to the 
disadvantage of the affected individual.

        The state of being handicapped is relative to other 
people - hence the importance of existing societal values, which, 
in turn, ale influenced by the institutional arrangements of 
society. Thus, the attitudes and responses of
the non-handicapped play a central role in modelling the ego 
concept, and
defining the possibilities, of an individual who is potentially 
handicapped -
the latter has a very limited freedom to determine or modify his 
own reality. In this context it is relevant to take note of 
differences in societal responses to visible as opposed to 
invisible impairments, and to serious as opposed to trivial 
disadvantages.

        Handicap is characterized by a discordance between the 
individual's performance or status and the expectations of the 
particular group of which he is a member. Disadvantage accrues as 
a result of his being unable to con-
form to the norms of his universe. Handicap is thus a social 
phenomenon,
representing the social and environmental consequences for the 
individual
stemming from the presence of impairments and disabilities. The 
essence of
an adverse valuation by society is discrimination by other 
people, but the
concept is, nevertheless, essentially neutral as regards its 
origins. Thus the individual's own intention is of no immediate 
concern; disadvantage can arise when the individual deviates in 
spite of his own wishes, but it can also develop when the 
deviation is inadvertent or the product of his own choice.
The concept also assimilates phenomena such as invalidism or 
excessive
dependence upon an institution.

Integration of concepts

        The ideas just discussed can be linked in the following 
manner:

DISEASE or
DISORDER-- IMPAIRMENT-- DISABILITY-- HANDICAP(intrinsic
situation   (exteriorized)   (objectified)      (socialized)

Although this graphic representation suggests a simple linear 
progression along the full sequence, the situation is in fact 
more complex. In the first place , handicap may result from 
impairment without the mediation of a state of disability. A 
disfigurement may give rise to interference with the normal 
operation of cues in social intercourse, and it may thus 
constitute a very real disadvantage , to say nothing of the 
embarrassment that the disfigured individual may feel. In this 
example, though, it would be difficult to identify any disability 
mediating between the disfigurement and the disadvantage. 
Similarly, a child with coeliac disease, who is functionally 
limited, may be able to live a fairly normal life and not suffer 
activity restriction; he could nevertheless suffer disadvantage 
by virtue of his inability to partake of a normal diet. More 
important than these incomplete sequences is the possibility of 
interruption at any stage. Thus one can be impaired without being
disabled, and disabled without being handicapped. The corollary 
of this is that there can be striking disparities in the degree 
to which the various elements of the sequence depart from their 
respective norms, and, as a result, one cannot assume consonance 
in degrees of disability and handicap. For instance , one 
individual with rheumatoid arthritis may be only mildly disabled 
and yet at a severe disadvantage, whereas another person with the 
same disease who is much more severely disabled may , perhaps 
because of greater support from the family or social network, 
experience considerably less disadvantage.

        Further complexity is introduced by two other phenomena. 
First, certain disabilities can retard or conceal the development 
or recognition of other abilities; thus, an impairment of 
language can interfere with the expression of other and dependent 
qualities, such as intelligence. Secondly, there can be a 
variable degree of influence in a reverse direction along the 
sequence. Thus, the experience of certain handicaps can engender, 
as part of illness behaviour, not only various disabilities but 
at times even the impairment of certain faculties; as already 
noted, each of the concepts is largely independent of its 
origins, so that these secondary phenomena should not be 
excluded.

        The great value of presenting the concepts in this way is 
that a problemsolving sequence is portrayed, intervention at the 
level of one element having the potential to modify succeeding 
elements. This is especially relevant to the purposes of this 
manual, since the sequence is also valuable as a means of 
identifying information deficits. It will probably be helpful to 
present further examples of how the concepts are expressed.
- A child born with a finger-nail missing has a malformation - a 
structural impairment - but this does not in any way interfere 
with the function of the hand and so there is no disability; the 
impairment is not particularly evident, and so disadvantage or 
handicap would be unlikely.
- A myope or a diabetic individual suffers a functional 
impairment but, because this can be corrected or abolished by 
aids, appliances, or drugs, he would not necessarily be disabled; 
however, the non-disabled juvenile diabetic could still be 
handicapped if the disadvantage is considerable, e.g., by not 
being allowed to partake of confectionery with his peers or by 
having to give himself regular injections.

- An individual with red-green colour blindness has an 
impairment, but it would be unlikely to lead to activity 
restriction; whether the impairment constitutes a handicap would 
depend on circumstances - if his occupation were agricultural he 
might well be unaware of his impairment, but he would be at a 
disadvantage if he aspired to drive a railway engine, because he 
would be prevented from following this occupation.

- Subnormality of intelligence is an impairment, but it may not 
lead to appreciable activity restriction; factors other than the 
impairment may determine the handicap because the disadvantage 
may be minimal if the individual lives in a remote rural 
community, whereas it could be severe in the child of university 
graduates living in a large city, of whom more might be expected. 
(This example illustrates how any attempt to differentiate 
between intrinsic and extrinsic components of handicap in fact 
neglects the fundamental property of this concept, which 
expresses the resultant of interaction between the intrinsic and 
the extrinsic; the intrinsic aspect is identified by any 
impairments and disabilities that may be present.)
- Perhaps the most graphic example of someone who is handicapped 
without being
disabled is the individual who has recovered from an acute 
psychotic episode but who bears the stigma of being a "mental 
patient"; note that this handicap complies with the definition, 
because it is consequent upon impairment and disability, but that 
neither the impairment nor the disability exists at the time the 
handicap develops.
* Finally, the same handicap can arise in different situations, 
and therefore as a result of different disabilities. Thus, 
personal hygiene might be difficult to maintain, but its 
antecedents could be very different for someone accustomed to a 
washbasin as compared with a way of life where ablutions are 
performed in a lake, or in a fast-moving river, or yet again in a 
desert environment.                                        


Application of the concepts

        Before one can attempt to apply this conceptual framework 
for the
consequences of disease, it is necessary to deal with two related 
difficulties.


Terminology   

        A major reason for the lack of information about the 
disabled in society?
is that the various agencies concerned have not shared a common 
un
ambiguous definition of what constitutes disablement, impairment, 
and limitation.[2]  Incongruence in problem identification also 
occurs, as was highlighted in a review of the need for 
definitions: "The word disability refers to an abnormality which 
interferes with function to a significant degree. A complete 
diagnosis should describe the disability, the abnormality 
underlying it, and the cause of the abnormality. Parents tend to 
think in terms of disability, whereas doctors often
speak of abnormalities or their causes, and this may lead to 
misunderstanding."[3]  Most of the terms over which confusion 
arises have been used with common-sense meanings in everyday 
speech and writing. The underlying problem has been that concepts 
relating to disability and disadvantage have been insufficiently 
explored, and, as a result, no systematized language usage 
specific to these concerns has developed.

        Two initiatives by the World Health Organization have 
helped to transform this state of affairs. The first took place 
in 1975-1976, when approval in principle was given to the 
conceptual framework put forward in the preliminary draft of this 
manual. The second, built on this foundation over the succeeding 
years, has secured agreement on usage for the most important 
terms between a number of international agencies. This preferred 
nomenclature has been employed throughout.

        Although too much can be made of the importance of 
semantic distinctions, the acid-test for a preferred nomenclature 
is whether it promotes practical benefits. The latter should come 
about as a clearer description of processes reveals to what 
extent and in what way problems may be solved. Considerable care 
has been applied to the selection of descriptive terms in this 
manual, so as to reinforce the conceptual distinctions. This 
effort can be seen at two levels:
(i) Avoidance of the same word to identify an impairment, a 
disability, and a handicap. In colloquial speech there has been a 
trend to euphemism, with words being debased as mental 
retardation first became mental disability and then mental 
handicap. This succeeds only in blurring the distinctions; the 
disadvantage experienced by individuals with psychological 
impairments can vary , so that it is inappropriate to refer to a 
handicap as "mental". Thus the descriptive adjectives "mental" 
and "physical" may correctly be applied to impairments, but their 
use in relation to disabilities is loose and to handicaps quite 
unsuitable. It is perhaps vain to hope that the tide of careless 
usage can be reversed , but at least in serious discourse the 
logic of terminology should be exploited to reinforce the 
conceptual framework.

(ii) In addition to seeking different descriptive terms, the use 
of different parts of
speech also seemed to be appropriate. Thus for the qualities 
represented by impairments an adjective derived from a 
substantive is apposite, but for the activities included as 
disabilities a participle was deemed more suitable, the "-ing" 
ending emphasizing the dynamic aspect. An exhaustive consistency 
in this regard has not been possible, but a trend should be 
apparent.
These points can best be illustrated with examples:

        Impairment                                         
DisabilityHandicap
        language                                           
speaking
        hearing                                            
listening orientation
        vision                                             seeing
        
        skeletal                                           
dressing, feeding                                          
physical independence
                                                           walkin
g         mobility
        psychological                                      
behaving  social integration

        For specific impairments, the nomenclature and 
classification preferred by
relevant international organizations, such as the International 
Society for
Prosthetics and Orthotics, have been employed wherever possible.

Deviation from norms

        All three of the concepts relevant to the consequences of 
disease - impairment, disability, and handicap - depend on 
deviations from norms.  "The amount of deviation regarded as 
being present depends on the operation of a definition of the 
norm in question, be the specification implicit or identified. 
There are three approaches to such definition:
(i) For quantitative phenomena, such as body height, the 
exploitation of statistical
concepts of "the normal" and of deviations therefrom is of some 
help. However, although the approach may be useful in indicating 
conformity to type, there are limitations and certainly 
statistical methods can have little application when the norm 
relates to a value. The attraction of statistical concepts is 
that they appear to be value-free, which appeals to the many 
health professionals with a scientific background. Such striving 
for objectivity is encouraged by the illusion that common notions 
of causality in science are non-normative, as if they represented 
matter-of-fact relations or contingent connexions between events. 
The reality is that the very notion of what will count as a 
causal agent in disease is connected with a normative view of the 
normal or healthy organism.
(ii) Normative views, such as those just indicated, are 
determined by reference to some ideal. This approach to the norm 
implicitly relates to threshold phenomena. To some degree the 
situation may be circumscribed by enunciation of standardized 
criteria for assignment to the class of those conforming, or 
failing to conform, to the ideal. Such methods can be applied to 
unquantified phenomena in the domain of impairment, and to most 
disabilities.
(iii) Drawing further on the theory of deviance, yet other norms 
are determined by social responses. These are relevant to some 
disabilities and to most handicaps. In general, these norms are 
more difficult to categorize reproducibly, other than by recourse 
to cumbersome and highly arbitrary methods such as those used for 
determining eligibility for benefits. However, the particular 
relevance of social norms in the present context is that they 
indicate that an individual's perceptions - his belief that he 
has a problem - or the identity that other people attribute to 
the individual can both give rise to disadvantage.

        Another problem stems from the very nature of norms. 
Specific individual impairments or disadvantages are not 
themselves universal, although when they are taken in aggregate 
most of us fail to escape some departure from the norm. The 
social definition of problems allows one to resolve the 
difficulties, because value orientation relates to social 
interest; thus, in a social context,disease occurring in wild 
species is likely to be of little concern, whereas maladies 
affecting domestic animals are of greater interest. Departures 
from the norm thus need to be regarded in such a way that views 
are tempered by consideration of the feasibility and desirability 
of intervention to restore the norm. This is also the place to 
introduce another note of caution. There has been a recent vogue 
for promoting the notion of social handicap, drawing attention to 
such problems as poverty and poor
housing out of relation to their direct influences on health. 
While one has sympathy with any attempt to combat social 
deprivation, such dilution of the concept of handicap is 
unhelpful because it tends to confound identification of specific 
health-related experiences and the means by which these might be 
controlled.

Measurement 

        In order to measure the consequences of disease, those 
who are affected have to be ascertained. The process of 
ascertainment of the disabled and handicapped is itself somewhat 
dubious, at least as an absolute proposition, and two crucial 
questions have to be acknowledged. The first concerns the sense 
in which the individual is disabled or handicapped, This should 
have been made clear by the definitions of concepts, and it is 
hoped that the ideas will serve to rebut those who try to dismiss 
the scheme as an attempt to classify the unclassifiable. The 
second question, which underpins the first, is directed at the 
reason for ascertainment, because any attempt to clarify thinking 
in this area can be vulnerable to the protests of those who are 
concerned that categorization or labelling engenders stigma. 
However, this attitude surely denies the possibility of any 
coherent attempt to alter the present situation; until categories 
can be identified, one is unable to begin to count, and until 
counting is possible one cannot know how big the problems are or 
deploy the resources intelligently in an endeavour to control the 
problems.

        In order to overcome the difficulties, it has been 
necessary to develop
three separate classification schemes supplementary to the ICD - 
one concerned with each of the three principal concepts. These 
classifications are                                        
intended to facilitate study of some of the consequences of 
disease. They have been designed as coding systems that will 
allow details from individual
case records to be reduced to standardized numerical form. This 
will allow                                                 
the simplest form of measurement,by counting the numbers in each 
category.  In turn, these counts can then be grouped with related 
problems so as to promote simplification for the preparation of 
statistical tabulations of aggregated data. The classifications 
therefore exemplify the underlying conceptual framework, but to a 
considerable degree their value can be considered separately from 
that of the theoretical constructs. This means that the 
classifications should be evaluated in the same way as the ICD - 
i.e., do they assist in the derivation of information of
value to users?

        Brief guidance on the acquisition of data compatible with 
these classifi-
cations was offered in the Introduction, and further suggestions 
about
assessment and assignment have been made at the end of each of 
the suc-
ceeding chapters. However, it is now necessary to provide a more 
detailed
description of the principles underlying the development of each 
of the
three classifications.

Classification of impairments

        For many clinicians, thought on an impairment axis is 
likely to be unfamiliar because it is cross-disciplinary. In many 
ways there is an approximate inverse relationship between the ICD 
and the impairment (I) code. Thus where the ICD allows a 
considerable array of causes, such as those for cardiovascular 
and respiratory diseases, the I code makes relatively limited 
provisions because the functional conditions of these various 
conditions are much more limited. Similarly, the functional 
consequences of an amputation are virtually identical, be it due 
to trauma or to a congenital deficiency, and so only a single 
series of coding categories is provided; the ICD would have to be 
used to distinguish which cause applied. However, amputations 
also illustrate how parts of the ICD fail to provide sufficient 
detail for clinical management, a problem that applies to other 
disorders of the limbs as well. An attempt has been made to 
embrace the diversity of the functional consequences of these 
conditions in some detail, although this has necessitated 
recourse to a fourth digit.

        The basic structure of the I code consists of two digits 
supplemented by a decimal digit; as just noted, in some parts the 
use of a fourth digit has been suggested as well. An attempt has 
been made to allot taxonomic space in relation to the frequency 
and importance of the various types of impairment. In form the 
code resembles the ICD, in that it is hierarchical and meaning is 
preserved even if the code is used only in abbreviated form. 
Again, like disease terms in the ICD, impairments are best 
conceived of as threshold phenomena; for any particular category, 
all that is involved is a judgement about whether the impairment 
is present or not. In developing a single exhaustive code, it has 
been necessary to make compromises in specificity and taxonomic 
purity for the sake of simplicity,
and a number of aspects obviously could not be accommodated ; 
perhaps the most important omissions are individual composite 
functions such as jumping and creeping. The classification had to 
simplify details, and the overwhelming consideration has been to 
identify the most important feature influencing the intervention 
OI support the individual might be likely to need. As soon as 
multiple impairments are present, specificity becomes less 
important. However, to allow for specificity when it is 
desired,an option has been provided wherever possible ; each 
individual impairment may be coded (multiple coding) or special 
combination categories, identified by an asterisk, may be used 
instead if the information has to be reduced to a single 
category. Alternatively, the code could be used to identify the 
most limiting impairment. This would be by analogy with the 
underlying cause concept in relation to the ICD. In this 
connexion, the prime function of the level of detail offered is 
to define the content of classes. It is up to the user to 
determine how much detail is recorded, so that the situation 
resembles that with the ICD - definition of subclasses by 
specification of considerable detail,but tabulation of aggregated 
data by broader classes such as ICD chapters.

        One other problem is that some categories of the I code 
and of the ICD appear to overlap. This occurs particularly in 
regard to symptoms, but a review of the purposes of the two 
classifications is likely to settle the difficulty. Interest in 
the condition leading to the consumption of medical services 
would probably require an ICD statement. A study of the reasons 
why 


people make contact with a health care system could use either I 
code or ICD statements, depending on the terms of reference of 
the study. Evaluation of the effectiveness of a health care 
system would call for two I code statements - one indicating 
initial status, and the other the status after contact with the 
system. Perhaps the likeliest use of the I code, though, would be 
as an indicator of unmet needs. In these circumstances, one might 
well wish to restrict consideration to relatively persistent 
impairments, eliminating transitory states and other trivia by 
adopting duration and severity criteria - such as that I code 
statements should be recorded only for impairments that had been 
present for a specified period of time, or that had persisted 
after medical treatment. Finally, it can be seen that in many 
ways a classification of impairments may be regarded as a 
classification of health-related problems that individuals are 
likely to encounter. The I code therefore has relevance to 
problem-oriented record systems and may be of value to those 
interested in automating the processing of such records, short of 
introducing full interactive visual display with a computer.


Classification of disabilities

In the preliminary draft of this manual a limited scheme was put 
forward for recording disability in a rather arbitrary manner, by 
means of a digit supplementary to the I code. This proved to be 
inadequate for many purposes. As a result, a more comprehensive 
disability (D) code has been designed - one that encompasses the 
more important behaviours and activities associated with everyday 
life. The key influence in designing this classification has been 
the feasibility of recording the interface between the individual 
and his environment in such a way as to display his potential; 
this may be supplemented by the handicap classification as a 
means of indicating the extent to which potential is realized. 
Perhaps the ideal aim for the D code would be to present a proof 
of the individual's functional abilities, as determined from what 
disabilities were present, in such a way that reciprocal 
specification of the environment allowed matching with the 
individual's capabilities. For instance, in the context of job 
placement, a factory extending over two floors but with toilet 
facilities located on only one of these would require separate 
specification of each floor for purposes of matching with the 
(residual) functional abilities of potential employees.

        If this effort succeeded, the D code could then be used 
as a means of
screening that could be applied not only to job placement in 
vocational rehabilitation but also to school placement, rehousing 
the disabled, identifying vulnerability in the elderly, and other 
related purposes.


        In view of these considerations, it proved necessary to 
eliminate much of the complexity and detail present in 
conventional assessments, such as those of the activities of 
daily living. Only in this way could procedures be developed that 
would be simple and confined to the most basic or key functions. 
The actual assessment procedures may need to retain their 
complexity but, as in the I code, this additional detail could be 
incorporated in the D code more as a means of clarifying the 
content of broader classes. In the circumstances, it is 
understandable that the D code is less developed than the schemes 
for impairment and handicap. However, its form allows of 
expansion in response to additional needs uncovered by further 
field experience. The basic structure of the code consists of two 
digits, with the option of a supplementary decimal] digit, but 
even the nine main chapters have not been fully utilized so far. 
Once again, the taxonomic form resembles that of the ICD in being 
hierarchical, meaning being preserved even if the code is used 
only in abbreviated form - this feature is essential for 
facilitating matching of the individual and environmental 
circumstances. However, there is one important difference from 
both the ICD and the I code - disabilities are not' threshold 
phenomena; they reflect failures in accomplishments, so that a 
gradation in performance is to be expected. Provision has 
therefore been made for recording the degree of disability by 
means of a supplementary digit. Furthermore, those engaged in 
rehabilitation also find a judgement on future outlook of 
potential value, and so provision has also been made for this on 
an additional supplementary digit.

Dimensions of disadvantage

        Before proceeding to the classification of handicaps, it 
is necessary to consider further the nature of disadvantage. Any 
direct attempt to measure values is fraught with difficulties. 
However, one can identify certain fundamental accomplishments 
that are related to the existence and survival of man as a social 
being and are expected of the individual in virtually every 
culture. An individual with reduced competence in any of these 
dimensions of existence is, ipso facto, disadvantaged in relation 
to his peers. The degree of disadvantage attached to reduced 
competence may vary appreciably in divers cultures, but some 
adverse valuation is almost universal. The key accomplishments 
include the ability of the individual to :
(i) orient himself in regard to his surroundings , and to respond 
to these; inputs;
(ii) maintain an effective i?dependent existence in regard to the 
more immediate physical needs of his body, including feeding and 
personal hygiene;


(iii) move around effectively in his environment;
(iv) occupy time in a fashion customary to his sex, age , and 
culture , including following an occupation (such as tilling the 
soil, running a household, or bringing up children) or carrying 
out physical activities such as play and recreation;
(v) participate in and maintain social relationships with others;
(vi) sustain socioeconomic activity and independence by virtue of 
labour or exploitation of material possessions, such as natural 
resources, livestock, or crops.
These six dimensions may be designated as survival roles, and the 
handicap classification is based on this analysis. However, 
before describing this scheme, a number of other points have to 
be taken into account.

The only value assumed in this analysis is that existence and 
survival are
necessary and good. In a consideration of health-related problems 
this proposition would not appear to require justification. 
Survival roles have the merit of being broadly transcultural; in 
fact, disturbances of orientation, physical dependence, 
immobility, restricted occupation, social isolation, and poverty 
are the biggest and most frequent problems of the impaired and 
disabled, even in urbanized and industrialized societies with 
appreciable surplus wealth.  Survival roles by no means exhaust 
the dimensions of handicap, and cognizance must be taken of other 
disadvantages. Maslow's hierarchy of needs[4] would appear to 
present a useful conceptual framework for understanding these 
problems. The three lowest planes are physiological, safety, and 
social needs, and it is with these that the handicap 
classification deals, largely in that order.  Ego needs and 
status recognition come next, and the highest level is 
self-fulfillment.  Maslow then asserts that man is motivated to 
satisfy needs in a predetermined order; the individual is no 
longer driven once a need is satisfied, but higher needs will be 
ignored until more basic needs are met.  These hierarchical 
distinctions can be of value in helping to determine priorities.  
Certainly the dominance of survival roles emergences very clearly 
from such an analysis.  Moreover, the symbolic values attached to 
such basic functions as eating and excretion can be seen to 
reflect a higher level of need.  However, these higher needs are 
more difficult problems as long as basic needs are neglected.  
For this reason the classification makes little provision for 
disadvantage other than in relation to survival roles.  Those 
interested in studying
these aspects in greater detail will doubtless develop their own 
supplementary schemes.
        One important source of confusion needs to be disposed of 
at this stage. Disadvantage has frequently been equated with 
dependence. Certainly dependence has the advantage of being 
fairly easy to define, and therefore to measure. Moreover, a 
fundamental self-sufficiency in regard to physical and material 
accomplishments is important, not least because dependence on 
others entails making demands on their productivity and time. 
This aspect is complicated in many societies, in which changes in 
family size, geographical mobility, and obligations within the 
family have led to demands for dependence to be responded to 
collectively rather than individually - a problem compounded by 
demographic changes that increase the proportion of the 
population at greatest risk, the elderly. The principal obstacle 
to subsuming disadvantage within the term "dependence" is that it 
obscures social needs that can themselves, if met, go a long way 
to overcoming many of the disadvantages associated with 
irremediable physiological and safety needs. Underlying this is 
the fact that the notable feature of highly integrated societies 
is the extreme dependence of the individual on others, both for 
social relationships and for opportunities for occupation and 
economic selfsufficiency. The reality is that man is a social 
being; the social relations an individual enjoys are equally as 
essential for his survival as is competence in attending to 
physiological needs. Thus man's situation can more appropriately 
be described as one of interdependence. Moreover, this helps to 
highlight another important aspect - if disadvantage in one 
dimension is reduced, disadvantage in another may also be made 
more bearable.

        The apparent lack of a clear operational differentiation 
has obviously served to perpetuate confusion between disability 
and handicap. In the past, the means of identifying handicap 
usually depended on the ascertainment of disability and its 
severity. To infer the existence of disadvantage from the 
presence of certain disabilities may not appear unreasonable , 
but important assumptions both about values and about the 
interrelationship between disadvantage and the nature and 
severity of disability are implied by this approach. Thus there 
is a danger that the goal of social action may too readily become 
deflected to disability alone. This is a reductionist response, 
submerging handicap within disability, and it can encourage views 
that are insensitive to other dimensions of disadvantage, so that 
inequities result. These are exemplified by the common and yet 
unacceptable
differences in the financial recompense offered to the disabled 
according to the cause of their impairment, feelings of guilt 
presumably accounting for the preferential rates often given to 
those disabled at war. There is also a tendency to concentrate 
excessively on disability resulting from physical impairments, to 
the neglect of that consequent upon psychological impairments.



        The difficulty is that the measure too readily determines 
the activity. For instance, measurements of intelligence 
quotients (IQ) have tended to influence educational opportunities 
out of relation to need, educational potential, or anything other 
than the availability of buildings and institutions to cope with 
the categories so identified. Much the same has happened with 
disability. Administratively , it may appear to be simpler to 
institute ascertainment and control at the level of disability; 
certainly one can see the need for some yardstick to reconcile 
the frequently conflicting needs of society and of the 
individual. However, disability will only indirectly influence 
disadvantage, and it is therefore important to be quite clear 
about one's goals. If handicap is the prime area of social 
concern, not all those with activity restriction are necessarily 
at a disadvantage - because activity restriction
cannot be viewed as a sociological phenomenon per se. There is a 
distinct cleavage between disability and handicap, both 
conceptually and in the means for intervention, and 
methodological obstacles need not compel social action on 
disadvantage to be determined by measures of disability alone. As 
evidence for this, the handicap classification is provided as the 
means of studying disadvantage direct.

Classification of handicaps

        Having indicated the challenge, it is now necessary to 
explain why the
handicap (H) code takes the form that it does. An attempt to 
classify
nominal variables is relatively easy. The principal requirement 
is that the classification should be exhaustive. In medical 
contexts, the other require-
ment of simple logic - that the classes be exclusive - is more 
problematical,
since more than one disease, impairment, or disability can occur 
in the same
individual. The difficulty can be overcome , however, either with 
multiple
coding or by adopting conventions such as combination categories 
or 
assignment rules based on concepts such as the underlying cause. 
A hierarchy
can be imposed on a classification of nominal variables by 
identifying
similarities and grouping these together. An example is provided 
by the
various axes of the ICD, based on etiology, system, location, and 
nature.



Impairments and disabilities can be classified in a similar 
manner.


        The essential property of nominal variables is that the 
classes are mutually exclusive. When one turns to the concept of 
handicap, the situation is very different. Whereas manifestations 
are finite, consequences relate to a more
complex whole that is difficult to partition. In terms of 
disadvantage, the
consequences are that an individual is unable to sustain the 
roles to which
he is accustomed or to attain those to which he might otherwise 
aspire. Through these roles one can identify dimensions or 
components of disadvantage, but these interact in such a way that 
it is important to reflect them all, while keeping them distinct. 
Thus the first task in constructing a taxonomy of handicap is to 
identify the dimensions that one wishes to classify.  This has 
been undertaken in the preceding section, where it was 
acknowledged that values, being difficult to measure, may best be 
studied in an indirect manner.  Thus the H code classifies items 
not according to individuals or their attributes, but according 
to the circumstances in which disabled people are likely to find 
themselves--circumstances that can be expected to place such 
individuals at a disadvantage in relation to their peers when 
judged by societal norms.  It is then necessary to recognize that 
one is concerned with degrees of these dimensions; thus, for each 
dimension, a gradation of circumstances is possible, and a 
specification of the individual's status in regard to each is 
therefore required.  As a result, the code is not hierarchical in 
the customarily accepted sense, and abbreviation is possible only 
by arbitrarily neglecting certain of the dimensions - rather than 
by compromise between various roles or axes, as is incorporated 
in the ICD.  Similarly, an attempt at synthesis would be both 
presumptuous and self-defeating; it would involve the imposition 
of value judgements in a dangerously subjective realm.

        Perusal of the outline of the H code should indicate 
these characteristics more clearly, when it will be seen that, as 
a descriptor, an H code statement is a means of summarizing the 
situation semi-quantitatively, rather than identifying discrete 
categories.  Overlap between categories in the different 
dimensions has been kept to a minimum, but it could not be 
eliminated altogether.  Thus an individual who is bedfast is not 
only immobile, but also totally dependent on others for care.  
Theoretically, it might be possible to eliminate such overlap, 
but in practice it appeared preferable for each dimension to 
stand on its own, for the
reasons noted above.  Much thought has been given to the 
ordination, the partitioning of the states of the various 
dimensions.  Not only must categories be meaningful in 
themselves, but differentiation between them must be feasible by 
fairly simple and yet reliable means.  For these reasons a full 
spectrum of sensitivity, spanning the available nine digits, has 
not always been possible.  One must acknowledge here the value of 
concepts such as that of critical interval needs,[5] which has 
been incorporated in the physical independence dimension and is 
much superior to more arbitrary distinctions such as those based 
upon the duration for which help is needed.  How successful all 
these attempts have been, and how appropriate the ordination 
within each dimension is, will become apparent only after further 
practical trials of the classification.

        Certain other problems are likely to be encountered. 
First,disadvantage may be perceived in three different ways - 
subjectively, by the individual himself; by others who are 
significant to the individual; and by the community as a whole. 
Secondly, there is ambiguity over how to regard third party 
handicap - i.e., handicap in an individual who is not himself 
impaired but who suffers disadvantage because of the demands made 
upon him by chronic illness or disability in the family. The 
difficulty is that, in following the definition of handicap with 
rigour, it is not possible to take account of such people in the 
present context, since their disadvantage is not consequent upon 
their own impairment and disability. Thirdly, it should be 
obvious from what has been said that it is not possible for any 
scheme intended for international use to correspond exactly with 
eligibility status for various benefits.



1. Wood, P.H.N. (1975) Classification of impairments and 
handicaps (Unpublished document WHO/ICD9/REV.CONF/75.15)

2. Townsend, P. (1967 The disabled in society.  London, Greater 
London Associated for the Disabled.

3. Mitchell, R. G. (1973) Editorial. Develop. Med. Child. Neurol. 
15, 279-280.

4. Maslow, A.H. (1954) Motivation and personality. 
New York, Harper & Row.

5. Isaacs, B., & Neville, Y. (1975) The measurement of need in 
old people, (Scottish Health Service Studies, No. 34) Edinburgh, 
Her Majesty's Stationery Office.

----------
SECTION 2

CLASSIFICATION OF IMPAIRMENTS

List of two-digit categories
1 Intellectual impairments
2 Other psychological impairments
3 Language impairments
4 Aural impairments
5 Ocular impairments
6 Visceral impairments
7 Skeletal impairments
8 Disfiguring impairments
9 Generalized, sensory, and other impairments
Guidance on assignment
Index
IMPAIRMENT

Definition     In the context of health experience, an impairment 
               is any loss or abnormality of  psychological, 
               physiological, or anatomical structure or function

                    (Note: "Impairment" is more inclusive than 
                    "disorder" in that it covers losses - e.g., 
                    the loss of a leg is an impairment, but not a  
                    disorder)

CharacteristicsImpairment is characterized by losses or 
               abnormalities that may be temporary or permanent, 
               and that include the existence or occurence of an 
               anomaly, defect or loss in a limb, organ, tissue, 
               or other structure of the body, including the 
               systems of mental function. Impairment represents  
               exteriorization of a pathological state, and in 
               principle it reflects disturbances at the level of 
               the organ
LIST OF TWO-DIGIT CATEGORIES OF IMPAIRMENT

1    INTELLECTUAL IMPAIRMENTS

     Impairments of intelligence (10-14)

10   Profound mental retardation
11   Severe mental retardation
12   Moderate mental retardation
13   Other mental retardation
14   Other impairment of intelligence

     Impairments of memory (15-16)

15   Amnesia
16   Other impairment of memory

     Impairments of thinking (17-18)

17   Impairment of flow and form of thought processes
18   Impairment of thought content

     Other intellectual impairments (19)

19   Other intellectual impairment

2    OTHER PSYCHOLOGICAL IMPAIRMENTS

     Impairments of consciousness and wakefulness (20-22)

20   Impairment of clarity of consciousness and the quality
     of conscious experience
21   Intermittent impairment of consciousness 
22   Other impairment of consciousness and wakefulness

     Impairments of perception and attention (23-24)
 
23   Impairment of perception
24   Impairment of attention

     Impairments of emotive and volitional functions (25-28)

25   Impairment of drives
26   Impairment of emotion, affect, and mood
27   Impairment of volition
28   Impairment of psychomotor functions

     Behaviour pattern impairments (29)

29   Impairment of behaviour pattern

3    LANGUAGE IMPAIRMENTS

     Impairments of language functions (30-34)

30   Severe impairment of communication
31   Impairment of language comprehension and use
32   Impairment of extralinguistic and sublinguistic functions
33   Impairment of other linguistic functions
34   Other impairment of learning

     Impairments of speech (35-39)

35   Impairment of voice production
36   Other impairment of voice function
37   Impairment of speech form
38   Impairment of speech content
39   Other impairment of speech

4    AURAL IMPAIRMENTS

     Impairments of auditory sensitivity (40-45)

40   Total or profound impairment of development of hearing
41   Profound bilateral hearing loss
42   Profound hearing impairment in one ear with moderately 
                                                       severe 
                                                       impairment 
                                                       of the 
                                                       other ear
43   Moderately severe bilateral hearing impairment 
44   Profound hearing impairment in one ear with moderate or 
                                                       lesser 
                                                       impairment 
                                                       of the 
                                                       other ear
45   Other impairment of auditory sensitivity

     Other auditory and aural impairments (46-49)

46   Impairment of speech discrimination
47   Other impairment of auditory function
48   Impairment of vestibular and balance function
49   Other impairment of aural function

5    OCULAR IMPAIRMENTS

     Impairments of visual acuity (50-55)

50   Absence of eye
51   Profound visual impairment of both eyes
52   Profound visual impairment of one eye with low vision in the 
                                                            other 
                                                            eye
53   Moderate visual impairment of both eyes
54   Profound visual impairment of one eye
55   Other impairment of visual acuity

     Other visual and ocular impairments (56-58)

56   Visual field impairment
57   Other visual impairment
58   Other ocular impairment

6    VISCERAL IMPAIRMENTS

     Impairments of internal organs (60-66)

60   Mechanical and motor impairment of internal organs
61   Impairment of cardiorespiratory function
62   Impairment of gastrointestinal function
63   Impairment of urinary function
64   Impairment of reproductive function
65   Deficiency of internal organs
66   Other impairment of internal organs

     Impairments of other special functions (67-69)

67   Impairment of sexual organs
68   Impairment of mastication and swallowing
69   Impairment related to olfaction and other special functions

7    SKELETAL IMPAIRMENTS

     Impairments of head and trunk regions (70)

70   Impairment of head and trunk regions
     
     Mechanical and motor impairments of limbs (71-74)

71   Mechanical impairment of limb
72   Spastic paralysis of more than one limb
73   Other paralysis of limb
74   Other motor impairment of limb

     Deficiencies of limbs (75-79)

75   Transverse deficiency of proximal parts of limb
76   Tranverse deficiency of distal parts of limb
77   Longitudinal deficiency of proximal parts of upper limb
78   Longitudinal deficiency of proximal parts of lower limb
79   Longitudinal deficiency of distal parts of limb

8    DISFIGURING IMPAIRMENTS

     Disfigurements of head and trunk regions (80-83)

80   Deficiency in head region
81   Structural deformity in head and trunk regions
82   Other disfigurement of head
83   Other disfigurement of trunk
     Disfigurements of limbs (84-87)

84   Failure of differentiation of parts
85   Other congenital malformation
86   Other structural disfigurement
87   Other disfigurement

     Other disfiguring impairments (88-89)

88   Abnormal orifice
89   Other disfiguring impairment

9    GENERALIZED, SENSORY, AND OTHER IMPAIRMENTS

     Generalized impairments (90-94)

90   Multiple impairment
91   Severe impairment of continence
92   Undue susceptibility to trauma
93   Metabolic impairment
94   Other generalized impairment

     Sensory impairments (95-98)

95   Sensory impairment of head
96   Sensory impairment of trunk
97   Sensory impairment of upper limb
98   Other sensory impairment

     Other impairments (99)

99   Other impairment
          1 INTELLECTUAL IMPAIRMENTS

Intellectual impairments include those of intelligence, memory, 
and thought 
     Excludes: impairment of language and learning (30-34)

          IMPAIRMENTS OF INTELLIGENCE (10-14)

     Includes: disturbances of the rate and degree of development 
               of cognitive functions, such as perception, 
               attention, memory, and thinking, and their 
               deterioration as a result of pathological 
               processes

10   Profound mental retardation
     IQ under 20
     Individuals who may respond to skill training in the use of 
     legs, hands, and jaws

11   Severe mental retardation
     IQ 20-34
     Individuals who can profit from systematic habit training

12   Moderate mental retardation
     IQ 35-49
     Individuals who can learn simple communication, 
elementaryhealth and safety habits, and simple manual skills, but 
do                                           not progress in 
functional reading or arithmetic

13   Other mental retardation

13.0 Mild mental retardation
     IQ 50-70
     Individuals who can acquire practical skills and functional 
     reading and arithmetic abilities with special education, and 
     who can be guided towards social conformity
13.8 Other
13.9 Unspecified

14   Other impairment of intelligence

14.0 Global dementia
     Dementia affecting all cognitive functions and skills
     Includes: deterioration of cognitive functioning as a result 
               of cerebral disease of trauma
14.1 Lacunar or patchy dementia
     With partial preservation of some cognitive functions and 
     skills
14.2 Other and unspecified dementia
14.3 Loss of learned skills
14.8 Other
14.9 Unspecified

     IMPAIRMENTS OF MEMORY (15-16)

15   Amnesia
     Includes: partial or complete loss of memory for past 
               events, and inability to register, retain, or 
               retrieve new information
15.0 Retrograde amnesia
     Impaired memory for happenings prior to some well-identified 
     event 
15.1 Impairment of long-term memory
15.2 Impairment of recent memory
     Includes: congrade amnesia, impaired ability to acquire new 
               information
15.3 Psychogenic amnesia
     Irregularity of pattern of memory loss
15.4 Impairment of memory for shapes
15.5 Impairment of memory for words
15.6 Impairment of memory for figures
15.8 Other
15.9 Unspecified

16   Other impairment of memory
     Memory includes the capacity to register, retain, and 
     reproduce information
     Includes: false memories and distortions of memory content
16.0 Confabulation
16.1 Memory illusions
     Paramnesia
16.2 Cryptomnesia
     Recall of facts or events without recognizing them as 
     memories
16.3 Other distortion of memory content
16.4 Forgetfulness
16.8 Other
16.9 Unspecified
     IMPAIRMENTS OF THINKING (17-18)

17   Impairment of flow and form of thought processes
     Includes: disturbances affecting the speed and organization 
               of thought processes, and the ability to form 
               logical sequences of ideas

17.0 Impairment of conceptualization or abstraction
     Relates to the ability to interpret the meaning of what is 
     perceived, to integrate perceptions, to form meaningful 
     relations among perceptions, and to abstract
17.1 Impairment of logical thinking
     Relates to the ability to relate ideas hierarchically
17.2 Slowness of thought
17.3 Acceleration of thought
17.4 Perseveration
     Includes: "getting stuck", repeating phrases, and constantly 
               returning to same topic
17.5 Circumstantial thinking
17.6 Obsessional ideas
17.7 Flight of ideas
     Includes: association of words by sound or rhyme

17.8 Other
     Includes: incoherence of thought processes
17.9 Unspecified

18   Impairment of thought content
     Includes: restriction of thought content, excessive or 
               unrealistic emphasis on and preoccupation with a 
               particular set of ideas to the exclusion of 
               critical examination of the ideas, and false 
               beliefs not amenable to correction through logical 
               argument and reality testing

18.0 Poverty of thought content
18.1 Overvalued ideas
18.2 Paranoid delusions
     A delusion is a false belief, impervious to the force of 
     reason, and not shared by others of similar education and 
     cultural background. A paranoid delusion or idea of 
     reference is a delusion in which the individual considers 
     that things in his surroundings are happening especially in 
     connexion with him
18.3 Depressive delusions
     Includes: delusions of guilt and impoverishment
18.4 Delusional jealousy
18.5 Delusions of grandeur
18.6 Fantastic delusions
18.7 Hypochondriacal and nihilistic delusions
18.8 Other delusions
18.9 Other and unspecified

     OTHER INTELLECTUAL IMPAIRMENTS (19)

19   Other intellectual impairment
     Includes: Impairments of gnosis and praxis functions, where 
               there is disturbance of higher cortical functions 
               underlying the recognition and purposeful 
               manipulation of objects
19.0 Agnosia
     Disturbed ability to recognise objects in the absence of 
     impairments of consciousness, memory, and thinking
19.1 Apraxia
     Disturbed ability to perform learned purposeful movements in 
     the absence of impairments of consciousness, memory, 
     thinking, and motor capacity
19.2 Acalculia
     Disturbed ability to count and operate with numbers in the 
     absence of impairments of consciousness, memory, and 
     thinking
19.3 Impairment of openness to new ideas
19.4 Misinterpretation
     A misinterpretation is a false construction put by the 
     individual on an occurence
19.8 Other
19.9 Unspecified
          2 OTHER PSYCHOLOGICAL IMPAIRMENTS

Psychological impairments have been interpreted so as to include 
interference with the basic functions constituting mental life. 
For the purpose of this scheme, the functions listed as being 
impaired are those that normally indicate the presence of basic 
neurophysiological and psychological mechanisms. The level of 
organization of these functions is that usually recorded in a 
clinical examination of the central nervous system and the 
examination of ``mental status''. In addition, some more complex 
psychological functions to do with drives, emotional control, and 
reality testing have also been included.

Conventionally symptoms such as hallucinations and delusions are 
usually thought of as very closely related to what have been 
defined here as impairments. In terms of the classification they 
can be regarded as the result of impairment of some essential 
psychological processes, which must normally exist even though we 
are as yet largely ignorant of their nature. For instance, severe 
anxiety symptoms can be thought of as an impairment of autonomic 
response control mechanisms; the same applies to morbid 
depressive affect, and to hypomanic affect. Similarly, 
hallucinations presumably result from impairment of mechanisms 
differentiating between self and non-self, while delusions 
indicate impairment of analogous mechanisms concerned with 
reality testing. For the purpose of the classification, symptoms 
have been included among impairments with the understanding that 
there is an inferred impairment of some underlying complex 
psychological mechanism.

Interferences with behaviour that represent complex purposeful 
and integrated sequences of interaction with and response to the 
environment and other persons are, for this purpose, properly 
regarded as disabilities rather than impairments.

     IMPAIRMENTS OF CONSCIOUSNESS AND WAKEFULNESS (20-22)

20   Impairment of clarity of consciousness and the quality of 
     conscious experience
     Includes: various degrees of diminished wakefulness, and 
               status characterized by changes in the level of 
               wakefulness combined with altered awareness of 
               self and the surrounding world
     Excludes: Intermittent impairment of consciousness (21)
20.0 Unconsciousness
     Includes: coma, sopor, and stupor
20.1 Clouding of consciousness
     Includes: transitional syndrome or post-concussional state
20.2 Narrowing of field of consciousness
     Includes: when due to affect
20.3 Delirium
     Includes: twilight status
20.4 Other confusional state
     Includes: disorientation for time, place, and persons
20.5 Dissociative state
20.6 Trance-like state
     Includes: hypnotic state
20.7 Akinetic mutism
20.8 Other
20.9 Unspecified

21   Intermittent impairment of consciousness
     Includes: intermittent ictal disturbances characterized by a 
               total or partial loss of consciousness or by 
               states of altered awareness, and a variety of 
               local cerebral signs and symptoms

21.0 Profound intermittent interruption of consciousness
     Includes: epilepsy with frequency of seizures of once per 
               day or greater
21.1 Severe intermittent interruption of consciousness
     Includes: epilepsy with frequency of seizures of once per 
               week or greater
22.2 Moderate intermittent interruption of consciousness
     Includes: epilepsy with frequence of seizures of once per 
               month or greater
21.3 Mild intermittent interruption of consciousness
     Includes: epilepsy with frequency of seizures less than once 
               per month
21.4 Intermittent disturbance of consciousness
     Includes: psychomotor epilepsy
21.5 Other seizures
     Includes: petit mal
21.6 Other intermittent interruption of consciousness
     Includes: syncope and drop-attacks
21.7 Fugue states
21.8 Other
21.9 Unspecified

22   Other impairment of consciousness and wakefulness
     Includes: impairments of the sleep/wakefulness cycle, both 
               disturbances affecting the quantity, quality, and 
               pattern of the processes of sleep and wakefulness, 
               and impairments of autonomic control of bodily 
               functions that are influenced by the sleep cycle

22.0 Difficulty in getting off to sleep
22.1 Premature awakening from sleep
     Includes: insomnia NOS
22.2 Hypersomnia
     Excessive sleeping
22.3 Other impairment of sleep/wakefulness pattern
     Includes: narcolepsy
22.4 Enuresis nocturna
22.5 Other abnormality of acitivity during sleep
     Includes: sleep-walking and sleep-talking
22.6 Other impairment of sleep/wakefulness cycle
22.7 Sleepiness
     Includes: somnolence
22.8 Other
     Includes: impairment of awareness (which is an 
               undifferentiated response to stimulus)
22.9 Unspecified

     IMPAIRMENTS OF PERCEPTION AND ATTENTION (23-24)
     
     Includes: disturbances of the functions enabling an 
               individual to receive through the senses, to 
               process information about the individual's own 
               body and his environment, and to focus selectively 
               on aspects or parts of such information

23   Impairment of perception

23.0 Impairment of the intensity of perception
     Includes: changes in the degree to which qualities and 
               attributes of objects are perceived as vived and 
               impressing on the mind
     23.00     Uniform dulling of perception
     23.01     Selective dulling of perception
               Includes: dulling in specific modalities
     23.02     Uniform heightening of perception
     23.03     Selective heightening of perception
           Includes: hypersensitivity to noise
     23.08     Other
     23.09     Unspecified
23.1 Distortion of perception
     Includes: illusions, disturbed percepts where the objective 
               content of sense data received in different 
               modalities is distorted
               - something actually to be seen or heard is 
               experienced as something else
     Excludes: depersonalization (23.30)
     23.10     Optical illusions
     23.11     Acoustic illusions
     23.12     Tactile illusions
     23.13     Kinaesthetic illusions
     23.14     Illusions in other sense modalities
     23.15     Composite illusions
               Includes: pareidolic imagery
     23.18Other
     23.19Unspecified
23.2 False perception
     Includes: hallucinations and pseudohallucinations, false or 
               abnormal percepts that are not based on objective 
               sense data
     23.20Visual hallucinations
     23.21Auditory hallucinations
     23.22     Tactile hallucinations
     23.23Olfactory hallucinations
     23.24Gustatory hallucinations
     23.25Other hallucinations
     23.26Pseudohallucinations
               Includes: those in any sense modality
     23.27Oneroid or dream-like hallucinatory state
     23.28Other
     23.29Unspecified
23.3 Disturbance of body awareness
     23.30Depersonalization
               Experiences of alienation from one's own body, and 
               the experience that one's relationship to the 
               environment and surroundings (and vice versa) is 
               altered
     23.31Derealization
               Alteration of the feeling of reality/unreality and 
               familiarity/unfamiliarity accompanying the 
               perception of objects
               Includes: d‚j… vu, jamais vu, and d‚j… v‚cu 
                         experiences
     23.32Body image disorder
               Includes: phantom limb experiences
     23.38Other
     23.39Unspecified
23.4 Disturbances of time and space perception
     Includes: time-standing-still, micropsy, and macropsy 
               experiences
23.5 Impairment of reality testing
     Includes: loss of ability to distinguish fantasy from 
               reality
23.8 Other
23.9 Unspecified

24   Impairment of attention
     Includes: disturbances of the intensity, span, and mobility 
               of attention, the latter being a differentiated 
               response to specific stimulus
24.0 Distractibility
24.1 Impaired concentration
24.2 Narrowing of attention span
24.3 Impaired ability to shift focus of attention
     Includes: fixed attention
24.4 Blank spells
     Includes: sudden stoppage or inattention while speaking for 
               a few seconds or longer (may be due to 
               thought-blocking or hallucination)
24.5 Inattentiveness
24.6 Impairment of alertness
     Includes: diminished ability to stay alert as reflected by 
               facial expression, speech, or posture
24.8 Other
24.9 Unspecified

     IMPAIRMENTS OF EMOTIVE AND VOLITIONAL FUNCTIONS (25-28)
     Refer to functions which contribute predispositions to 
     action and purposeful behaviour

25   Impairment of drives
     Includes: increase, decrease, or changes of pattern of 
               various behaviours related to basic physiological 
               needs or instincts
     Excludes: impairment of volition (27)
25.0 Decreased appetite
     Includes: anorexia
25.1 Increased appetite
     Includes: hyperorexia and bulimia
25.2 Impairment of heterosexual role
     Includes: homosexuality and lack of interest in a 
               relationship or contact with individuals of the 
               opposite sex
25.3 Decrease of libido
     Includes: loss of libido
25.4 Other impairment of sexual performance
     In the presence of normal libido
     Includes: other disturbances of sexual functioning
     Excludes: impairment of reproductive function (64) and of 
               sexual organs (67)
     25.40Impotence
     25.41Ejaculatio praecox
     25.42Frigidity
     25.48Other
     25.49Unspecified
25.5 Alcohol dependence
     Includes: alcoholism
25.6 Other drug dependence
     Includes: drug addiction
25.7 Other pathological craving
     Includes: states of pathological craving related to 
               substance dependence, and alcohol abuse
25.8 Other
     25.80Inability to sustain goals
     25.81Impairment of motivation
     25.88Other

25.9 Unspecified

26   Impairment of emotion, affect, and mood
     Includes: disturbances of the intensity and quality of 
               feelings and their somatic accompaniments, and 
               disturbances of the duration and stability of 
               feelings states
     Excludes: pathological affect leading to narrowing of field 
               of consciousness (20.3)
26.0 Anxiety
     Includes: tense, worried look or posture, fearful 
               apprehensive look, frightened tone of voice, and 
               tremor
     Excludes: tremor NOS (74.90)
     26.00Pathological anxiety
               Includes: free-floating anxiety
     26.01Phobic anxiety
               Includes: panic attacks
     26.08Other
     26.09Unspecified
26.1 Depression
     Includes: anhedonia, and features such as sad, mournful 
               look, tears, gloomy tone of voice, deep sighing, 
               and choking of voice on depressing topic
26.2 Other blunting of affect
     Includes: apathy, expressionless face or voice, uniform 
               blunting whatever the topic of conversation, 
               indifference to distressing topics, and flatness 
               of affect
26.3 Gross excitement
     Includes: the individual is manic, or throws things, runs or 
               jumps around, waves arms wildly, shouts, or sreams
26.4 Other excitement
     Includes: euphoria, elation, hypomania, and unduly cheerful 
               or smiling
     Excludes: psychomotor excitement (28.2)
26.5 Irritability
     Includes: angry outbursts
26.6 Emotional lability
     Includes: lability of one mood, changing from one mood to 
               another, and proneness to periods of depression or 
               elation
26.7 Incongruity of affect
     Includes: emotion shown but not congruent with topic, and 
               ambivalent affect
26.8 Other
     26.80"Catastrophic reaction"
     26.81Attempted control of affect display
               Includes: attempt to suppress crying or anger, or 
                         to fake a socially appropriate affect
     26.82Restlessness
     26.83Feelings of guilt
     26.84Emotional immaturity
     26.85Distress NEC
     26.88Other
26.9 Unspecified
     Includes: emotionally disturbed NOS, emotional impairment 
               NEC
     
27   Impairment of volition
     Includes: disturbances of the capacity for purposeful 
               behaviour and control of own actions
     Excludes: obsessional traits (29.5) and mutism (30.0)
27.0 Lack of initiative
     Includes: impairment of manifestations of independent or 
               unprompted action and self determination (the 
               latter including expression of personal opinion 
               such as spontaneous criticism or disagreement (not 
               negativism, 27.3), situation-relevant acts such as 
               closing a door or lifting an object from the 
               floor, asking questions, and making requests or 
               demands)
27.1 Restriction of interests
     Includes: loss of interests
27.2 Overcompliance
     Includes: excessive cooperation with elements of passivity, 
               and automatic submission
27.3 Negativism
27.4 Ambitendence
27.5 Compulsions
     Includes: rituals
27.6 Impairment of impulse control
     Includes: impulsive acts
27.8 Other
     Includes: impairment of adaptability, and other impairment 
               of cooperation (e.g. misleading responses such as 
               consistenly negative responses and frequent 
               selfcontradiction, or appearance of being 
               deliberately misleading)
     Excludes: Fatigability (28.5)
27.9 Unspecified

28   Impairment of psychomotor functions
     Includes: disturbances in the speed, rate, and quality of 
               voluntary movements in the presence of an intact 
               neural motor apparatus
     Excludes: involuntary movements of face (70.21), head 
               (70.31), and body (70.54), and facial mannerisms 
               (70.22)
28.0 Slowness
     Includes: slowness of psychic tempo, reduction of rate or 
               speed of voluntary movements, and delays in 
               responding to questions or in initiating requested 
               tasks or movements (such as walking abnormally 
               slowly, delay in performing movements, slowness of 
               speech with long pauses before answering or 
               between words, and reduction of facial movements)
     Excludes: indistinct speech (35.5)
28.1 Other underactivity
     Includes: hypoactivity, semistuporous states, and reduction 
               of extent of voluntary movements (such as sitting 
               abnormally still, near total lack of voluntary 
               movement, ''doing nothing'', and immobility of 
               face)               
     Excludes: stupor (20.0)
28.2 Psychomotor excitement
28.3 Hyperkinesia in children
28.4 Other overactivity
     Includes: over-talkativeness, pacing up and down restlessly, 
               and not sitting down for a minute
28.5 Fatigability
     Fatigue out of proportion to demands experienced
     Includes: abnormal fall-off in alertness or speed of 
               response or initiative
     Excludes: sleepiness (22.7) and generalized fatigue (94.6)
28.8 Other
28.9 Unspecified

          BEHAVIOUR PATTERN IMPAIRMENTS (29)
     Refer to habitual patterns of behaviour that may interfere 
     with social adjustment and functioning. Such patterns of 
     behaviour may be present since adolescence and throughout 
     most of adult life (e.g., in personality disorders), or may 
     occur as persisting sequelae of neurological or mental 
     illnesses. They manifest themselves mainly as accentuated 
     character traits.
     
     Excludes: mood instability (26.6)

29   Impairment of behaviour pattern
29.0 Suspiciousness
29.1 Social withdrawal
     Includes: active avoidance of verbal or non-verbal 
               interaction with other people, or of being in the 
               physical presence of other people (e.g., avoidance 
               of customarily expected social activities outside 
               the home such as visiting kin or friends, going 
               out with friends, and participating in games)
29.2 Excessive shyness
     Includes: excessive sensitivity and vulnerability, and other 
               impairment of ability to mix with people
29.3 Hypochondriasis
29.4 Worrying
     Excludes: anxiety (26.0)
29.5 Obsessional traits
     Includes: insecurity, indecisiveness, and repetition 
               compulsion
29.6 Other phobias
     Includes: agoraphobia
29.7 Hostility
     Includes: aggressivity, being uncooperative, angry, overtly 
               hostile, discontented, antagonistic, threatening, 
               or violent (hitting out at or attacking others)
29.8 Other
     29.80Histrionic traits
     29.81Perplexity
               Includes: puzzlement
     29.82Self-injury
               Includes: head banging, picking at sores, and 
                         beating eyes
     29.83Other destructiveness
               Includes: damaging furniture and tearing up pages, 
                         magazines, or clothing
     29.84Attention-seeking
               Includes: will not leave (other) adults
     29.85Solitary behaviour
     29.88Other
29.9 Unspecified
     Includes: personality disorder NEC
               3 LANGUAGE IMPAIRMENTS

Language impairments relate to the comprehension and use of 
language and its associated functions, including learning
     
     IMPAIRMENTS OF LANGUAGE FUNCTIONS (30-34)

30   Severe impairment of communication

30.0 Severe functional impairment of communication
     Includes: mutism
30.1 Combined central disorders of speech and visual function 
     with severe impairment of communication
     Includes autism
30.2 Impairment of higher centres for speech with inability to 
     communicate
     Includes: severe dysphasia
30.3 Other dysphasia
30.4 Other severe impairment of communication due to cerebral 
     damage
30.5 Other total or severe interference with communication
30.8 Other impairment of higher centres for speech
30.9 Unspecified

31   Impairment of language comprehension and use

31.0 Central disorders of visual function with inability to 
     communicate
     Includes: severe dyslexia
31.1 Other dyslexia
31.2 Other central disorders of visual function
31.3 Impairment of vocabulary
31.4 Impairment of syntax
31.5 Impairment of semantic function
31.8 Other
31.9 Unspecified
32   Impairment of extralinguistic and sublinguistic functions

32.0 Impairment of extralinguistic functions
     Includes: imitation (reproduction of sounds without 
               comprehension)
32.1 Impairment of processing, patterning, and retention of 
     auditory stimuli in a temporal and form-integrated manner
32.8 Other impairment of sublinguistic functions
32.9 Unspecified

33   Impairment of other linguistic functions

33.0 Impairment of use of other language systems
     Includes: finger spelling and sign language
33.1 Impairment of listener feedback
     Includes: lack of signals usually emitted by listener (e.g., 
               affirmative nodding and phrases such as "I see 
               ...." and "Is that so?")
33.2 Other impairment of facial expression
     Includes: increase, reduction, or inappropriateness of 
               quantity or range of facial expression (such as 
               gaze avoidance, looking up, and abnormal staring)
     Excludes: disturbance of facial expression (70.23)
33.3 Other impairment of body language
     Includes: pantomime, gesture, idiosyncratic or involuntary 
               patterns of body movement, and disturbance of 
               posture, orientation, and tonus (such as 
               abnormally reclined, relaxed, uncomfortable, 
               inappropriate, or closed posture position), 
               uncommunicative body orientation (e.g., turned 
               away from conversation partner at 90ø angle), 
               abnormally limited gesture, abnormal muscle 
               tension, agitation (e.g., fidgety, restless, 
               pacing, or frequent unnecessary movements), and 
               catatonic movements (echopraxia, flexibilitas 
               cerea, "Mitgehen", and echolalia)
     Excludes: slowness of body movement (28.0), sterotypies and 
               postural mannerisms (70.5), negativism (27.3), and 
               ambitendence (27.4)
33.4 Other impairment of language comprehension, verbal
33.5 Other impairment of language comprehension
     Includes: nonverbal
33.6 Other impairment of language formulation, oral
33.7 Other impairment of language formulation
     Includes: graphic
33.8 Other
33.9 Unspecified

34   Other impairment of learning
     Excludes: those related to impairment of intelligence 
               (10-14), and impairment of openness to new ideas 
               (19.3)
34.0 Delayed language comprehension and use for auditory stimuli
34.1 Delayed language comprehension and use for visual stimuli
34.2 Reading difficulties
34.3 Other impairment of reading
34.4 Impairment of writing
     Includes: mirror writing
34.5 Other specific learning difficulties
     A child with specific learning difficulties is one with 
     average or above-average intelligence and with no evidence 
     of major motor disorder, neurosensory loss, primary 
     emotional disorder, or environmental disadvantage, who 
     exhibits difficulties in understanding or using spoken or 
     written language as manifested by disorders of listening, 
     thinking, reading, writing, spelling, or arithmetic
34.8 Other
34.9 Unspecified

     IMPAIRMENTS OF SPEECH (35-39)

35   Impairment of voice production

35.0 Use of substitute voice
     Includes: artificial larynx
35.1 Other deficiency of larynx
35.2 Other total loss of voice production
35.3 Severe dysarthria
35.4 Other dysarthria
35.5 Indistinct speech
     Includes:  drawling, mumbling, slurring, and other features 
               making speech difficult to understand
     Excludes: impairments of speech form (37)
35.6 Other impairment of neurological control
     Includes: laryngeal palsy
35.7 Other impairment of speech organs
35.8 Other
35.9 Unspecified

36   Other impairment of voice function

36.0 Other impairment of nonverbal "grammar"
     Includes: lack of changes of pitch and loudness to amplify 
               meaning
     Excludes: impaired use of gesture (33.3)
36.1 Impairment of voice modulation
     Includes: expressionless and flat tone of voice
36.2 Impairment of pitch
36.3 Abnormally quiet voice
36.4 Other impairment of loudness
36.5 Other impairment of intonation
36.6 Impairment of voice quality
     Includes: harsh, breathy
36.7 Impairment of other qualities of voice
36.8 Other
36.9 Unspecified

37   Impairment of speech form

37.0 Impairment of speech fluency
     Includes: stammering and stuttering
37.1 Impairment of speech pressure
     Includes: more copious speech than normal, too rapid speech
37.2 Other impairment of speech patterning
     Includes: impairment of rate, rhythm, and stress
37.3 Other impairment of phonation
37.4 Other impairment of resonation
37.5 Impairment of coherence
     Includes: distorted grammar, lack of logical connexion, 
               sudden irrelevancies, and answering off the point

37.6 Nonsocial speech
     Includes: talking, muttering, or whispering out loud or out 
               of context of conversation
37.7 Other impairment of conversational form
     Includes: simultaneous talking or talking out of turn
37.8 Other
37.9 Unspecified

38   Impairment of speech content
     Excludes: perseveration (17.4) and flight of ideas (17.7)
38.0 Idiosyncratic use of words or phrases
     Includes: use of neologisms
38.1 Other inappropriate speech
     Includes: excessive use of puns, rhymes, jokes, and song, 
               and irrelevant speech
38.2 Other impairment of humour
     Includes: other inappropriate humour or lack of humour 
               although appropriate occasions offered by 
               conversation

38.3 Impairment of speech length
     Includes: abnormally lengthy or circumstantial speech, and 
               individual difficult to interrupt
38.4 Other impairment of speech quantity
     Includes: restricted quantity of speech (frequently fails to 
               answer, or restricted to minimum necessary, or no 
               extra sentences or additional comments)
38.5 Poverty of speech content
38.8 Other
38.9 Unspecified

39   Other impairment of speech
          4 AURAL IMPAIRMENTS

Aural impairments relate not only to the ear, but also to its 
associated structures and functions. The most important subclass 
of aural impairment is made up of impairments relating to the 
function of hearing

     IMPAIRMENTS OF AUDITORY SENSITIVITY (40-45)

TerminologyThe term "deaf" should be applied only to individuals 
          whose hearing impairment is so severe that they are 
          unable to benefit from any amplification
               Auditory sensitivity is determined by the average 
               hearing threshold level, measured in decibels 
               (dB), for pure tone stimuli of 500, 1000, and 2000 
               hertz (Hz), with reference to ISO: R389-1970. 
               Distinction is customarily made between the 
               following levels of hearing impairment:

               total hearing loss
               profound hearing impairmentmore than 91 dB(ISO)
               severe hearing impairment71-91 dB(ISO)
               moderately severe hearing
                impairment              56-70 dB(ISO)
               moderate hearing impairment41-55 dB(ISO)
               mild hearing impairment  26-40 dB(ISO)

Coding         Where hearing impairment is asymmetrical it should 
               be classified according to the less impaired side.

40   Total or profound impairment of development of hearing

     An individual who has lost or never had the ability to hear 
     and understand speech even when amplified, this loss having 
     been suffered prior to the age of 19 years

     Includes: deaf mutism

41   Profound bilateral hearing loss

41.0 Total bilateral hearing loss
41.1 Total hearing loss in one ear, profound impairment in the 
     other ear
41.2 Profound bilateral impairment of hearing
41.3 Other profound hearing impairment of one ear specified as 
     the better ear
41.9 Unspecified
     Includes: (bilateral) deafness NOS, profound hearing loss 
               NOS
     Excludes: profound hearing impairment where only one ear is 
               mentioned and not specified as the better ear 
               (44.3 and 44.7)

42   Profound hearing impairment in one ear with moderately 
     severe impairment of the other ear

42.0 Total hearing loss in on ear, hearing impairment of the ear 
     severe
42.1 Total hearing loss in one ear, hearing impairment of other 
     ear moderately severe
42.2 Profound hearing impairment in one ear, hearing impairment 
     of other ear severe
42.3 Profound hearing impairment in one ear, hearing impairment 
     of other ear moderately severe
42.4 Other severe hearing impairment in one ear specified as the 
     better ear

43   Moderately severe bilateral hearing impairment

43.0 Severe bilateral hearing impairment
43.1 Severe hearing impairment in one ear, hearing impairment in 
     other ear moderately severe
43.2 Moderately severe bilateral hearing impairment
43.3 Other moderately severe hearing impairment in one ear 
     specified as the better ear
43.8 Hard of hearing bilaterally NOS
43.9 Unspecified
     Includes: bilateral hearing impairment NOS, hard of hearing 
               NOS, psychogenic deafness
     Excludes: moderately severe hearing impairment where only 
               one ear mentioned and not specified as the better 
               ear (45.1, 45.3)
44   Profound hearing impairment in one ear with moderate or 
     lesser impairment of the other ear

44.0 Total hearing loss in one ear, hearing impairment in other 
     ear moderate
44.1 Total hearing loss in one ear, hearing impairment in other 
     ear mild
44.2 Total hearing loss in one ear, no hearing impairment in 
     other ear
44.3 Total hearing loss in one ear, hearing impairment in other 
     ear not stated
44.4 Profound hearing impairment in one ear, hearing impairment 
     in other ear moderate
44.5 Profound hearing impairment in one ear, hearing impairment 
     in other ear mild
44.6 Profound hearing impairment in one ear, no hearing 
     impairment in other ear
44.7 Profound hearing impairment in one ear, hearing impairment 
     in other ear not stated
44.9 Unspecified
     Includes: deafness of one ear NOS

45   Other impairment of auditory sensitivity

45.0 Severe hearing impairment in one ear, hearing impairment in 
     other ear moderate or mild
45.1 Severe hearing impairment in one ear, hearing impairment in 
     other ear not present or not stated
45.2 Moderately severe hearing in one ear, hearing impairment in 
     other ear moderate or mild
45.3 Moderately severe hearing impairment in one ear, hearing 
     impairment in other ear not present or not stated
45.4 Moderate bilateral hearing impairment
45.5 Moderate hearing impairment in one ear, hearing impairment 
     in other ear mild
45.6 Moderate hearing impairment in one ear, hearing impairment 
     in other ear not present or not stated
45.7 Mild bilateral hearing impairment
45.8 Mild hearing impairment in one ear, hearing impairment in 
     other ear not present or not stated
45.9 Unspecified
     Includes:  hearing impairment NOS

     OTHER AUDITORY AND AURAL IMPAIRMENTS (46-49)

46   Impairment of speech discrimination
     A distortion of hearing function where the basic problem 
     exists in discrimination and recognition, involving auditory 
     distortion not accountable in terms of sensorineural 
     sensitivity. It is assessed by speech audiometry 
     (discrimination for monosyllabic words in quiet, with speech 
     presented at comfort level in sound field), but is a 
     function of auditory sensitivity and can be calculated from 
     the pure tone threshold of hearing, and so often is not 
     distinguished

     Excludes: impairments accompanied by impairment of auditory 
               sensitivity (40-45)

46.0 Profound bilateral impairment of discrimination (less than 
     40% correct)
46.1 Severe bilateral impairment of discrimination (40-49% 
     correct)
46.2 Moderately severe bilateral impairment of discrimination 
     (50-59% correct)
46.3 Moderate bilateral impairment of discrimination (60-79% 
     correct)
46.4 Mild bilateral impairment of discrimination (80-90% correct)
46.5 Profound unilateral impairment of discrimination (less than 
     40% correct)
46.6 Severe or moderately severe unilateral impairment of 
     discrimination (40-59% correct)
46.7 Moderate or mild unilateral impairment of discrimination 
     (60-90%)
46.8 Other and unspecified bilateral impairment of discrimination
     Includes: where correctness not quantified but specified as 
               bilateral
46.9 Other and unspecified
     Includes: where correctness not quantified

47   Other impairment of auditory function 
 
47.0 Impairment of sound conduction NEC
47.1 Sensorineural impairment NEC
47.2 Tinnitus
47.3 Other subjective impairments of hearing
47.4*Mixed impairment of auditory function
47.8 Other impairment of auditory function
47.9 Unspecified

48   Impairment of vestibular and balance function

48.0 Vertigo
     Includes: dizziness
48.1 Impairment of labyrinthine function
48.2 Impairment of locomotion related to vestibular or cerebellar 
     function
48.3 Other impairment of cerebellar and coordination function
48.4 Other impairment of vestibular function
48.5 Liability to falls
     Includes: those occurring suddenly while walking, giving 
               rise to a tendency to walk holding on to furniture 
               and associated with rejection of human help
     Excludes: impulsive falls (48.6)
48.6 Impulsive falls
     Includes: the impulsive elderly individual who gets up and 
               tries to walk and then overbalances and falls 
               (i.e., is able to walk but requires supervision 
               because of the risk of falling)
48.7 Other impairment of balance
48.8 Other
     Excludes: impairment of coordination of limbs (74)
48.9 Unspecified

49 Other impairment of aural function

49.0 Deficiency of inner ear
49.1 Deformity of inner ear
49.2 Aural discharge
     Includes: otorrhoea
49.3 Aural irritation
     Includes: dermatitis and ear pain
49.4 Other aural infection
49.5 Deficiency of middle ear
49.6 Deformity of middle ear
49.7 Deformity of external ear
     Includes: deficiency and disfigurement
49.8 Other impairment of external ear
49.9 Other and unspecified
               5 OCULAR IMPAIRMENT

Ocular impairments relate not only to the eye, but also to its 
associated structures and functions, including the eyelids. The 
most important subclass of ocular impairments is made up of 
impairments relating to the function of vision

          IMPAIRMENTS OF VISUAL ACUITY (50-55)

Scope     The degree of impairment may be reduced by compensating 
          aids, and a refractive error that can be fully 
          corrected by glasses or contact lenses is generally not 
          regarded as a visual impairment. However, provision for 
          identifying such individuals has been made in category 
          57.0

TerminologyDifferent meanings are attached to the term 
          "blindness", particularly in the context of legal 
          definitions.
               In order to avoid ambiguity a preferred 
               nomenclature for visual impairments is defined in 
               the table, in which synonymous terms are also 
               identified

Coding         1.   The degree of impairment may be different for 
                    the two eyes of an individual. Unfortunately 
                    there is no consistency in identifying these 
                    differences - sometimes the performance of 
                    both eyes is recorded, sometimes only that of 
                    what is specified as the better or the worse 
                    eye, and sometimes only that of one eye 
                    without further qualification. A reference 
                    chart is appended after category 55

               2.   Absence of an eye is classified separately 
                    from other profound impairments of visual 
                    function. This distinction is made because 
                    the individual with a missing eye is 
                    additionoally impaired in regard to 
                    appearance, i.e., he has a disfiguring 
                    deficiency

               3.   As the reference chart indicates, provision 
                    is made for all possible combinations of 
                    impairments of visual acuity; multiple coding 
                    within this section is therefore unnecessary
          Terminology for impairments of visual acuity

WHO category   Degree of      Visual acuity            Synonyms 
                                                       and 
                                                       alternativ
                                                       e  
of vision      impairment(with best possible 
                              correction)

Normal         None           0.8 or better            range of 
                                                       normal 
                                                       vision
vision                        (5/6, 6/7.5, 20/25 or
                              better)

               Slight         less than 0.8            
                                                       near-norma
                                                       l vision
                              (< 5/6, 6/7.5, or 20/25)

Low visionModerate       less than 0.3            moderate low 
vision
                              (< 5/15, 6/18 or 6/20,
                              or 20/80 or 20/70)

               Severe         less than 0.12           severe low 
               vision - legal blind-         (< 5/40
 

 









50   Absence of eye

50.0 Absence of both eyes
50.1 Absence of one eye, visual impairment of other eye total
50.2 Absence of one eye, visual impairment of other eye 
     near-total
50.3 Abssence of one eye, visual impairment of other eye profound
50.4 Absence of one eye, visual impairment of other eye severe
50.5 Absence of one eye, visual impairment of other eye moderate
50.6 Absence of one eye, visual impairment of other eye slight
50.7 Absence of one eye, no visual impairment of other eye
50.8 Other absence of one eye
     Includes: absence of one eye when degree of visual 
               performance in other eye not specified
50.9 Unspecified

51   Profound visual impairment of both eyes
     (see chart after category 55)

51.0 Total visual impairment of both eyes
51.1 Total visual impairment of one eye, visual impairment of 
     other eye near-total
51.2 Total visual impairment of one eye, visual impairment of 
     other eye profound
51.3 Near-total visual impairment of both eyes
51.4 Near-total visual impairment of one eye, visual impairment 
     of other eye profound
51.5 Other near-total visual impairment of one eye specified as 
     the better eye
51.6 Profound visual impairment of both eyes
51.7 Other profound visual impairment of one eye specified as the 
     better eye
51.9 Unspecified
     Includes: (bilateral) blindness NOS
     Excludes: profound visual impairment where only one eye 
               mentioned and not specified as the better eye 
               (54.2, 54.5 and 54.8)

52   Profound visual impairment of one eye with low vision in the 
     other eye
     (see chart after category 55)
52.0 Total visual impairment of one eye, visual impairment of 
     other eye severe
52.1 Total visual impairment of one eye, visual impairment of 
     other eye moderate
52.2 Near-total visual impairment of one eye, visual impairment 
     of other eye severe
52.3 Near-total visual impairment of one eye, visual impairment 
     of other eye moderate
52.4 Profound visual impairment of one eye, visual impairment of 
     other eye severe
52.5 Profound visual impairment of one eye, visual impairment of 
     other eye moderate
52.6 Other severe visual impairment of one eye specified as the 
     better eye
52.9 Unspecified
     Includes: blindness (WHO category) of one eye and low vision 
               of other eye NOS

53   Moderate visual impairment of both eyes
     (see chart after category 55)

53.0 Severe visual impairment of both eyes
53.1 Severe visual impairment of one eye, visual impairment of 
     other eye moderate
53.2 Moderate visual impairment of both eyes
53.3 Other moderate visual impairment of one eye specified as the 
     better eye
53.8 Low vision of both eyes NOS
53.9 Unspecified
     Includes: bilateral visual impairment NOS, low vision NOS 
     Excludes: moderate visual impairment where only one eye 
               mentioned and not specified as the better eye 
               (55.2, 55.5, and 55.8)

54   Profound visual impairment of one eye
     (see chart after category 55)

54.0 Total visual impairment of one eye, visual impairment of 
     other eye slight
54.1 Total visual impairment of one eye, no visual impairment of 
     other eye
54.2 Total visual impairment of one eye, visual impairment of 
     other eye not stated
54.3 Near-total visual impairment of one eye, visual impairment 
     of other eye slight
54.4 Near-total visual impairment of one eye, no visual 
     impairment of other eye
54.5 Near-total visual impairment of one eye, visual impairment 
     of other eye not stated
54.6 Profound visual impairment of one eye, visual impairment of 
     other eye slight
54.7 Profound visual impairment of one eye, no visual impairment 
     of other eye
54.8 Profound visual impairment of one eye, visual impairment of 
     other eye not stated
54.9 Unspecified
     Includes: blindness of one eye NOS

55   Other impairment of visual acuity
     (see chart below)
55.0 Severe visual impairment of one eye, visual impairment of 
     other eye sligt
55.1 Severe visual impairment of one eye, no visual impairment of 
     other eye
55.2 Severe visual impairment of one eye, visual impairment of 
     other eye not stated
55.3 Moderate visual impairment of one eye, visual impairment of 
     other eye slight
55.4 Moderate visual impairment of one eye, no visual impairment 
     of other eye
55.5 Moderate visual impairment of one eye, visual impairment of 
     other eye not stated
55.6 Slight visual impairment of both eyes
55.7 Slight visual impairment of one eye, no visual impairment of 
     other eye
55.8 Slight visual impairment of one eye, visual impairment of 
     other eye not stated
55.9 Unspecified
     Includes: (unilateral) impairment of vision NOS, loss of 
               vision NOS

     OTHER VISUAL AND OCULAR IMPAIRMENTS (56-58)

     Excludes: central disorders of visual function
               (30.1, 31.0, and 31.2)

56   Visual field impairment
     Excludes: impairments accompanied by impairments of visual 
               acuity (50-55)
56.0 Total impairment of visual fields (field diameter 0ø)
56.1 Near-total impairment of visual fields (field diameter 5ø or 
     less)
56.2 Profound impairment of visual fields (field diameter 10ø or 
     less)
56.3 Severe impairment of visual fields (field diameter 20ø or 
     less)
56.4 Moderate impairment of visual fields (field diameter 60ø or 
     less)
56.5 Slight impairment of visual fields (field diameter 120ø or 
     less)
56.6 Tunnel vision NOS
56.7 Hemianopia
56.8 Other unilateral visual field impairment
56.9 Other and unspecified

57   Other visual impairment

57.0 Wears correcting lenses (with resultant normal of 
     near-normal vision)
57.1 Astignatism
57.2 Impairment of visual accommodation
57.3 Diplopia
     Includes: strabismus
57.4 Other impairment of ocular motility and binocular vision
     Includes: nystagmus
57.5 Impairment of colour vision
57.6 Impairment of night vision
57.7 Subjective impairment of vision
     Includes: amblyopia, distortions, floaters, and transient 
               visual loss
     Excludes: blurred vision, eye pain, and eye strain (58.7)
57.8 Other impairment of vision
     Includes: light sensitivity
57.9 Unspecified

58   Other ocular impairment

58.0 Ocular discharge
     Includes: excessive lacrimal secretion, running eye
58.1 Other ocular infection
58.2 Anaesthetic eye
58.3 Dry eye
     Includes: irritating eye
58.4 Deformity of eyeball
     Includes: disfigurement and exophthalmos
     Excludes: absence of eyeball (50)
58.5 Deformity of eyelid
     Includes: blepharitis, everted eyelids, ptosis, and 
               deficiency or disfigurement of eyelids
58.6 Other impairment of eyelid
58.7 Ill-defined ocular impairment
     Includes: blurred vision, eye pain, eye strain
58.8 Other ocular impairment
58.9 Unspecified
     6 VISCERAL IMPAIRMENTS

Visceral impairments include impairments of internal organs and 
of other special functions. The array of underlying disorders 
that may give rise to these impairments is very considerable, 
extending over large sections of the ICD. However, the functional 
consequences of such disorders are much more limited. For 
instance, cardiovascular and respiratory diseases occupy 129 
categories in two chapters of the ICD, but their common 
functional consequences can be identified comprehensively within 
a single two-digit category of the impairment classification.

     IMPAIRMENTS OF INTERNAL ORGANS (60-66)

60   Mechanical and motor impairment of internal organs

60.0 Tracheobronchial obstruction
60.1 Oesophageal or gastric obstruction
60.2 Intestinal obstruction
60.3 Other mechanical impairment of internal organs
     Excludes: urinary obstruction (63.4) and genital obstruction 
               (66.5)
60.4 Diaphragmatic palsy
60.5 Other motor or analogous functional impairment of 
internalorgans
     Excludes: laryngeal palsy (35.6)
60.8*Combinations of the above
60.9 Unspecified

61   Impairment of cardiorespiratory function
     Excludes: syncope (21.6), peripheral manifestations 
               classifiable to disfigurements of head (82) and to 
               limbs (84-87) such as cyanosis and oedema, and 
               gangrene (99.1-99.3)

61.0 Shortness of breath
     Includes: dyspnoea, orthopnoea, and respiratory failure
61.1 Other disturbance of breathing
     Includes: stridor and wheezing
61.2 Other abnormal sounds
     Includes: cardiac murmurs and abnormal sounds in chest
61.3 Exercise pain in chest
61.4 Other chest pain
61.5 Other exercise intolerance
     Includes: intermittent claudication
     Excludes: fatigue (94.6) and pain on exercise in arm (97.3)
61.6 Disturbance of cardiac rhythm
     Includes: arrhythmia, heart block, palpitation, and 
               tachycardia
61.7 Cough or sputum
61.8 Other impairment of cardiorespiratory function
     Includes: haemopthysis
     Excludes: subject to corrective or prosthetic intervention 
               or surgery (65.0)
61.9 Unspecified

62   Impairment of gastrointestinal function
     Excludes: impairment of mastication and swallowing (68)

62.0 Food intolerance
     Includes: nausea
     Excludes: specific dietary intolerance (93.2) and anorexia 
               (25.0)
62.1 Vomiting and regurgitation
62.2 Flatulence
     Includes: borborygmi, eructation, and hiccough
62.3 Abdominal pain
     Includes: intestinal colic and biliary colic
62.4 Constipation
62.5 Diarrhoea
62.6 Irritable colon
62.7 Other intestinal functional impairment
     Includes: gastrointestinal hypermotility, dumping, and 
               intestinal hurry
62.8 Other impairment of gastrointestinal function
     Includes: piles and rectal bleeding, mucus, and pain
     Excludes: severe impairment of continence (91)
62.9 Unspecified
     Includes: faecal incontinence NOS

63   Impairment of urinary function

63.0 Renal colic
63.1 Other impairment of renal function
     Includes: renal failure
     Excludes: renal dialysis (94.0) and transplantation (65.60)
63.2 Frequency of micturition
     Includes: polyuria
63.3 Reflex incontinence
     Voluntary loss of urine due to abnormal reflex activity in 
     the spinal cord in the absence of the sensation usually 
     associated with the desire to micturate
     Includes: automatic bladder
63.4 Overflow incontinence
     Involuntary loss of urine when the intravesical pressure 
     exceeds the maximum urethral pressure owing to an elevation 
     of intravesical pressure associated with bladder distension 
     but in the absence of detrusor activity
     Includes: outflow obstruction of micturition, and prostatism
63.5 Urge incontinence
     Involuntary loss of urine associated with a strong desire to 
     void; it may be motor, associated with uninhibited detrusor 
     contractions, or sensory, not due to uninhibited detrusor 
     contractions
63.6 Stress incontinence
     Involuntary loss of urine when the intravesical pressure 
     exceeds the maximum urethral pressure but in the absence of 
     detrusor activity
63.7 Other impairment of micturition
     Includes: dysuria
63.8 Other impairment of urinary function
     Excludes: severe impairment of continence (91)
63.9 Unspecified

64   Impairment of reproductive function
     Excludes: impairment of sexual organs (67), impotence 
               (25.40), and frigidity (25.42)

64.0 Currently subject to contraceptive procedure
     Includes: consuming a contraceptive pill, intrauterine 
               device in situ, and post-vasectomy
64.1 Sterility
     Excludes: impairments of internal genitalia (65.8 and 66.5)
64.2 Subfertility
     Includes: infertility other than that due to sterility
64.3 Dyspareunia
     Excludes: that related to vaginal discharge (67.3)
64.4 Sexual ambiguity
     Includes: hermaphroditism
     Excludes: if of psychological origin (25.2)
64.5 Dysmenorrhoea
64.6 Menorrhagia
     Includes: vaginal bleeding and excessive menstrual loss
64.8 Other disturbance of menstrual function
64.9 Other and unspecified

65   Deficiency of internal organs

65.0 Deficiency of tracheobronchial tree
     Excludes: deficiency of larynx (35.1)
65.1 Deficiency of lung
65.2 Deficiency of heart
     65.20subject to corrective or prosthetic intervention or 
          surgery
               Excludes: pacemaker (94.0)
     65.21anomalies of cardiac development (such as patent 
          interventricular septum)
     65.22acquired valvular lesions
     65.28other
     65.29unspecified
65.3 Deficiency of oesophagus and stomach
65.4 Deficiency of intestine and rectum
65.5 Deficiency of gall bladder, liver, or spleen
65.6 Deficiency of kidney
     65.60subject to renal transplantation
     65.68other
     65.69unspecified
65.7 Deficiency of bladder
65.8 Deficiency of internal genitalia
65.9 Other and unspecified

66   Other impairment of internal organs
     Excludes: artificial and abnormal orifices (88)
66.0 Abnormality of blood vessels of thorax and abdomen
     Includes: aortic aneurysm
66.1 Haemorrhage from internal organs
     Includes: pulmonary, intrathoracic, gastrointestinal, and 
               intra-abdominal
     Excludes: epistaxis (69.3), haemoptysis (61.8), and rectal 
               bleeding (62.8)
66.2 Transposition of viscera
     Includes: situs inversus viscerum
66.3 Accessory viscera
     Includes: splenunculus
66.4 Other structural abnormality of viscera
     Excludes: deficiencies (65)
66.5 Other impairment of internal genitalia
     Includes: tubal obstruction
     Excludes: deficiency (65.8) and malpositioning (67.4, 67.5)
66.8 Other impairments of internal organs
66.9 Unspecified
     
     IMPAIRMENTS OF OTHER SPECIAL FUNCTIONS (67-69)

67   Impairment of sexual organs

67.0 Absence of nipples
67.1 Hypertrophy of breasts
67.2 Other impairment of nipples and breasts
67.3 Genital discharge
     Includes: urethritis, vaginitis, and urethral or vaginal 
               discharge or irritation
67.4 Prolapse
     Includes: procidentia
67.5 Other malposition of internal sex organs
     Includes: undescended testicle
67.6 Other deformity or deficiency of external genitalia
     Includes: hypospadias 
67.7 Other impairment of external genitalia
67.8 Other impairment of sexual organs
67.9 Unspecified
68   Impairment of mastication and swallowing
     Excludes: impairment of jaw (70) and dentofacial impairments 
               (80)

68.0 Currently wearing dental prosthesis
68.1 Deficiency of teeth, complete
     Includes: edentulous
     Excludes: if wearing prosthesis (68.0)
68.2 Other deficiency of teeth
     Includes: caries or decay
     Excludes: if wearing prosthesis (68.0)
68.3 Toothache
68.4 Impairment of salivation
     Includes: dry mouth
68.5 Other impairment of salivary function
68.6 Other impairment of mastication
68.7 Other impairment of swallowing
68.8 Other
68.9 Unspecified

69   Impairment related to olfaction and other special functions

69.0 Impairment of smell and taste
69.1 Impairment of smell
69.2 Impairment of taste
69.3 Nasal discharge
     Includes: epistaxis and rhinorrhoea
69.4 Nasal obstruction
69.5 Other impairment of nasal function
     Excludes: nasal deficiency (80.6) and nasal deformity (81.0)
69.8 Impairment of other special functions
     Excludes: impairment of sleep (22)
69.9 Unspecified
               7 SKELETAL IMPAIRMENTS

Skeletal impairments have been interpreted broadly so as to 
reflect the dispositon of the body and its visible parts. 
Skeletal impairments include mechanical and motor disturbances of 
the face, head, neck, trunk, and limbs, as well as deficiencies 
of the limbs. Recourse to a fourth-digit has often been necessary 
in order to encompass the level of detail desired
     
          Excludes: certain more evidently disfiguring 
                    impairments (80/87)

     IMPAIRMENTS OF HEAD AND TRUNK REGIONS (70)

70   Impairment of head and trunk regions
     Excludes: most deficiencies and disfigurements (80-83)

70.1 Mechanical and motor impairment of jaw
     70.10Trismus
     70.11Malocclusion
     70.12Prognathism
     70.13Underdevelopment of lower jaw
     70.14Other disturbance of jaw development
     70.15Other jaw dysfunctions
               Includes: clicking
     70.18Other
     70.19Unspecified
70.2 Mechanical and motor impairment of face
     70.20Facial paralysis
               Includes: facial palsy
     70.21Involuntary facial movements
               Includes: tics and masticatory movements
     70.22Other facial mannerisms
               Includes: stereotypies and distinct idiosyncratic 
                         or repetitive movements of unclear 
                         meaning not classifiable as tics or 
                         automatisms (e.g., constant repetition 
                         of movements, or postures such as
                         rubbing and grimacing)
     70.23Other disturbance of facial expression
               Excludes: impairment of facial expression (33.2)
     70.28Other
     70.29Unspecified
70.3 Other mechanical and motor impairment of head
     70.30Mechanical impairment of head
     70.31Abnormal movement of head
               Includes: titubation
     70.32Other motor impairment of head
     70.38Other
               Includes: both mechanical and motor impairments of 
                         head
     70.39Unspecified
70.4 Mechanical and motor impairment of neck
     70.40Torticollis
     70.41Other mechanical impairment of neck
     70.42Other motor impairment of neck
     70.48Other
               Includes: both mechanical and motor impairments of 
                         neck
     70.49Unspecified
70.5 Impairment of posture
     70.50Spinal curvature
               Includes: kyphosis, lordosis, and scoliosis
     70.51Deficiency of vertebra
     70.52Other deficiency of spine
     70.53Other spinal deformity
     70.54Involuntary body movements
               Includes: dyskinesia and dystonia
               Excludes: those of limbs (74)
     70.55Postural mannerisms
               Includes: odd stylized movements or acts (usually 
                         idiosyncratic and often suggestive of 
                         special meaning or purpose) and stereo-
                         typies (constant repetition of movements 
                         or postures such as rocking, rubbing, 
                         and nodding)
               Excludes: other impairments of body language
                         (33.3)
     70.58Other
     70.59Unspecified

70.6 Impairment of physique
     70.60Dwarfism
               Includes: short stature
               Excludes: generalized skeletal defect (70.65)
     70.61Gigantism
               Includes: unduly tall stature
     70.62Other impairment of stature
     70.63Emaciation
               Includes: undue thinness
     70.64Obesity
     70.65Generalized skeletal defect
               Includes: achondroplasia
     70.68Other
     70.69Unspecified

70.7 Other mechanical and motor impairment of trunk
     70.70Impairment of pelvis potentially interfering with 
          normal delivery
               Includes: contracted pelvis
               Excludes: deficiency of pelvis (75.4 and 
                         78.0-78.2)
     70.71Other impairment of skeletal structures of trunk NEC
     70.72Other abnormality of tissues in trunk region NEC
     70.78Other
     70.79Unspecified
70.8 Other impairment of head and trunk region NEC
     Includes: reduced plasticity or slowing of physical 
               functions encountered in association with ageing
70.9 Unspecified

     MECHANICAL AND MOTOR IMPAIRMENTS OF LIMBS (71-74)

As elsewhere in this section, differentiation is made between 
mechanical and motor impairments. The distinction is analogous to 
that between the physical state of a piece of machinery and its 
constituent parts on the one hand, and that of the power source 
and its transmission on the other.

Throughout this section certain terms are used with particular 
meanings:

extent of involvement:complete if there is involvement of the 
                    whole of a limb, and
                         incomplete if only
                         part of a limb is affected
degree of involvement:total if the attribute is totally lacking, 
                    and partial if there is a reduction of the 
                    attribute
71   Mechanical impairment of limb
          
     The following fourth-digit subclassification to indicate the 
     nature of the mechanical impairment is suggested for use 
     with categories 71.0-71.7
     0    total loss of movement, with or without deformity 
          bilateral
          Includes: ankylosis and fixation specified as bilateral
     1    other total loss of movement
          Includes: ankylosis and fixation
     2    instability, bilateral
          Includes: flail joint specified as bilateral
     3    other instability
          Includes: flail joint
     4    other deformity, including deviation of axis, bilateral
          Excludes: with fixation (0, above)
     5    other deformity
          Excludes: with fixation (1, above), or if congenital 
                    (84)
     6    other restriction or loss of movement, bilateral
          Includes: stiffness related to mechanical impairment 
                    bilaterally
          Excludes: congenital contracture (84)
     7    other restriction or loss of movement
          Includes: dislocation, and stiffness related to 
                    mechanical impairment
     8*   mixed impairment
          (e.g., otherwise classifiable to 1, above, on one side 
          and 7, above, on other)
     9    unspecified

71.0 Mechanical impairment of shoulder and upper arm
71.1 Mechanical impairment of elbow and forearm
71.2 Mechanical impairment of wrist and carpus
     Excludes: impairment also involving the hand (71.3)
71.3 Mechanical impairment of metacarpus and hand
     Includes: impairment also involving the wrist and carpus
71.4 Mechanical impairment of finger
     Includes: impairment of thumb
     Excludes: impairment of finger if hand also impaired (71.3)
71.5 Mechanical impairment of hip and thigh
71.6 Mechanical impairment of knee and leg
71.7 Mechanical impairment of ankle and foot
     Includes: impairment of subtaloid, tarsal, and metatarsal 
               joints
     Excludes: toes (71.90 and 71.91)
71.8 Mixed and other upper limb mechanical impairment
     Excludes: impairments classifiable to 71.08*, 71.18*, 
               71,28*, 71.38*, and 71.48*
     71.80*    Mechanical impairment of more than one region of 
               an upper limb or limbs
               Includes: shoulder-hand syndrome
     71.81*    Upper arm impairment on one side with forearm 
               impairment on the other
     71.82*    Upper arm impairment on one side with wrist or 
               hand impairment on the other
     71.83*    Upper arm impairment on one side with finger 
               impairment on the other
     71.84*    Forearm impairment on one side with wrist or hand 
               impairment on the other
     71.85*    Forearm impairment on one side with finger 
               impairment on the other
     71.86*    Wrist or hand impairment on one side with finger 
               impairment on the other
     71.88*    Other mixed mechanical impairment of upper limb
     71.89Other and unspecified mechanical impairment of upper 
          limb
71.9 Mixed and other mechanical impairment of limb
     Excludes: impairments classifiable to 71.58*, 71.68*, 
               71.78*, and 71.8
     71.90Mechanical impairment of toes, bilateral
     71.91Other mechanical impairment of toes
     71.92Impairment of lower limbs due to unequal lenght of legs 
          NEC
     71.93Other and unspecified mechanical impairment of lower 
          limb
               Includes: impairment of walking NOS
     71.94*    Hip or thigh impairment on one side with knee or 
               leg impairment on the other
     71.95*    Hip or thigh impairment on one side with ankle, 
               foot, or toe impairment on the other
     71.96*    Knee or leg impairment on one side with ankle, 
               foot, or toe impairment on the other
     71.97*    Other mixed mechanical impairment of lower limb
     71.98*    Mixed mechanical impairment of upper and lower 
               limb
     71.99*    Unspecified mechanical impairment of limb

72   Spastic paralysis of more than one limb
     Includes: hemiplegia, paraplegia, and tetraplegia

72.0 Complete spastic paralysis of upper and lower limbs on same 
     side, with involvement of speech
     Includes: (spastic)hemiplegia, dominant side or with 
               involvement of speech
72.1 Other complete spastic paralysis of upper and lower limbs on 
     same side
72.2 Other spastic paralysis of upper and lower limb on same side
     Includes: (spastic)hemiparesis
72.3 Bilateral complete paralysis of lower limbs
     Includes: (spastic)paraplegia
72.4 Other bilateral spastic paralysis of lower limbs
     Includes: (spastic)paraparesis
72.5 Spastic paralysis of three limbs
72.6 Complete paralysis of all four limbs
     Includes: (spastic)tetraplegia
72.7 Other spastic paralysis of all four limbs
     Includes: (spastic)tetraparesis
72.8 Other spastic paralysis of more than one limb
72.9 Unspecified

73   Other paralysis of limb

     The following fourth-digit subclassification to indicate the 
     nature of the paralysis is suggested for use with categories 
     73.0-73.9
     0    complete spastic paralysis
          Excludes: paralysis classifiable to 72.0, 72.1, 72.3, 
                    and 72.6
     1    other spastic paralysis
          Excludes: paralysis classifiable to 72.2, 72.4, 72.5, 
                    and 72.8
     2    complete total flaccid paralysis
     3    other total flaccid paralysis
     4    complete partial flaccid paralysis
     5    other flaccid paralysis
     6    other weakness of limb
     7    fatigue of limb
     9    unspecified
73.0 Bilateral paralysis of upper limbs
73.1 Paralysis of dominant upper limb
73.2 Other paralysis of upper limb
73.3 Bilateral paralysis of lower limbs
     Excludes: paralysis classifiable to 72.3 and 72.4
73.4 Other paralysis of lower limb
73.5 Paralysis of upper and lower limbs on same side
     Excludes: paralysis classifiable to 72.0, 72.1, and 72.2
73.6 Paralysis of three limbs
     Excludes: paralysis classifiable to 72.5
73.7 Paralysis of all four limbs
     Excludes: paralysis classifiable to 72.6 and 72.7
73.8 Other paralysis
     73.80Spastic paralysis, complete
     73.81Other spastic paralysis
               Includes: spastic paresis or paralysis NOS
     73.82Total flaccid paralysis, complete
     73.83Other total flaccid paralysis
     73.84Partial flaccid paralysis, complete
     73.85Other flaccid paralysis
               Includes: flaccid paralysis NOS
     73.86Other weakness of limbs
     73.87Fatigue of limbs
               Excludes: fatigue NOS (94.5)
73.9 Unspecified

74   Other motor impairment of limb
     Excludes: stiffness related to mechanical impairment (71)

     The following fourth-digit subclassification to indicate the 
     nature of the impairment is suggested for use with this 
     category:
     0    rigidity or stiffness, complete
     1    other rigidity or stiffness
     2    abnormal movement, complete
          Includes: tremor
     3    other abnormal movement
     4    lack of coordination, complete
     5    other lack of coordination
     6    other impairment of dexterity
     7    other
     8*   mixed
          (e.g., otherwise classifiable as both 0 and 5, above) 
          unspecified
74.0 Other bilateral motor impairment of upper limbs
74.1 Other motor impairment of dominant upper limb
74.2 Other motor impairment of upper limb
74.3 Other bilateral motor impairment of lower limbs
74.4 Other motor impairment of lower limb
74.5 Other motor impairment of upper and lower limbs on same side
     74.50     Hemiballismus
74.6 Other motor impairment involving three or four limbs
74.8 Other motor impairment
74.9 Unspecified
     74.92Tremor NOS
     74.97Limping NOS
               Excludes: impairment of walking NOS (71.93)
          
               DEFICIENCIES OF LIMBS (75-79)
          Excludes: other congential malformations of limbs (84 
                    and 85)

Scope     Transverse deficiencies (75-76) present essentially as 
          an amputation-like stump; they may arise as a failure 
          of formation of parts, or as the result of surgical 
          intervention. These impairments include those 
          previously designated as peromelia or terminal 
          transverse deficiencies. A deficiency is customarily 
          identified by the level at which the limb terminates 
          (the most proximal part that is missing), it being 
          understood that all elements distal to the level
          named are also absent

               Excludes: where a deficiency is not complete 
                         across the limb at the same level (when 
                         it is probably longitudinal rather than 
                         transverse)
               Longitudinal deficiencies (77-79). All skeletal 
               limb deficiencies other than those of the 
               transverse type should be placed in the 
               longitudinal category, though by the same token 
               almost all arise as a failure of formation of 
               parts.
               These impairments include those previously 
               designated as extromelias or terminal 
               longitudinal, intercalary transverse, and 
               intercalary longitudinal deficiences. All absent 
               bones or portions of bones that are missing are 
               named, any bones not named as being missing being 
               understood to be present

TerminologyThe International Society for Prosthetics and 
          Orthotics (ISPO) has developed a preferred nomenclature 
          and recommended abbreviations for describing the 
          appropriate levels, and these have been incorporated in 
          the classification

Coding         1  A reference chart is appended after category 
                  79, indicating the equivalence between 
                  preferred and previous nomenclature
               
               2  The terms "complete" and "incomplete" have been 
                  used with consistency throughout the 
                  classification to indicate the extent of an 
                  impairment, "complete" denoting involvement of 
                  the whole of the part and
                  "incomplete" that less than the whole of the 
                  part is affected. However, in practice the 
                  terms "total" and
                  "partial" may be encountered and in this 
                  context they should be interpreted as 
                  equivalent to "complete" and "incomplete" 
                  respectively

               3  ISPO has a strong preference for full 
                  specification of deficiencies, which calls for 
                  multiple coding. As a result only a very 
                  limited provision for combination categories 
                  has been incorporated for other users

               4  The degree of detail that is desirable varies 
                  in relation to the structure of the part 
                  affected. Thus, in proximal parts, particularly 
                  those related to long bones, it is the level of 
                  the deficiency that is of most concern. In 
                  contrast, in distal parts with greater 
                  transverse differentiation it is the ray 
                  manifesting the deficiency that is of greater 
                  interest. For this reason separate 
                  subclassifi-cations have been developed for 
                  deficiencies of proximal parts, 75, 77, 78, and 
                  for those of distal parts, 76 and 79
75   Transverse deficiency of proximal parts of limb
     (see chart after category 79)
     Includes: those of arm, carpus, leg, and tarsus

     The following fourth-digit subclassification to indicate the 
     extent of the deficiency is recommended for use with this 
     category:
     0    complete deficiency, right
     1    other complete deficiency
          Includes: left, bilateral*, and side unspecified
     2    incomplete deficiency, upper third right
     3    other incomplete deficiency, upper third
     4    incomplete deficiency, middle third right
     5    other incomplete deficiency, middle third
     6    incomplete deficiency, lower third right
     7    other incomplete deficiency, lower third
     8    other incomplete deficiency, right
          Includes: incomplete deficiency of carpus or 
tarsus,right
     9    other incomplete, or unspecified extent

75.0 Transverse deficiency of shoulder (Sh)
     Includes: fore-quarter amputation
     Excludes: deficiencies where only a portion of the 
shoulderis missing (77)
               shoulder disarticulation (75.1)
75.1 Transverse deficiency of upper arm (Ar)
     Includes: shoulder disarticulation
75.2 Transverse deficiency of forearm (Fo)
     Includes: elbow disarticulation
75.3 Transverse deficiency of carpus (Ca)
     Includes: wrist disarticulation
75.4 Transverse deficiency of pelvis (Pel)
     Includes: hind-quarter amputation
75.5 Transverse deficiency of thigh (Th)
     Includes: hip disarticulation
75.6 Transverse deficiency of lower leg (Le)
     Includes: knee disarticulation
75.7 Transverse deficiency of tarsus (Ta)
     Includes: ankle disarticulation
75.8*Transverse deficiencies at multiple sites in proximal 
partsof limbs
75.9 Unspecified site in proximal parts of limb
     Includes: upper limb (UL) (transverse) deficiency
               lower limb (LL) (transverse) deficiency
               deficiency of hand or foot NOS

76   Transverse deficiency of distal parts of limb
     (see chart after category 79)
     Includes: where rays identifiable in hand or foot

     The following fourth-digit code to indicate the extent ofthe 
deficiency is suggested for use with this category:
     0    deficiency of all rays
     1    deficiency of first ray, complete
     2    other deficiency of first ray
     3    deficiency of second ray, complete
     4    other deficiency of second ray
     5    deficiency of third ray, complete
     6    other deficiency of third ray
     7    deficiency of fourth ray, complete
     8    other deficiency of fourth ray
     9    deficiency of fifth ray, or of unspecified ray
76.0 Transverse deficiency of metacarpal, right (MC)
76.1 Other transverse deficiency of metacarpal
76.2 Transverse deficiency of phalanges of fingers, right (Ph)
76.3 Other transverse deficiency of phalanges of fingers
76.4 Transverse deficiency of metatarsal, right (MT)
76.5 Other transverse deficiency of metatarsal
76.6 Transverse deficiency of phalanges of toes, right (Ph)
76.7 Other transverse deficiency of phalanges of toes
76.8*Transverse deficiencies at multiple sites in limb
     Includes: deficiencies at multiple sites in distal parts 
oflimbs, and mixed transverse deficiencies of proximal and distal 
parts of limbs
76.9 Unspecified site

77   Longitudinal deficiency of proximal parts
of upper limb
     (see chart after category 79)
     Includes: those of arm and carpus
     The following fourth-digit subclassification to indicate 
theextent of the deficiency is suggested for use with this 
category, and also with 78
     0    complete deficiency, right
     1    other complete deficiency
     2    incomplete deficiency, right
     3    other incomplete deficiency
     8    other
     9    unspecified extent
77.0 Longitudinal deficiency of scapula (Sc)
77.1 Longitudinal deficiency of clavicle (Cl)
77.2 Longitudinal deficiency of humerus (Hu)
77.3 Longitudinal deficiency of radius (Ra)
77.4 Longitudinal deficiency of ulna (Ul)
77.5 Longitudinal deficiency of radial elements of carpus (Ca)
77.6 Longitudinal deficiency of central elements of carpus
77.7 Longitudinal deficiency of other elements of carpus
77.8 Longitudinal deficiencies at multiple sites in proximalparts 
of upper limb
77.9 Unspecified site in proximal part of upper limb
     Includes: upper limb (UL) longitudinal deficiency

78   Longitudinal deficiency of proximal parts of lower limb
     (see chart after category 79)
     Includes: those of leg and tarsus

     The same fourth-digit subclassification as for 77 
issuggested for use with this category

78.0 Longitudinal deficiency of ilium (Il)
78.1 Longitudinal deficiency of ischium (Is)
78.2 Longitudinal deficiency of pubis (Pu)
78.3 Longitudinal deficiency of femur (Fem)
78.4 Longitudinal deficiency of tibia (Ti)
78.5 Longitudinal deficiency of fibula (Fib)
78.6 Longitudinal deficiency of tibial elements of tarsus (Ta)
78.7 Longitudinal deficiency of other elements of tarsus
78.8*Longitudinal deficiencies at multiple sites in proximalparts 
of limb
78.9 Unspecified site
     Includes: lower limb (LL) longitudinal deficiency, 
andlongitudinal deficiency NOS

79   Longitudinal deficiency of distal parts of limb
     (see chart on next page)
     Includes: where rays identifiable in hand or foot

     The following fourth-digit subclassification to indicate 
theextent of the deficiency is suggested for use with this 
category:
     0    deficiency of all rays
     1    deficiency of first ray, complete
     2    other deficiency of first ray
     3    deficiency of second ray, complete
     4    other deficiency of second ray
     5    deficiency of third ray, complete
     6    other deficiency of third ray
     7    deficiency of fourth ray, complete
     8    other deficiency of fourth ray
     9    deficiency of fifth ray, or of unspecified ray

79.0 Longitudinal deficiency of metacarpal, right (MC)
79.1 Other longitudinal deficiency of metacarpal
79.2 Longitudinal deficiency of phalanges of fingers, right (Ph)
79.3 Other longitudinal deficiency of phalanges of fingers
79.4 Longitudinal deficiency of metatarsal, right (MT)
79.5 Other longitudinal deficiency of metatarsal
79.6 Longitudinal deficiency of phalanges of toes, right (Ph)
79.7 Other longitudinal deficiency of phalanges of toes
79.8*Longitudinal deficiencies at multiple sites in limbs
79.9 Unspecified
REFERENCE CHART FOR NOMENCLATURE OF DEFICIENCIES OF LIMBS

ISPO-preferred                Frantz-O'Rahilly    
Frantz-O'Rahilly                                                      
European                      Other
                              (original)          (revised)

TRANSVERSE DEFICIENCIES(T-)                                                     

arm, complete                 amelia, upper            amelia, 
upper                                                                 
amelia, upper                 shoulder disarticulation
thigh, complete          amelia, lower            amelia, lower       
amelia, lower                 hip disarticulation
arm, middle (third)           hemimelia (A/E)     meromelia, 
humerus M                                                             
peromelia, mid-humeral   short above-elbow stump
thigh, lower (third)     hemimelia (A/K)     meromelia, femur D       
peromelia, lower femoral      long above-knee stump
forearm, complete        hemimelia (E-D)     meromelia, 
radio-ulnar                                                           
peromelia at level of elbow   elbow disarticulation
leg, complete                 hemimelia (K-D)     meromelia, 
tibio-fibular                                                         
peromelia at level of kneeknee disarticulation
forearm, lower (third)   partial hemimelia   meromelia, radius D, 
ulna D                                                                
peromelia, lower radio-ulnar  partial aplasia of radius
                                                                      
and ulna
leg, upper (third)            partial hemimelia   meromelia, 
tibia P, fibula Pperomelia, upper tibio-fibularpartial aplasia of 
tibia
                                                                      
and fibula
carpal, complete         acheiria                                     
wrist disarticulation
metacarpal, complete     adactylia
phalanges, complete           aphalangia

LONGITUDINAL DEFICIENCIES (L/)

humerus, complete        proximal phocomelia                          
(intercalary transverse)
tibial-fibular, complete distal phocomelia
ulnar, complete          complete paraxial   meromelia, ulnar         
ectromelia with complete      (intercalary longitudinal)
                              hemimelia, ulnar    axial aplasia, 
ulnar
radial, complete; carpal complete paraxial   meromelia, radial        
ectromelia with axial    (terminal longitudinal)
partial; MC 1.2, complete;hemimelia, radial                           
aplasia
Ph 1.2, complete    
tibial, partial; tarsalincomplete paraxial   meromelia, tibial M, 
D                                                                     
ectromelia with partial aplasia
partial; MT 1.2, complete;hemimelia, tibial                           
of tibia and complete aplasia
Ph 1.2, complete                                                      
of tarsals, metatarsals, and
                                                                      
phalanges

The above are only examples, and further details may be derived 
from "The proposed international terminology for the 
classification 
of congenital limb  deficiencies", Developmental medicine and 
child neurology. 17, Suppl. 34 (1975).


               8 DISFIGURING IMPAIRMENTS

Disfiguring impairments include those with a potential to 
interfere with or otherwise disturb social relationships with 
other people. The concept has been interpreted broadly so as to 
include conditions that may not be the concequence of specific 
diseases, such as disfigurement, as well as disorders that may 
impair control of bodily functions in the manner that is 
customary and socially acceptable. However, more specifically 
bio-medical impairments with a potential to engender aversion 
(for instance, abnormal movements of parts of the body) have been 
classified to one of the preceding sections

     DISFIGUREMENTS OF HEAD AND TRUNK REGION (80-83)
          Excludes: those of ear (49), of eye (58), of sexual 
organs (67), and of posture and physique (70)

80   Deficiency in head region 

80.0 Deficiency of cranial vault
80.1 Deficiency of upper jaw
80.2 Deficiency of lower jaw
     Excludes: prognathism and underdevelopment of lower jaw     
(70.1)
80.3 Other deficiency of skull
80.4 Cleft palate
80.5 Other dentofacial deficiency
80.6 Deficiency of nose
80.8 Other
80.9 Unspecified

81   Structural deformity in head and trunk regions

81.0 Deformity of nose
81.1 Deformity of head shape
     Includes: hydrocephaly, microcephaly, and abnormality of    
skull shape
81.2 Accessory structures in head region
81.3 Other deformity of head region
     Includes: lips, tongue, and palate
81.4 Deficiency in neck region
     Excludes: deficiency of vertebra (70.51)
81.5 Deficiency in thorax
     Excludes: internal organs (65)
81.6 Deficiency in abdominal wall
81.7 Other deficiency in abdomen
     Excludes: internal organs (65)
81.8 Other
     Includes: funnel chest
81.9 Unspecified

82   Other disfigurement of head
     Includes: face

82.0 Other soft tissue deficiency of head
     Includes: wasting
82.1 Swelling of part of head
     Includes: tumours
82.2 Pigmentation of skin of head
     Includes: depigmentation
82.3 Other colour changes of head
     Includes: cyanosis, flushing, rashes, and skin infections
82.4 Baldness, partial or complete
82.5 Other abnormality of hair
82.6 Scarring of head
82.7 Other abnormality of skin of head
82.8 Other disfigurement of head
     Includes: marked ugliness (e.g., gargoylism)
     Excludes: deformity of nose (81.0), dentofacial deficiencies
               (80.4 and 80.5), and deformity of head shape      
(81.1)
82.9 Unspecified

83   Other disfigurement of trunk

83.0 Other soft tissue deficiency of trunk
     Includes: wasting
83.1 Swelling of trunk
     Includes: tumours
     Excludes: hypertrophy of breasts (67.1)
83.2 Pigmentation of skin of trunk
     Includes: depigmentation
83.3 Other colour changes of trunk
     Includes: rashes and skin infections
83.4 Abnormal hair on trunk
83.5 Scarring of trunk
83.6 Other abnormality of skin of trunk
     Excludes: absence of nipples (67.0)
83.7 Accessory structures on trunk
     Excludes: accessory nipples (67.2)
83.8 Other disfigurement of trunk
83.9 Unspecified

     DISFIGUREMENTS OF LIMBS (84-87)

     Excludes: limb deficiencies (76-79)

     The following fourth-digit subclassification to indicate 
thelocation of limb disfigurements is suggested for use 
withcategories 84-87

     0    shoulder and upper arm
     
     1    elbow and forearm
     
     2    wrist and carpus
          Excludes: disfigurement also involving the hand (3, 
below)

     3    metacarpus and hand
          Includes: disfigurement also involving wrist and carpus

     4    finger    
          Includes: thumb
          Excludes: disfigurements classifiable under 3 (above)

     5    hip an thigh

     6    knee and leg

     7    ankle, foot, and toe

     8*   multiple
          Includes: those affecting whole of limb or affecting        
both upper and lower limbs

     9    location unspecified

84   Failure of differentiation of parts
     Includes: failure of separation of parts

84.0 Congenital deformity
84.1 Synostosis
84.2 Congenital soft-tissue contracture
     Includes: contracture secondary to failure of          
differentiation of muscle, ligament, and capsularstructures, such 
as arthrogryposis, camptodactyly,and trigger digit
84.3 Congenital skeletal contracture
     Includes: clinodactyly
84.4 Simple syndactylia
84.5 Soft-tissue syndactylia
     Includes: synonychia
84.6 Skeletal syndactylia
     Includes: fusions, acrosyndactylia, Apert's syndrome, and 
brachysyndactylia
84.8 Other
84.9 Unspecified

85   Other congenital malformation
     Excludes: those of internal organs (65 and 66)

85.0 Hypoplasia of skin and nails
85.1 Hypoplasia of musculotendinous structures
85.2 Hypoplasia of neurovascular structures
85.3 Other hypoplasia
     Includes: hypoplasia of more than one of preceding types of 
tissue (85.0-85.2)
     Excludes: dwarfism (70.60), and achondroplasia and     
generalized skeletal defect (70.65)
85.4 Overgrowth
     Excludes: impairment of physique and gigantism (70.61)
85.5 Skeletal duplications
     Includes: those of bones of limbs
85.6 Other duplications
     Includes: those of all tissues, such as polydactylism and 
mirror hand
85.7 Congenital constriction band
85.8 Other
     Includes: arachnodactyly
85.9 Unspecified

86   Other structural disfigurement

86.0 Wasting, complete
     Excludes: emaciation (70.63)
86.1 Other wasting
86.2 Other soft-tissue deficiency, complete
86.3 Other soft-tissue deficiency
86.4 Swelling of tissues
     Includes: tumours
     Excludes: that due to fluid (86.5 and 86.6)
86.5 Other swelling, complete
     Includes: lymphoedema
86.6 Other swelling
     Includes: oedema
86.7 Accessory structures
     Excludes: accessory digits (85.6)
86.8 Other structural disfigurement
86.9 Unspecified

87   Other disfigurement

87.0 Pigmentation
     Includes: depigmentation
87.1 Cyanosis
87.2 Other disturbance of skin colouration
     Includes: bruising, rashes, and skin infections
     Excludes: generalized bruising (92.4)
87.3 Other circulatory disturbance of skin
     Includes: varicose veins
87.4 Disturbance of sweating
87.5 Exudation
     Includes: scaling
87.6 Scarring
87.7 Abnormal hair
87.8 Other abnormality of skin
87.9 Other and unspecified

     OTHER DISFIGURING IMPAIRMENTS (88-89)

88   Abnormal orifice

88.0 Tracheostomy
88.1 Gastrostomy
88.2 Ileostomy
88.3 Colostomy
88.4 Other gastrointestinal diversion
88.5 Indwelling urinary catheter
88.6 Other urinary diversion
     Includes: extraurethral incontinence
88.7 Other artificial orifice
88.8 Other abnormal orifice
88.9 Unspecified

89   Other disfiguring impairment
     9    GENERALIZED, SENSORY, AND
          OTHER IMPAIRMENTS

     GENERALIZED IMPAIRMENTS (90-94)

90   Multiple impairment

90.0*Multiple, of all classes
90.1*Multiple, of mental functions, speech, and special senses
     Includes: if with viscera or with skeleton
90.2*Multiple, of mental functions and speech
90.3*Multiple, of special senses, viscera, and skeleton
90.4*Multiple, of special senses
90.5*Multiple, of viscera and skeleton
90.8*Other
90.9*Unspecified

91   Severe impairment of continence
     Excludes: reflex, overflow, urge, and stress incontinence 
(63)                   

91.0 Subject to control by devices
     Includes: adaptive devices and electrical stimulators
     Excludes: special protective clothing (classify        
appropriately to 91.1-91.8)
91.1 Double incontinence with frequency greater than once 
everynight and once every day
     Includes: soiling (faecal incontinence) and wetting 
(incontinence of urine) greater than specified frequencies
91.2 Other double incontinence every night and every day
91.3 Double incontinence with frequency greater than once 
everyweek by night and day
91.4 Other double incontinence
91.5 Faecal incontinence with frequency greater than once every24 
hours
91.6 Other faecal incontinence with frequency greater than 
onceevery week
91.7 Incontinence of urine with frequency greater than once 
every24 hours
91.8 Other
91.9 Unspecified
     Excludes: faecal incontinence NOS (62.9)
92   Undue susceptibility to trauma
     Excludes: intermittent impairment of consciousness (21) and 
impairment of balance function (48)

92.0 Haemorrhagic disorders
     Includes: bleeding tendencies
     Excludes: bruising (92.4)
92.1 Skeletal fragility
92.2 Other undue susceptibility to fracture
92.3 Undue susceptibility to pressure sores
92.4 Generalized bruising
92.5 Undue insensitivity to pain
92.6 Other undue susceptibility of tissues
     Includes: scurvy
92.7 Reduced recuperative powers associated with ageing
92.8 Other
92.9 Unspecified

93   Metabolic impairment
     Excludes: impairment of physique (70.6) and skeletal        
fragility (92.1)
93.0 Impairment of growth
     Includes: failure to thrive and failure of maturation
93.1 Delicate
93.2 Specific dietary intolerance
     Includes: gluten sensitivity
93.3 Other dietary limitation
     Includes: diabetes
     Excludes: food intolerance (62.0)
93.4 Malnutrition
93.5 Weight loss
     Excludes: emaciation (70.63)
93.6 Weight gain
     Excludes: obesity (70.64)
93.7 Polydipsia
93.8 Other
93.9 Unspecified
94   Other generalized impairment
     Excludes: impairment of sleep (22)

94.0 Subject to electromechanical devices for life support
     Includes: pacemaker, renal dialysis, and respirator
94.1 Intermittent prostration
     Includes: such as may occur with asthma or migraine
     Excludes: vertigo (48.0)
94.2 Generalized pain
94.3 Fever
     Includes: pyrexia
94.4 Generalized pruritus
94.5 Other weakness
     Includes: (generalized) weakness NOS
94.6 Generalized fatigue
     Includes: fatigue NOS
     Excludes: fatigability (28.5)
94.8 Other
94.9 Unspecified

     SENSORY IMPAIRMENTS (95-98)

95   Sensory impairment of head

95.0 Anaesthesia
     Excludes: anaesthetic eye (58.2)
95.1 Disturbance of sweating
95.2 Temperature change
95.3 Facial pain
95.4 Headache
95.5 Other ache in head
     Includes: congestion, throbbing, and tightness
     Excludes: earache (49.3)
95.6 Itching
95.7 Numbness
     Includes: paraesthesia and tingling
95.8 Other
95.9 Unspecified

96   Sensory impairment of trunk

96.0 Anaesthesia
96.1 Disturbance of sweating
96.2 Temperature change
96.3 Back pain
     Includes: neck pain and lumbago
96.4 Other pain in trunk region
     Excludes: abdominal pain (62.3), chest pain (61.3 and 61.4)
               and renal colic (63.0)
96.5 Other ache in trunk region
     Includes: congestion and tightness
     Excludes: chest pain (61.3 and 61.4) and tightness of chest
               related to exercise (61.5)
96.6 Itching
96.7 Numbness
     Includes: paraesthesia and tingling
96.8 Other
96.9 Unspecified

97   Sensory impairment of upper limb

97.0 Anaesthesia
97.1 Disturbance of deep sensibility
     Includes: astereognosis
97.2 Temperature change
97.3 Pain on exercise
97.4 Other pain
     Includes: causalgia
97.5 Other ache
     Includes: congestion and tightness
97.6 Itching
97.7 Numbness
     Includes: paraesthesia and tingling
97.8 Other
     Includes: burning or prickling, and cramp or spasm
97.9 Unspecified

98   Other sensory impairment
     Includes: that of lower limb

98.0 Anaesthesia
98.1 Disturbance of deep sensibility
     Includes: astereognosis
98.2 Temperature change
98.3 Pain
     Includes: causalgia
     Excludes: pain on exercise (61.5)
98.4 Other ache
     Includes: congestion or tightness
     Excludes: intermittent claudication (61.5)
98.5 Itching
     Excludes: generalized pruritus (94.4)
98.6 Numbness
     Includes: paraesthesia and tingling
98.8 Other
     Includes: burning or prickling, and cramp or spasm
98.9 Unspecified

     OTHER IMPAIRMENTS (99)

99   Other impairment

99.0 Currently pregnant
     (Pregnancy has been included within this 
classificationbecause it is associated with certain 
functionallimitations)
99.1 Gangrene of upper limb
99.2 Gangrene of lower limb
99.3 Other gangrene
     Includes: that affecting upper and lower limb
99.8 Other
99.9 Unspecified
     Includes: impairment NOS
               GUIDANCE ON ASSIGNMENT

Impairment resemble disease terms in the ICD in that they are 
best conceived of as threshold phenomena; for any particular 
category, all that is involved is a judgement about whether the 
impairment is present or not.

The apparent comprehensiveness of the code may at first appear to 
be daunting. However, the level of detail provided serves two 
purposes; first, as a means of defining the content of classes, 
and, secondly, to allow for considerable specificity for users 
who may wish to record such detail. The taxonomic structure of 
the code resembles that of the ICD in that it is hierarchical, 
with meaning preserved even if the code is used only in 
abbreviated form. Thus the level of detail to be recorded is a 
matter of choice for the user.

Hitherto, the more immediate consequences of disease - the major 
impairments - are generally likely to have been noted in records. 
Thus coding to appropriate categories of the I code of whatever 
has been recorded should not present insuperable difficulties. 
The principal problem is likely to be concerned with 
under-ascertainment - the degree to which significant impairments 
may not have been noted.

From now on, it is suggested that the nine major sections of the 
I code be used as a check-list that is applied to each 
individual. This would require that the observer ask himself a 
series of questions: "Does this person have an intellectual 
impairment, does he have any other psychological impairment, does 
he have a language impairment?" and so on, in sequence. Further 
information on any questions answered affirmatively, along the 
lines of the greater detail contained in the code, could then be 
elicited.

The main aspect likely to command attention in the future relates 
to identification criteria and their relation to severity. The 
difficulties have been noted under "Deviation from norms", in the 
earlier section on the Consequences of disease.

SECTION 3
CLASSIFICATION OF DISABILITIES

List of two-digit categories
1 Behaviour disabilities
2 Communicaton disabilities
3 Personal care disabilities
4 Locomotor disabilities
5 Body disposition disabilities
6 Dexterity disabilities
7 Situational disabilities
8 Particular skill disabilities
9 Other activity restrictions
Supplementary gradings
Guidance on assignment
                    DISABILITY

Definition     In the context of health experience, a disability 
               is any restriction or lack (resulting from an 
               impairment) of ability to perform an activity in 
               the manner or within the range considered normal 
               for a human being

CharacteristicsDisability is characterized by excesses or 
               deficiencies of customarily expected activity 
               performance and behaviour, and these may be 
               temporary or permanent, reversible or 
               irreversible, and progressive or regressive.
                    Disabilities may arise as a direct 
                    consequence of impairment or as a response by 
                    the individual, particularly psychologically, 
                    to a physical, sensory, or other impairment. 
                    Disability represents objectification of an 
                    impairment, and as such it reflects 
                    disturbances at the level of the person
     
                    Disability is concerned with abilities, in 
the                                                                   
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
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                                                                      .
                    Examples include disturbances in behaving in 
                    an appropriate manner, in personal care (such 
                    as excretory control and the ability to wash 
                    and feed oneself), in the performance of 
                    other activities of daily living, and in 
                    locomotor activities (such as the ability to 
                    walk)
LIST OF TWO-DIGIT CATEGORIES OF DISABILITY

1         BEHAVIOUR DISABILITIES

          Awareness disabilities (10-16)

10        Self-awareness disability
11        Disability relating to location in time and space
12        Other identification disability
13        Personal safety disability
14        Disability relating to situational behaviour
15        Knowledge acquisition disability
16        Other educational disability

          Disabilities in relations (17-19)

17        Family role disability
18        Occupational role disability
19        Other behaviour disability

2         COMMUNICATION DISABILITIES

          Speaking disabilities (20-22)

20        Disability in understanding speech
21        Disability in talking
22        Other speaking disability

          Listening disabilities (23-24)

23        Disability in listening to speech
24        Other listening disability

          Seeing disabilities (25-27)

25        Disability in gross visual tasks
26        Disability in detailed visual tasks
27        Other disability in seeing and related activities
          Other communication disabilities (28-29)

28        Disability in writing
29        Other communication disability

3         PERSONAL CARE DISABILITIES

          Excretion disabilities (30-32)

30        Controlled excretory difficulty
31        Uncontrolled excretory difficulty
32        Other excretion disability

          Personal hygiene disabilities (33-34)

33        Bathing disability
34        Other personal hygiene disability

          Dressing disabilities (35-36)

35        Clothing disability
36        Other dressing disability

          Feeding and other personal care disabilities (37-39)

37        Disability in preliminaries to feeding
38        Other feeding disability
39        Other personal care disability

4         LOCOMOTOR DISABILITIES

          Ambulation disabilities (40-45)

40        Walking disability
41        Traversing disability
42        Climbing stairs disability
43        Other climbing disability
44        Running disability
45        Other ambulation disability
          Confining disabilities (46-47)

46        Transfer disability
47        Transport disability

          Other locomotor disabilities (48-49)

48        Lifting disability
49        Other locomotory disability

5         BODY DISPOSITION DISABILITIES

          Domestic disability (50-51)

50        Subsistence disability
51        Household disability

          Body movement disabilities (52-27)

52        Retrieval disability
53        Reaching disability
54        Other disability in arm function
55        Kneeling disability
56        Crouching disability
57        Other body movement disability

          Other body disposition disabilities (58-59)

58        Postural disability
59        Other body disposition disability

6         DEXTERITY DISABILITIES

          Daily activity disabilities (60-61)

60        Environmental modulation disability
61        Other daily activity disability

          Manual activity disabilities (62-66)

62        Fingering disability
63        Gripping disability
64        Holding disability
65        Handedness disability
66        Other manual activity disability
          Other dexterity disabilities (67-69)

67        Foot control disability
68        Other body control disability
69        Other dexterity disability

7         SITUATIONAL DISABILITIES

          Dependence and endurance disabilities (70-71)

70        Circumstantial dependence
71        Disability in endurance

          Environmental disabilities (72-77)

72        Disability relating to temperature tolerance
73        Disability relating to tolerance of other 
climaticfeatures
74        Disability relating to tolerance of noise
75        Disability relating to tolerance of illumination
76        Disability relating to tolerance of work stresses
77        Disability relating to tolerance of other 
environmentalfactors

          Other situational disabilities (78)

78        Other situational disability

8         PARTICULAR SKILL DISABILITIES

9         OTHER ACTIVITY RESTRICTIONS
          1    BEHAVIOUR DISABILITIES

Refer to an individual's awareness and ability to conduct 
himself, both in everyday activities and towards others, and 
including the ability to learn

     Excludes: communication disabilities (2)

     AWARENESS DISABILITIES (10-16)

     Awareness refers to having knowledge

10   Self-awareness disability

     Includes: disturbance of the ability to develop or maintain 
               a mental representation of the identity of the 
               individual's self or body ("body image") and its 
               continuity over time; and disturbance of behaviour 
               resulting from interference with consciousness or 
               sense of identity and confusion (inappropriate 
               interpretation of and response to external events, 
               which expresses itself in agitation, restlessness, 
               and noisiness)

10.0 Transient self-awareness disability
10.1 Disability in body image orientation
     Includes: disturbance in the mental representation of the         
individual's body, such as inability in right-left     
differentiation, "phantom limb" experiences, andother related 
phenomena
10.2 Personal uncleanliness
     Includes: neglect of shaving or state of hair, and dirty  
clothing
10.3 Other disturbance of appearance
     Includes: careless dress or make-up, and appearance that is 
bizarre (such as "secret documents" and special clothes or 
ornaments with idiosyncratic meaning, which may be related to 
delusions), of very inappropriate taste, or conspicuously out of 
fashion)
10.4 Other disturbance of self-presentation
     Includes: disturbance of the ability to present a favourable 
image in social situations, such as by inattention                    
to supportive social routines (e.g., greetings,   partings, 
giving thanks, apologizing, excusing,and reciprocation of these), 
and lack of "presence" (e.g., total absence of originality, or 
excessive conformity in demeanour)
     Excludes: intended unconventional behaviour (which is not a 
disability)
10.8 Other 
10.9 Unspecified

11   Disability relating to location in time and space
     Includes: disturbance of the ability of the individual to 
correctly locate external objects, events, and                   
himself in relation to the dimensions of time and space
11.0 Transient disability relating to location in time and space
11.8 Other
11.9 Unspecified

12   Other identification disability
     Includes: disturbance of the ability to identify objects and 
persons correctly
12.0 Transient disability in identifying objects and persons
12.1 Conduct out of context
     Conduct that is generally appropriate but which 
isinappropriate to the place, time, or stage of maturation
     Includes: cultural shock (such as in immigrants), moving in 
different identities (e.g., transvestism and                     
passing, such as black passing for white), 
pseudo-feeble-mindedness, and breaking taboos
12.8 Other
12.9 Unspecified

13   Personal safety disability
     Includes: disturbance of the ability to avoid hazards to the 
integrity of the individual's body, such as being                     
in hazard from self-injury or from inability to   safeguard self 
from danger
13.0 Liability to self-injury
     Includes: risk of suicide or self-inflicted injury
13.1 Personal safety disability in special situations
     Includes: being in hazard in special situations, such as    
those related to travel and transport, occupation,and recreation, 
including sport
     Excludes: occupational role disability (18)
13.2 Conduct potentially dangerous to the individual himself
     Includes: leaving gas taps or fires on 
13.3 Other irresponsible conduct
     Includes: tossing lighted matches on carpet
13.4 Getting lost
13.5 Other wandering
     Includes: when inappropriately clad
13.8 Other
13.9 Unspecified

14   Disability relating to situational behaviour
     Includes: disturbance of the capacity to register and       
understand relations between objects and personsin situations of 
daily living
     Excludes: personal safety disability in special situations 
(13.1)
14.0 Situation comprehension disability
     Includes: disturbance of the capacity to perceive, register,     
or understand relations between things and people
14.1 Situation interpretation disability
     Includes: false interpretation of the relations between and 
meaning of things and people
14.2 Situation coping disability
     Includes: disturbance of the ability to perform everyday    
activities in specific situations, such as outsidethe home or in 
the presence of particular animalsor other objects
     Excludes: disability in crisis conduct (18.6)
14.8 Other
14.9 Unspecified

15   Knowledge acquisition disability
     Includes: general disturbance of the ability to learn, such      
as may arise from impairments of intellect or of  the ability to 
learn new skills

16   Other educational disability
     Includes: other inability to benefit from educational 
opportunities because of disturbance of specific individual 
capacities for acquiring, processing,                                 
and retaining new information
     Excludes: those arising from communication (2) and other 
disabilities (3-7)
16.9 Unspecified
     Includes: slowing of mental functios NOS

     DISABILITIES IN RELATIONS (17-19)

17   Family role disability
17.0 Disability in participation in household activities
     Includes: customary common activities such as having meals 
together, doing domestic chores, going out or                    
visiting together, playing games, and watchingtelevision, and 
conduct during these activities,as well as household 
decision-making, such as decisions about children and money
17.1 Disability in affective marital role
     Includes: affective relationship with steady heterosexual 
partner or spouse, and communication (such as                    
talking about children, news, and ordinaryevents), ability to 
show affection and warmth (butexcluding culturally customary 
outbursts of anger                                                    
or irritability), and engendering a feeling of    being a source 
of support in the partner
17.2 Other marital role disability
     Includes: disturbance of sexual relations with steady 
heterosexual partner (including occurrence of                    
sexual intercourse and whether both individual andpartner find 
sexual relations satisfactory)
17.3 Parental role disability
     Includes: undertaking and performance of child care tasks 
appropriate to the individual's position in                      
household (such as feeding, putting to bed, ortaking to school, 
for small children, and lookingafter child's needs, for older 
children) and taking interest in child (such as playing with, 
reading to, and taking interest in child's                       
problems or school work)
17.8 Other family role disability
17.9 Unspecified
18   Occupational role disability
     Includes: disturbance of the ability to organize and 
participate in routine activities connected with                      
the occupation of time, not just confined to the  performance of 
work
     Excludes: situational disabilities (70-79)
18.0 Disability in motivation
     Includes: interference with the ability to work by virtue of 
severe impairment of drive
18.1 Disability in cooperation
     Includes: inability to cooperate with others and to "give        
and take" in social interaction
18.2 Disability in work routine
     Includes: other aspects of conformity to work routine (such      
as going to work regularly and on time, and  observing the rules)
18.3 Disability in organizing daily routine
     Includes: disturbance of the ability to organize activities      
in temporal sequences, and difficulty in making   decisions about 
day-to-day matters
18.4 Other disability in work performance
     Includes: other inadequacy in performance and output
18.5 Recreation disability
     Includes: lack of interest in leisure activities (such as 
watching television, listening to radio, reading newspapers or 
books, participating in games, and hobbies) and in local and 
world events (including efforts to obtain information)
18.6 Disability in crisis conduct
     Includes: unsatisfactory or inappropriate responses to      
incidents (such as sickness) accident, or otherincident affecting 
family member or involvingother people), emergencies (such as 
fire), and other experiences customarily requiring quick         
decision and action
18.8 Other occupational role disability
     Includes: for individuals not working, their interest in    
obtaining or returning to work and actual stepsundertaken to this 
end
     Excludes: other social role disability (19.2)
18.9 Unspecified

19   Other behaviour disability
     Includes: disturbance of interpersonal relationships outside     
the household
     Excludes: occupational role disability (18)
19.0 Antisocial behaviour
     Includes: severely maladjusted, psychopathic, and delinquent 
19.1 Indifference to accepted social standards
     Includes: conduct that is embarrassing (such as making      
sexual suggestions or advances, or lacking   restraint in 
scratching genitals or in passingloud flatus), irreverent (such 
as singing, making facetious silly jokes or flippant remarks, or 
being unduly familair), or histrionic (such asexpression of 
feelings in an exaggerated,dramatic, or histrionic manner)
19.2 Other social role disability
     Includes: overt conduct by the individual involving          
               arguments, arrogance, anger, marked irritability, 
               or other friction arising in social situations 
               outside own home (such as with supervisors, 
               co-workers, or customers, if the individual 
               engages in outside work: with neighbours and other 
               people in the community, if the individual has a 
               domestic role; with teachers, administrators, and 
               fellow students, if the individual is a student; 
               and with fellow inhabitants, if the individual 
               lives in                                      
               communal accommodation)
     Excludes: self-awareness (10) and identification       
disabilities (11-12)
19.3 Other personality disability
     Includes: other excess or lack of any customary trait of 
personality NOS
19.4 Other severe behaviour disorder
     Includes: other disturbance of behaviour (such as      
aggressiveness, destructiveness, extremeoveractivity, and 
attention-seeking) that presents problems in management and that 
are NEC
19.8 Other
19.9 Unspecified
     Includes: behaviour disorder NOS
          2    COMMUNICATION DISABILITIES

Refer to an individual's ability to generate and emit messages, 
and to receive and understand messages

     SPEAKING DISABILITIES (20-22)

20   Disability in understanding speech
     Includes: loss or restriction of the ability to understand       
the meaning of verbal messages
     Excludes: listening disabilities (23) and situation-related 
difficulties such as lack of knowledge of a local language

21   Disability in talking
     Includes: loss or restriction of the ability to produce     
audible verbal messages and to convey meaningthrough speech

22   Other speaking disability
22.0 Disability in understanding other audible messages
     Excludes: listening disabilities (24)
22.1 Disability in expression through substitute language codes
     Includes: loss or restriction of the ability to convey 
information by a code of sign language
22.2 Other disability with substitute language codes
     Includes: loss or reduction of the ability to receive 
information by a code of sign language
22.8 Other
22.9 Unspecified

     LISTENING DISABILITIES (23-24)

23   Disability in listening to speech
     Includes: loss or reduction of the ability to receive verbal 
messages

24   Other listening disability
     Includes: loss or reduction of the ability to receive other 
               audible messages
     SEEING DISABILITIES (25-27)

25   Disability in gross visual tasks
     Includes: loss or reduction of the ability to execute tasks 
               requiring adequate distant or peripheral vision

26   Disability in detailed visual tasks
     Includes: loss or reduction of the ability to execute tasks 
               requiring adequate visual acuity, such as reading, 
               recognition of faces, writing, and visual 
               manipulation

27   Other disability in seeing and related activities
     Excludes: disability related to tolerance of illumination 
               (75)
27.0 Disability in night vision
27.1 Disability in colour recognition
27.2 Disability in comprehending written messages
     Includes: loss or reduction of the ability to decode and 
               understand written messages
27.3 Other disability in reading written language
     Includes: difficulty with speed or endurance
27.4 Disability in reading other systems of notation
     Includes: loss or reduction of the ability to read Braille 
               by an individual disabled in near sight who had 
               previously had this ability, or difficulty in 
               learning this system of notation by an individual 
               disabled in near sight
27.5 Disability in lip reading
     Includes: loss or reduction of the ability to lip-read by an 
               individual disabled in listening who had 
               previously had this ability, or difficulty in 
               learning this skill by an individual disabled in 
               listening
27.8 Other
27.9 Unspecified

     OTHER COMMUNICATION DISABILITIES (28-29)

28   Disability in writing
     Includes: loss or reduction of the ability to encode 
               language into written words and to execute written 
               messages or to make marks
29   Other communication disability
29.0 Disability in symbolic communication
     Includes: loss or restriction of the ability to understand 
               signs and symbols associated with conventional 
               codes (e.g., traffic lights and signs, and 
               pictograms) and to read maps, simple diagrams, and 
               other schematic representations of objects
29.1 Other disability in nonverbal expression
     Includes: loss or restriction of the ability to convey 
               information by gesture, expression, and related 
               means
29.2 Other disability in nonverbal communication
     Includes: loss or restriction of the ability to receive 
               information by gesture, expression, and related 
               means
29.8 Other
29.9 Unspecified
     Includes: communication disability NOS
          3    PERSONAL CARE DISABILITIES

Refer to an individual's ability to look after himself in regard 
to basic physiological activities, such as excretion and feeding, 
and to caring for himself, such as with hygiene and dressing

          EXCRETION DISABILITIES (30-32)

30   Controlled excretory difficulty
     Control relates to mitigation of the consequences of 
     excretory difficulty by effecting a degree of regulation, 
     either by adaptive devices, electrical stimulators, special 
     protective clothing, or by some other means, so that an 
     effectively customary existence becomes possible

30.0 Control by adaptive devices
30.1 Control by electrical stimulators
30.2 Gastrointestinal diversion
     Includes: ileostomy and colostomy
     Excludes: internal short-circuit operations (70.5)
30.3 Indwelling urinary catheter
30.4 Other urinary diversion
     Includes: with abnormal orifice (such as cystostomy)
     Excludes: internal short-circuit operations (70.5)
30.5 Control by special protective clothing
30.8 Other control of excretory difficulty
30.9 Unspecified

31   Uncontrolled excretory difficulty
31.0 Severe double incontinence
     Frequency every night and every day
     Includes: soiling (faecal incontinence) and wetting 
               (incontinence of urine)
31.1 Moderate double incontinence
     Frequency greater than once every week by night and by day
31.2 Other double incontinence
31.3 Other faecal incontinence
31.4 Other urinary incontinence
31.8 Other uncontrolled incontinence
31.9 Unspecified

32   Other excretion disability
32.0 Associated with transfer difficulty at home
     Difficulty for the individual in transferring self to and 
     from a lavatory at home
32.1 Associated with thransfer difficulty elsewhere
32.2 Other difficulty in using sanitary facilities
32.8 Other excretion disability
32.9 Unspecified

     PERSONAL HYGIENE DISABILITIES (33-34)

33   Bathing disability
     Includes: having and all-over wash, washing the body and the 
               back, and drying self thereafter
33.0 Associated with transfer difficulty
     Difficulty for the individual in transferring self to and 
     from a bath 
33.1 Other difficulty in using a bath
33.2 Difficulty in using a shower
33.8 Other bathing disability
33.9 Unspecified

34   Other personal hygiene disability

34.0 Washing face
34.1 Washing hair   
     Includes: washing neck and ears
34.2 Care of hands
     Includes: washing, and care of fingernails
34.3 Care of feet
     Includes: washing, and care of toenails
34.4 Post-excretion hygiene
34.5 Menstrual hygiene
34.6 Dental hygiene
34.7 Gender-specific care
     Includes: brushing and combing hair, and shaving
34.8 Other
34.9 Unspecified
               DRESSING DISABILITIES (35-36)

35   Clothing disability
     Excludes: footwear (36.1)
35.0 Underclothes
35.1 Lower part of body
     Includes: putting on skirts and trousers
35.2 Over arms and shoulders
     Includes: putting on jackets
35.3 Over the head
     Includes: putting on blouses, shirts, and nightdresses
35.4 Outer clothing
     Includes: putting on overalls, smocks, and overcoats
35.5 Fastenings
     Includes: doing up buttons, hooks, and zips
35.8 Other
35.9 Unspecified

36   Other dressing disability
36.0 Hosiery
     Includes: putting on socks and stockings
36.1 Footwear
     Includes: putting on shoes and tying shoelaces
36.2 Protective covering of hands
36.3 Headwear
36.4 Cosmetics
36.5 Other aspects of adornment
36.8 Other
36.9 Unspecified

     FEEDING AND OTHER PERSONAL CARE DISABILITIES (37-39)

37   Disability in preliminaries to feeding
37.0 Dispensing beverages
     Includes: pouring tea
37.1 Holding drinking vessel
37.2 Dispensing food
     Includes: serving food
37.3 Making food ready
     Includes: cutting meat and buttering bread
37.4 Eating utensils
     Includes: holding cutlery and other eating utensils
37.8 Other
37.9 Unspecified

38   Other feeding disability
38.0 Drinking
     Includes: conveying beverages to mouth and consuming (such 
               as sipping)
38.1 Eating
     Includes: conveying food to mouth and ingesting
38.2 Chewing
     Includes: mastication
38.3 Swallowing
38.4 Gastrostomy
38.5 Poor appetite
38.8 Other
38.9 Unspecified
     
39   Other personal care disability
39.0 Difficulty in getting to bed
     Includes: difficulty in getting up, and inability to make 
               the decision to go to bed
     Excludes: transfer disability (46)
39.1 Difficulty in bed
     Includes: difficulty in managing bedclothes
39.8 Other
39.9 Unspecified
          4    LOCOMOTOR DISABILITIES

Refer to an individual's ability to execute distinctive 
activities associated with moving, both himself and objects, from 
place to place
     Excludes: overall mobility and consideration of the degree 
               to which this may be restored by aids (code under 
               the handicap classification), and also 
               disabilities arising from diminished endurance 
               (71)

          AMBULATION DISABILITIES (40-45)

40   Walking disability
     Includes: ambulation on flat terrain
     Excludes: negotiation of discontinuities in terrain (41-43)

41   Traversing disability
     Includes: negotiation of discontinuities in terrain such as 
               the occasional step between different levels
     Excludes: fights of stairs (42) and other aspects of 
               climbing (43)

42   Climbing stairs disability
     Includes: negotiation of flights of stairs and similair 
               man-made obstacles such as ladders
     Excludes: the occasional step (41)

43   Other climbing disability
     Includes: natural obstacles

44   Running disability

45   Other ambulation disability

          CONFINING DISABILITIES (46-47)

46   Transfer disability
     Excludes: those related to excretion (32), bathing (33), and 
               transport (47)
46.0 Transfer from lying
     Includes: difficulty in rising from and lying down on bed
     Excludes: difficulties in getting to bed and getting up that 
               are not related to the actual transfer (39.0)
46.1 Transfer from sitting
     Includes: difficulty in getting in and out of chairs
     Excludes: difficulty associated with getting on or off a 
               lavatory (32) or in and out of a car (47.0)
46.2 Standing transfer
     Includes: difficulty in standing transfer to or from bed 
               associated with manipulative problems
46.3 Reaching bed or chair
     Includes: difficulty in reaching a bed or chair
46.8 Other
46.9 Unspecified

47   Transport disability
47.0 Personal transport
     Includes: difficulty such as transfer in and out of car or 
               in using other forms of personal transport
47.1 Other vehicles
     Includes: mounting and dismounting from public transport
47.2 Other difficulty with remote shopping
     Includes: inaccessibility from location to which transported 
               (such as that vehicles cannot be parked 
               sufficiently close)
     Excludes: neighbourhood shopping (50.0) and lack of 
availibility of transport (which is a handicap)
47.7 Other transport disability
47.8 Other confining disability
47.9 Unspecified

          OTHER LOCOMOTOR DISABILITIES (48-49)

48   Lifting disability
     Includes: carrying
     Excludes: difficulty in lifting and carrying related only to 
               sustenance disability (50)
49   Other locomotor disability
     Excludes: body movement disabilities (52-27)
          5    BODY DISPOSITION DISABILITIES

Refer to an individual's ability to execute distinctive 
activities associated with the disposition of the parts of the 
body, and including derivative activities such as execution of 
tasks associated with the individual's domicile
     Excludes: dexterity disabilities (6)

          DOMESTIC DISABILITIES (50-51)

50   Subsistence disability
50.0 Procuring sustenance
     Includes: shopping in immediate neighbourhood
     Excludes: remote shopping associated with transport 
               disability (47)
50.1 Transporting sustenance
     Includes: laying in supplies by transporting to home (such 
               as carrying shopping)
50.2 Opening containers
     Includes: opening cans
50.3 Preparing food
     Includes: cutting and shopping
50.4 Mixing food
     Includes: beating
50.5 Cooking solids
     Includes: lifting and serving from pots and pans
50.6 Cooking liquids
     Includes: managing and pouring from containers of hot fluids
50.7 Serving food
     Includes: carrying trays
50.8 Catering hygiene
     Includes: washing up utensils after meals
50.9 Other and unspecified

51   Household disability
51.0 Care of bedding
51.1 "Smalls" laundry
     Includes: gentle hand washing (such as of small or delicate 
               garments)
51.2 Bulk laundry
     Includes: washing large garments and household linen
51.3 Drying laundry
     Includes: wringing, hanging out, and spreading out
51.4 Manual cleaning
     Includes: wiping, dusting, rubbing, and polishing
51.5 Assisted cleaning
     Includes: sweeping and use of floor cleaner (such as vacuum 
               cleaner)
51.6 Care of dependants
     Includes: helping children or other dependants with tasks 
               such as feeding and dressing
51.8 Other
     Excludes: moving objects (61.3) and reaching or stretching 
               up (53)
51.9 Unspecified

     BODY MOVEMENT DISABILITIES (52-57)
     Excludes: those classifiable as domestic disabilities (50-       
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      
                                                                      )

52   Retrieval disability
     Includes: picking up objects from floor, and bending
     Excludes: picking and carrying small objects (61.3)

53   Reaching disability
     Includes: reaching or stretching up for objects

54   Other disability in arm function
     Includes: the ability to push or pull with the upper limbs

55   Kneeling disability

56   Crouching disability
     Includes: stooping

57   Other body movement disability

     OTHER BODY DISPOSITION DISABILITIES (58-59)

58   Postural disability
     Includes: difficulty in attaining or maintaining postures 
               (such as disturbance of balance)
     Excludes: those related to limited endurance (71)
59   Other body disposition disability
     Includes: other difficulty in maintaining appropriate 
               relations between different parts of the body
          6    DEXTERITY DISABILITIES

Refer to adroitness and skill in bodily movements, including 
manipulative skills and the ability to regulate control 
mechanisms

          Excludes: ability to write or make marks (28)

     DAILY ACTIVITY DISABILITIES (60-61)

60   Environmental modulation disability
60.0 Security disability
     Includes: operation of latches and other closures (such as 
               door handles), and use of keys
60.1 Ingress disability
     Includes: opening and closing of doors
60.2 Fire
     Includes: kindling fire and striking matches
60.3 Domestic appliances
     Includes: use of taps, pumps, switches, and plugs
60.4 Ventilation
     Includes: opening windows
60.8 Other
60.9 Unspecified

61   Other daily activity disability
61.0 Use of standard (dial) telephone
61.1 Currency
     Includes: handling money
61.2 Other fine movements
     Includes: winding watches and clocks
61.3 Moving objects
     Includes: picking up and carrying small objects and avoiding 
               dropping objects
     Excludes: retrieving objects (52)
61.4 Handling objects
     Includes: managing a newspaper
61.8 Other
61.9 Unspecified
     MANUAL ACTIVITY DISABILITIES (62-66)
     Excludes: writing disability (28)

62   Fingering disability
     Includes: ability to manipulate with fingers

63   Gripping disability
     Includes: ability to grasp or grip objects and move them

64   Holding disability
     Includes: ability to immobilize objects by holding them

65   Handedness disability
     Includes: disabled by virtue of being a sinistral in a 
               predominantly dextral culture

66   Other manual activity disability
     Includes: other difficulty in coordination

     OTHER DEXTERITY DISABILITIES (67-69)

67   Foot control disability
     Includes: ability to use foot control mechanisms

68   Other body control disability
     Includes: ability to use parts of body to regulate control 
               mechanisms

69   Other dexterity disability
          7    SITUATIONAL DISABILITIES

Although some of the difficulties incorporated in this section 
are not strictly disturbances of activity performance (in fact, 
some could more properly be conceived of as impairments), they 
have been included here for practical reasons - particularly in 
regard to reciprocal specification of the environment (see 
earlier section on the Consequences of disease)

     DEPENDENCE AND ENDURANCE DISABILITIES (70-71)

70   Circumstantial dependence
     Includes: dependence for continued existence and activity 
               upon life-sustaining equipment or special 
               procedures or care

70.1 Dependent on external mechanical equipment
     Includes: dependence on any form of external life-saving 
               machine, such as an aspirator, a respirator, and a 
               kidney (dialysis)machine, or any form of 
               electromechanical device for the sustance or 
               extension of activity potential, such as Possum 
               and related enabling devices

70.2 Dependent on internal devices for life sustenance
     Includes: cardiac pacemaker

70.3 Dependent on other internal devices
     Includes: cardiac valve prostheses and joint replacements

70.4 Dependent on organ transplantation
     Includes: post-transplantation status

70.5 Dependent on other alterations to the internal environmentof 
the body
     Includes: internal short-circuit operations and existence of  
               artificial orifices
     Excludes: organ removal without functional consequences 
               (such as appendicectomy or cholecystectomy), and 
               artificial orifices related to excretion (30) or 
               feeding (38)

70.6 Dependent on special diet
     Includes: inability to partake of the meals customary to the 
               individual's culture

70.8 Dependent on other forms of special care
     Excludes: dependence on the help of another individual (see 
               Supplementary gradings of disability)

70.9 Unspecified dependence
71   Disability in endurance

71.0 Disability in sustaining positions
     Includes: sitting and standing

71.1 Disability in exercise tolerance
 
71.2 Disability in other aspects of physical endurance

71.8 Other disability in endurance

71.9 Unspecified

     ENVIRONMENTAL DISABILITIES (72-77)

72   Disability relating to temperature tolerance

72.0 Tolerance of cold

72.1 Tolerance of heat

72.8 Tolerance of other aspect of ventilation

72.9 Unspecified

73   Disability relating to tolerance of other climatic features

73.0 Tolerance of ultraviolet light
     Includes: sunlight
     Excludes: intolerance of bright illumination (75.0)

73.1 Tolerance of humidity

73.2 Tolerance of extremes of barometric pressure
     Includes: intolerance of pressurization associated with 
               flying 

73.9 Unspecified

74   Disability relating to tolerance of noise

75   Disability relating to tolerance of illumination

75.0 Tolerance of bright illumination

75.1 Tolerance of fluctuation in illumination

75.8 Other

75.9 Unspecified
76   Disability relating to tolerance of work stresses
     Includes: inability to cope with the speed or other aspects 
               of the pressure of work
     Excludes: that attributable to occupational role disability 
               (18)

77   Disability relating to tolerance of other 
environmentalfactors

77.0 Tolerance of dust

77.1 Tolerance of other allergens

77.2 Undue susceptibility to chemical agents
     Includes: that associated with liver disease, and that 
               arising from previous exposure to safe limits of 
               toxic chemicals

77.3 Undue susceptibility to other toxins

77.4 Undue susceptibility to ionizing radiation
     Includes: that arising from previous exposure to safe limits 
               of irradiation

77.8 Tolerance of other environmental factors

77.9 Unspecified

     OTHER SITUATIONAL DISABILITIES (78)

78   Other situational disability
     Includes: generalized activity restrictions arising from 
               such reasons as the individual's being delicate or 
               unduly susceptible to trauma
          8    PARTICULAR SKILL DISABILITIES

Vocational resettlement calls for assessment of many aspects of 
the individual's abilities and accomplishments. These include:

i)        behaviour abilities, such as intelligence, drive, 
          motivation (including attitude to rehabilitation), 
          perception, awareness (including ability to see 
          possibilities and limitations), learning ability 
          (including openness to new ideas and learning 
          potential), orientation for shape and space, 
          concentration (including intensity and ability to be 
          sustained), memory (for words, figures, and shapes, and 
          longterm), and thinking (abstract and logical), as well 
          as reaction to criticism, ability to cooperate, and 
          other aspects of social relationships

ii)       task fulfilment abilities, such as capacity to plan 
          tasks, problem solving (flexibility and 
          resourcefulness), adaptability, independence in 
          fulfilment, task motivation and interest, capacity to 
          control own work and compare it with that of others, 
          sensorimotor coordination, dexterity (fine and gross), 
          accuracy, tidiness, punctuality, safety behaviour, 
          endurance (both as regards sustaining full-time 
          occupation and in relation to work circumstances, such 
          as fatigue resistance), performance rate (both for 
          repetitive and for complex tasks), and performance 
          quality

Most of these attributes have already been accommodated, as 
appropriate, in the impairment and disability classifications. 
However, there is also a need to accommodate particular 
occupation-related physical and other skills that have not been 
included elsewhere. This need may vary in different contexts at 
present, and there is insufficient basis at the moment for 
development of a subclassification of such skills that might have 
universal application. Nevertheless this section has been 
provided in anticipation of these needs, in the hope that 
preliminary experience in the use of these classifications will 
indicate the most useful approach. It is hoped that individual 
users of the disability classification will develop their own 
tentative subclassifications for this section
          9    OTHER ACTIVITY RESTRICTIONS

This section also has been made available so as to provide a 
means of meeting needs not satisfied in other parts of the 
classification. Again, it is hoped that individual users of the 
disability classification will develop their own tentative 
subclassifications for this section, so as to provide the basis 
for a more standardized scheme in the future
               SUPPLEMENTARY GRADINGS OF DISABILITY

Severity       Most people concerned with helping individuals who 
               have a disability usually qualify their 
               assessments with a grading of the severity of 
               restriction in activity performance. Provision has 
               therefore been made for a fourth-digit supplement 
               to disability classification assignments for this 
               purpose

Outlook        Some users have expressed a wish to be able to 
               codify the outlook for individuals who have a 
               disability. Provision has therefore been made for 
               an optional fifth-digit supplement to disability 
               classification assignments for this purpose

Coding         The structure of the disability classification is 
conventions                                                           
such that it may extend to a three-digit field. In order to avoid 
                                                  ambiguity, 
                                                  therefore, it 
                                                  is recommended 
                                                  that these 
                                                  supplementary 
                                                  gradings always 
                                                  be coded to the 
                                                  fourth and 
                                                  fifth digit 
                                                  positions, even 
                                                  if the 
                                                  classification 
                                                  is only being 
                                                  used at one or 
                                                  two digit 
                                                  levels

               INTERVENTION AND SEVERITY

In everyday life, performance is very rarely an all-or-none 
characteristic, and most people acknowledge this fact by grading 
the severity of restriction. It is recommemded that grading to 
the scale categories shown in the next section be recorded as a 
fourth-digit supplement to disability classification assignments; 
there are very few disabilities to which the standard scale 
categories are not applicable

As far as scale categories are concerned, there are four goals 
for intervention in regard to disability:

(i)       Disability prevention, when the individual is able to 
          perform activities unaided and on his own without 
          difficulty
(ii) Enhancement, when the individual is able to perform 
     activities unaided and on his own but only with difficulty
(iii)Supplementation, when the individual is able to perform 
     activities only with aid, including that of others
(iv)      Substitution, when the individual cannot perform 
          activities, even with aid
These goals can be illustrated by different levels of disability 
in seeing. Thus:
Level (i)      the individual can carry out all visual tasks
Level (ii)the individual's vision needs enhancement in order for 
          him to be able to carry out detailed visual tasks 
          without difficulty; enhancement may be accomplished 
          directly, such as the use of reading glasses, or 
          indirectly by adaptation, either by adjustment of 
          illumination or by complementary assistance such as the 
          use of large print
Level (iii)the individual can accomplish gross visual tasks only 
          by supplementing his performance with aid; 
          supplementation may be direct, e.g., by the continuous 
          use of appliances such as powerful correcting lenses or 
          by help from a guide dog, or with other types of 
          physical disability, by the assistance of other people, 
          or indirect, e.g., by adjustment or adaptation of the 
          environment (for instance, by use of raised marks on 
          control gear, such as knobs, to allow tactile 
          reinforcement of precision in adjustment)
Level (iv)the individual has no useful vision and so is dependent 
          on substitution to accomplish tasks that are 
          customarily mediated by vision; substitution may be 
          accomplished in various ways, such as by radio as a 
          replacement for newspapers as a source of news, by 
          provision of talking books, or by provision of a 
          suitably adapted environment to eliminate hazards that 
          the individual usually avoids by reliance on his vision

At first it might be though that these four levels could provide 
the basis for a simple scaling of severity of disability. 
Certainly the categories have the merit of being fairly easy to 
define, and hence to ascertain, and such a fourpoint scale has 
been used quite widely. However, the categories are too broad to 
indicate with enough presion the quality of intervention required 
to improve performance. Moreover, they are unequal in their 
scope; thus levels i, ii, and iii can all refer to individuals 
who, under most circumstances, could be regarded as being 
independent, whereas both levels iii and iv are susceptible to 
subdivision that displays more sensitively the types of 
intervention required
  
                    SEVERITY OF DISABILITY
                    (optional fourth-digit supplement)

Definition
Severity of disability reflects the degree to which an 
individual's activity performance is restricted

Characteristics
Scale construct:the potential for intervention at the level of 
               the individual to improve functional performance 
               in relation to current status
     Includes:      indications of the potential to meet some 
                    unfulfilled needs in regard to disability
     Excludes:      severity of underlying impairments, and also 
                    the potential to reduce the individual's 
                    handicap (disadvantage) status, particularly 
                    by social policy and social welfare measures

Severity scale categories

0    Not disabled (not in categories 1-9)
     Includes:      no disability present (i.e., the individual 
                    can perform the activity or sustain the 
                    behaviour unaided and on his own without 
                    difficulty)

1    Difficulty in performance (not in categories 2-9)
     Includes:      difficulty present (i.e., the individual can 
                    perform the activity or sustain the behaviour 
                    unaided and on his own but only with 
                    difficulty

2    Aided performance (not in categories 3-9)
     Includes:      aids and appliances necessary (i.e., the 
                    individual can perform the activity only with 
                    a physical aid or appliance)
     Excludes:      assistance by other people (category 3)

3    Assisted performance (not in categories 4-9)
     Includes:      the need for a helping hand (i.e., the 
                    individual can perform the activity or 
                    sustain the behaviour, whether augmented by 
                    aids or not, only with some assistance from 
                    another person)

4    Dependent performance (not in categories 5-9)
     Includes:      complete dependence on the presence of 
                    another person (i.e., the individual can 
                    perform the activity or sustain the 
                    behaviour, but only when someone is with him 
                    most of the time)
     Excludes:      inability (categories 5 and 6)

5    Augmented inability (not in categories 6-9)
     Includes:      activity impossible to achieve other than 
                    with the help of another person, the latter 
                    needing an aid or appliance to enable him to 
                    provide this help (for example, the 
                    individual cannot be got out of bed other 
                    than by the use of a hoist); behaviour can be 
                    sustained only in the presence of another 
                    person and in a protected environment

6    Complete inability (not in categories 8 or 9)
     Includes:      activity or behaviour impossible to achieve 
                    or sustain (for example, an individual who is 
                    bed-bound is also unable to transfer)

8    Not applicable
     Includes:      severity grading not applicable to particular 
                    disability 

9    Severity unspecified

It can be seen that the scale categories correspond to 
intervention goals in the following manner:
Enhancement    scale category 1
Supplementationscale categories 2-4
Substitution        scale categories 5-6

Rules for assignment

i    categorize an individual according to his activity 
     performance, taking account of aids, appliances, and 
     assistance needed to permit this level of accomplishment;
ii   aids and appliances that it is intended to provide or 
     prescribe should not be taken into account - this would then 
     permit use of the scale as a rough measure of what had been 
     accomplished when such aid or appliance was provided;
iii  if doubt is experienced about the category to which a 
     disability shoud be assigned, rate it to the less favourable 
     category (i.e., that with a higher number)

                    ASSESSMENT OF OUTLOOK
                    (optional fifth-digit supplement)

Definition
Outlook reflects the likely course of the individual's disability 
status

Characteristics
Scale construct:the potential for intervention at the level of 
               the individual to improve functional performance 
               in relation to expected future status
     Includes:      indications of the potential to anticipate 
                    some needs in regard to disability
     Excludes:      prognosis for underlying impairments, other 
                    than to the extent that disability status may 
                    correlate closely with the outlook for the 
                    impairment
                    the potential to reduce the individual's 
                    handicap (disadvantage) status, particularly 
                    by social policy and social welfare measures

Outlook scale categories

0    Not disabled (not in categories 1-9)
     Includes:      no disability present


1    Recovery potential (not in categories 2-9)
     Includes:      disability present but diminishing, and 
                    recovery without ultimate restriction in 
                    functional performance expected

2    Improvement potential (not in categories 3-9)
     Includes:      disability present but diminishing, though 
                    the individual is likely to be left with 
                    residual restriction in functional 
                    performance

3    Assistance potential (not in categories 4-9)
     Includes:      disability in stable or static state, but 
                    functional performance could be improved by 
                    provision of aids, assistance, or other 
                    support

4    Stable disability (not in categories 5-9)
     Includes:      disability in stable or static state with no 
                    outlook for improvement in functional 
                    performance

5    Amelioration potential (not in categories 6-9)
     To ameliorate means to make more bearable
     Includes:      disability increasing, but functional 
                    performance could by improved by provision of 
                    aids, assistance, or other support

6    Deteriorating disability (not in categories 8 or 9)
     Includes:      disability increasing with no outlook for 
                    amelioration
8    Indeterminable outlook

9    Outlook unspecified

Rules for assignment

i    categorize an individual according to the outlook for his 
     activity performance (i.e., disability status), and not for 
     the prognosis of the underlying impairments, other than to 
     the extent that disability may correlate closely with the 
     outlook for the impairments, and taking account of aids and 
     appliances, modification or adaptation of his immediate 
     environment, and assistance received from other persons;
ii   aids or adaptations that it is intended to provide or 
     prescribe should not be taken into account - this would then 
     permit use of the scale as a rough measure of what had been 
     accomplished when such an aid or adaptation was provided;
     (Note: the ordination of this scale according to the 
     potential for intervention determines that categories with a 
     potential for assistance or amelioration have lower numbers 
     than the corresponding stable or deteriorating categories - 
     thus provision of assistance or amelioration is likely to 
     lead reassignment to a category with a higher number, since 
     no further potential for improvement can be assumed)
iii  if doubt is experienced about the category to which 
adisability should be assigned, rate it to the lessfavourable 
category (i.e., that with a higher number)
                       GUIDANCE ON ASSIGNMENT

To some extent, disabilities can be conceived of in the first 
instance as threshold phenomena. Thus, to establish the existence 
and nature of a disability calls only for a judgement about 
whether a particular accomplishment can be performed or not. In 
principle, the assignment of failures in accomplishment to the 
appropriate categories in the code should not prove to be unduly 
difficult.

The taxonomic structure of the code resembles that of the ICD in 
that it is hierachical, with meaning preserved even if the code 
is used only in abbreviated form. Once again, the level of detail 
provided is intended to define the content of classes and to 
allow specificity for users who desire it. However, the scheme is 
less exhaustive than the I code, and provision has been made for 
expansion in response to needs uncovered by further experience of 
applying the code. Thus the level of detail to be recorded is a 
matter of choice for the user.

Information about major difficulties is generally likely to have 
been noted in existing records. Coding whatever has been recorded 
to the appropriate categories of the D code should therefore not 
present insuperable difficulties. However, two problems should be 
acknowledged. First, existing records will usually be vulnerable 
in regard to under-ascertainment - the degree to which 
significant disabilities may not have been noted. Secondly, some 
caution is required in connexion with potential variability 
related to the method of ascertainment. Thus differences are to 
be expected between assignments based on clinical assessments, 
functional testing (including the activities of daily living), or 
questionnaires.

From now on, it is suggested that the major sections of the D 
code be used as a check-list that is applied to each individual. 
This would require that the observer ask himself a series of 
questions': "Does this person have a behaviour disability, does 
he have a communication disability, does he have a personal care 
disability?" and so on, in sequence. Further information on any 
question answered affirmatively, along the lines of the greater 
detail contained in the code, could then be elicited.

Having established the presence of particular disabilities, 
further questions then arise. This occurs because disability 
represents a failure in accomplishment, so that a gradation in 
performance is to be expected. Thus assessment of the severity of 
individual disabilities is called for. Assessment of outlook is 
also likely to prove helpful. The basis for such assessments has 
been indicated on the immediately preceding pages, dealing with 
supplementary gradings. It is unfortunate that, in attempting 
retrospective assessment on the basis of existing records, 
insufficient details of the level of performance may prevent full 
application of the supplementary gradings.

Two aspects of the D code are likely to command particular 
attention in the future. First, the proposals in the code 
contrast fairly markedly with the complexity and exhaustiveness 
of conventional assessment schedules for the activities of daily 
living. The difference in approach is based on preliminary 
reappraisal of goals and methods[1], and it is hoped that further 
experience with the code will help resolve the differences
in such a way as to promote economy in future assessment effort. 
Secondly, users have the opportunity to expand the code in order 
to meet their own needs more satisfactorily. It is hoped that, as 
requested in the Introduction, such developments will be 
communicated to the originators of these classifications.
                         SECTION 4

                    CLASSIFICATION OF HANDICAPS

                    List of dimensions
                    1  Orientation handicap
                    2  Physical independence handicap
                    3  Mobility handicap
                    4  Occupation handicap
                    5  Social integration handicap
                    6  Economic self-sufficiency handicap
                    7  Other handicap
                    Guidance on assessment
                         HANDICAP

Definition     In the context of health experience, a handicap is 
               a disadvantage for a given individual, resulting 
               from an impairment or a disability, that limits or 
               prevenmts the fulfilment of a role that is normal 
               (depending on age, sex, and social and cultural 
               factors) for that individual

CharacteristicsHandicap is concerned with the value attached to 
               an individual's situation or experience when it 
               departs from the norm. It is characterized by a 
               discordance between the individual's performance 
               or status and the exceptations of the individual 
               himself or of the particular group of which he is 
               a member. Handicap thus represents socialization 
               of an impairment or disability, and as such it 
               reflects the consequences for the individual - 
               cultural, social, economic, and environmental - 
               that stem from the presence of impairment and 
               disability

                    Disadvantage arises from failure or inability 
                    to conform to the exceptations or norms of 
                    the individual's universe.
                    Handicap thus occurs when there is 
                    interference with the ability to sustain what 
                    might be designated as "survival roles" (see 
                    next page)

Classification      It is important to recognize that the 
                    handicap classification is neither a taxonomy 
                    of disadvantage nor a classification of 
                    individuals. Rather is it a classification of 
                    circumstances in which disabled people are 
                    likely to find themselves, circumstances that 
                    place such individuals at a disadvantager 
                    relative to their peers when viewed from the 
                    norms of society
     
          LIST OF DIMENSIONS OF HANDICAP

               SURVIVAL ROLES

          1    Orientation handicap
          2    Physical independence handicap
          3    Mobility handicap
          4    Occupation handicap
          5    Social integration handicap
          6    Economic self-sufficiency handicap

               OTHER HANDICAPS

          7    Other handicaps

Survival roles      The six key dimensions of experience in which 
                    competence is expected of the individual have 
                    been designated as survival roles. For each 
                    of these dimensions the more important array 
                    of circumstances that may apply has been 
                    scaled.
                    In contrast to the impairment and disability 
                    classifications, in which individuals are 
                    likely to be identified only in the 
                    categories that apply to them, in the 
                    handicap classification it is desirable that 
                    individuals always be identified on each 
                    dimensions or survival role. This will 
                    provide a profile of their disadvantage 
                    status

Other handicapsThe six major survival roles by no means exhaust 
               the possibilities of disadvantage, although they 
               do cover the major problems. The varied nature of 
               other handicaps precludes scaling, and so 
               provision has been made just for the 
               identification of these difficulties
          1    ORIENTATION HANDICAP

Definition is the individual's ability to orient himself in 
relation to his surroundings

Characteristics
Scale construct:orientation to surroundings, including 
               reciprocation or interaction with surroundings
     Includes:      reception of signals from surroundings (such 
                    as by seeing, listening, smelling, or 
                    touching), assimilation of these signals, and 
                    expression of response to what is 
                    assimilated; consequences of disabilities of 
                    behaviour and communication, and including 
                    the planes of seeing, listening, touching, 
                    speaking, and assimilation of the functions 
                    by the mind
     Excludes:      response to reception and assimilation of 
                    signals from the surroundings manifest as 
                    handicaps of personal care (physical 
                    independence handicap, 2), evasion of 
                    physical hazard (mobility handicap, 3), 
                    behaviour in specific situations (occupation 
                    handicap, 4) and behaviour towards others 
                    (social integration handicap, 5)

Scale categories
0    Fully oriented (not in categories 1-9)

1    Fully compensated impediment to orientation (not in 
     categories 2-9)
     Includes:      continuous use of aids for seeing (e.g., 
                    spectacles), listening (e.g., amplification), 
                    or extension of touching (e.g., a cane), or 
                    continuous use of medication to control 
                    behaviour or communication disabilities, with 
                    resultant restoration of full orientation
     Excludes:      aids or medication used imtermittently (other 
                    handicaps, 7)

2    Intermittent disturbance of orientation (not in categories 
     3-9)
     Includes:      episodic experiences that interfere with full 
                    orientation, such as vertigo, those 
                    associated with Menieres disease, diplopia 
                    (as may be encountered with multiple 
                    sclerosis), intermittent interruption of 
                    consciousness (e.g., epilepsy), and certain 
                    impediments of speech form (e.g., stuttering)
     Excludes: fully corrected or controlled disturbances 
               (category 1)
          
3    Partially compensated impediment to orientation (not in 
     categories 4-9)
     Includes: individuals otherwise classifiable to categories 1 
               or 2 but who experience disadvantage in some 
               aspect of their lives because the impediment to 
               orientation renders them vulnerable in certain 
               circumstances, such as critical dependence on 
               levels of illumination, for some seeing 
               disabilities; critical dependence on levels of 
               background noise and other competing signals, for 
               listening disabilities and some speaking 
               disabilities (e.g., where speech volume is 
               impaired); and disadvantage attributed to the need 
               for aids or medication (e.g., by virtue of 
               resultant ineligibility to take up certain 
               employments or to drive an automobile - code such 
               instances additionally as curtailed occupation, 
               category 2, of occupation handicap, 4)

4    Moderate impediment to orientation (not in categories 5-9)
     Includes: where aids or medication fail to produce 
               satisfactory compensation of impediment, so that 
               apreciable difficultu in orientation is 
               experienceed; or where assistance is required from 
               other people, such as for individuals who are 
               partially sighted, have appreciable hearing loss, 
               have insensitivity to touch, are confused, or have 
               other appreciable impediments

5    Severe impediments to orientation (not in categories 6-9)
     Includes: severe behaviour or communication disabilities 
               where substitution is necessary, such as more 
               severe degrees of the states encountered in 
               category 4 (i.e., the individual cannot perform 
               the activity, even with aid, and so is dependent 
               on substitution by other planes of orientation in 
               order to compensate, such as the reliance of the 
               blind on listening or touching), or moderate 
               disorientation

6    Orientation deprivation (not in categories 7-9)]
     Includes: where there is moderate or severe impediment in 
               more than one plane of orientation, these planes 
               being seeing, listening, touching, and speaking
     Excludes: disabilities of speech form associated with 
               deafness (assign such individuals solely according 
               to listening status unless speaking disturbance is 
               so severe as to interfere with communication; 
               assign individuals in the latter situation to 
               category 6)
7    Disorientation (not in categories 8 or 9)
     Includes: inability of the individual to orient himself to 
               his surroundings to the extent that he requiries 
               institutional care

8    Unconscious

9    Unspecified

Rules for assignment
i.   occasional difficulty or depedence on help should not 
     preclude assignment to a less disadvantaged category (i.e., 
     that with a lower number);
ii   aids or adaptations that it is intended to provide or 
     prescribe should not be taken into account - this would then 
     permit use of the classification as a rough measure of what 
     had been accomplished when such an aid or adaptation was 
     provided;
iii  if doubt is experienced about the category to which an 
     individual should be assigned, rate him to the less 
     favourable category (i.e. that with a higher number);
iv   morale is obviously an important factor, but an individual 
     should be assigned according to his actual degree of 
     dependence, rather than to what the assessor thinks he may 
     be capable of



          2    PSYSICAL INDEPENCE HANDICAP

Definition
Psysical indepence is the individual's ability to sustain a 
customarily effective independent existence

Characteristics
Scale construct:indenpence in regard to aids and the assistance 
               of others
     Includes:      self-care and other activities of daily 
                    living
     Excludes:      aids or assistance in orientation 
                    (orientation handicap,1)

Scale categories
0    Fully independent (not in categories 1-9)
     Includes:      indenpendence in self-care and without 
                    dependence on aids, appliances, environmental 
                    modification, or the assistance of other 
                    people, or dependent only on minor aids not 
                    essential to independence (the latter should 
                    be identified as other handicaps, 7)

1    Aided independence (not in categories 2-9)
     Assignment to this category depends on the provision and use 
     of an aid or appliance. Individuals who have been provided 
     with an aid or appliance but do not make use of it, and thus 
     forfeit some of their independence, and individuals living 
     in cultures where suitable aids and appliance are not 
     available, should be assigned to category 3 or 4.
     Includes: dependence on the use of aids and appliances, such 
               as an artificial or substitute limb, other 
               prostheses, walking aids, or aids to daily living, 
               as well as controlled excretory difficulty
     Excludes: minor aids and appliances not essential to 
               independence, such as artificial dentures or ring 
               pessaries to control prolaps of the womb, and 
               seeing aids (spectacles) provided that the 
               individual would not otherwise be dependent on 
               assistance of the type described in categories 
               4-8; individuals whose lives are assisted or 
               improved by minor aids of this type should be 
               assigned to category 0 and should also be 
               identified, as appropriate, under orientation (1) 
               or other handicaps (7)

2    Adapted independence (not in categories 3-9)
     Assignment to this category presupposes two conditions. 
     First, that the immediate environment customary to the way 
     of life of the individual and the group of which he is a 
     member creates physical ob stacles to independence, e.g., 
     structural or architectural barriers such as ladders or 
     stairs (for the purpose of this category immediate 
     environment shall be interpreted as the dwelling), and 
     secondly, that the potential to create or provide an 
     alternative environment is available in that culture. For 
     example, a lake dweller encounters obstacles in climbing a 
     ladder to his dwelling, and yet the means for an alternative 
     environment do not exist in that culture
     Includes:      dependece on modification or adaptation of 
                    the immediate environment, such as 
                    individuals who are dependent on a 
                    wheelchair, provided that the individual can 
                    get in and out of, operate, and otherwise 
                    transfer to and from the chair without 
                    assistance from another individual; 
                    individuals who have been
                    rehoused in order to reduce their physical 
                    dependence, because of their previous 
                    inability to cope with a dwelling of more 
                    than one storey; and individuals who have had 
                    structural alterations or special adaptations 
                    to their dwellings, such as the provision of 
                    a ramp or a lift, or an alteration in the 
                    height of working surfaces, etc. 
     Excludes:      architectural barriers not related to the 
                    individual's dwelling (difficulties in this 
                    regard should be assigned to category 3 or 4, 
                    as appropriate); individuals who decline an 
                    offer of a dwelling with amenities that would 
                    reduce their physical dependence, who should 
                    be assigned to category 3 or 4

3    Situational dependence (not in categories 4-9)
     Includes:      difficulty in meeting personal needs but 
                    without being largely dependent on others, 
                    such as may arise because aids and appliances 
                    or environental modifications or adaptations 
                    are not feasible or not available within the 
                    culture in which the individual lives, or, if 
                    available, are declined; difficulty in 
                    mobility outside the home that is overcome 
                    only with the assistance of other people; and 
                    moderate impediments to orientation that 
                    require assistance from other people

4    Long-interval dependence (not in categories 5-9)
     Long-interval needs are those that arise once every 24 hours 
     or less frequently
     Includes:      dependence on other individuals for meeting 
     Excludes:      culturally determined dependence, such as the 
                    customary dependence of an employed male on 
                    his spouse (which in this context shall not 
                    be regarded as a disadvantage)

5    Short-interval dependence (not in categories 6-9)
     Short-interval needs are those that arise every few hours 
byday
     Includes:      dependence on other individuals for meeting 
                    short-interval needs, such as those 
                    identified under personal hygiene, feeding, 
                    and other personal care disabilities; 
                    mobility within the home; transferring to 
                    chair or commode; emptying chamber pot, 
                    commode, or bucket; stripping beds and 
                    washing linen soiled by urine or faeces; and 
                    need for residential care in order to be 
                    looked after

6    Critical-interval dependence (not in categories 7-9)
     Critical-interval needs are those that arise at short and 
     unpredictable intervals by day and which require the 
     continuous availability of help from other persons
     Includes:      dependence on other individuals for meeting 
                    critical-interval needs such as going to the 
                    toilet, unfastening and removing clothes, 
                    using toilet paper, and cleansing; 
                    individuals who are unabler to rise from a 
                    bed or chair, walk to the toilet unassisted, 
                    use it, and return safely without danger of 
                    falling; and individuals with physical 
                    frailty or mental instability giving rise to 
                    potential hazard;
                    need for institutional care in order to 
                    provide supervision such as for behaviour 
                    that is socially unacceptable 

7    Special-care dependence (not in categories 8 or 9)
     Special-care needs are those that arise predominantly 
     throughout the day or throughout the night and that give 
     rise to continuous demands for supervison and hel (as 
     opposed to the mere availability of such help, category 6)
     Includes:      individuals who need someone to suply most of 
                    their personal needs and to care for them as 
                    far as customary every day functions are 
                    concerned, or are sufficiently senile, or 
                    otherwise mentally impaired, to need a 
                    similar order of care, and who as a result 
                    require the constant attendance of other 
                    people throughout the day; substantial 
                    soiling of clothing or bedding by urine ir 
                    faeces of frequent occurence other than in 
                    response only to physical stress; and 
                    individuals who need help with excretory or 
                    similar critical functions (such as 
                    behaviour) practically every night but who 
                    are less dependent by day;
                    need for institutional care in order to 
                    provide restraint of behaviour
8    Intensive-care dependence
     Intensive-care needs are those that arise practically every 
     night as well as throughout the day and which as a result 
     require the constant attendence of other people throughout 
     the 24 hours
     Includes:      individuals who need help with excretory or 
                    similar critical functions (such as 
                    behaviour) practically every night as well as 
                    throughout the day - most individuals in this 
                    category need to be fed and dressed, as well 
                    as requiring a lot help during the day with 
                    washing and excretory functions, or are 
                    incontinent

9    Unspecified

Rules for assignment
i    occasional difficulty or dependence on help should not 
     preclude assignment to a less disadvantaged category (i.e., 
     that with a lower number);

ii   aids or adaptations that it is intended to provide or 
     prescribe should not be taken into account - this would then 
     permit use of the classification as a rough measure of what 
     had been accomplished when such an aid or adaptation was 
     provides;

iii  if doubt is experienced about the category to which an 
     individual should be assigned, rate hime to the less 
     favourable category (i.e., that with a higher number);

iv   morale is obviously an important factor, but an individual 
     should be assigned according to his actual degree of 
     dependence, rather than to what the assessor thinks he may 
     be capable of            
          3    MOBILITY HANDICAP

Definition
Mobility is the individual's ability to move about effectively in 
his surroundings

Characteristics
Scale construct:extent of mobility from a reference point, the 
               individual's bed
     Includes:      the individual's abilities augmented, where 
                    appropriate, by prostheses or other physical 
                    aids, including a wheelchair (all these 
                    should have been identified in categories 1 
                    or 2 of physical independence handicap, 2)
     Excludes:      mobility attainments with the assistance of 
                    other individuals (the latter should be 
                    identified as long-interval dependence, 
                    category 4 of physical independence handicap, 
                    2)

Scale categories
0    Fully mobile (not in categories 1-9)

1    Variable restriction of mobility (not in categories 2-9)
     Includes:      a bronchitic with winter impairment of 
                    exercise tolerance, or a severe asthmatic 
                    with intermittent impairment of exercise 
                    tolerance, and impairments and disabilities 
                    following a fluctuating course, such as mild 
                    rheumatoid arthritis or (osteo)arthrosis

2    Impaired mobility (not in categories 3-9)
     Includes:      restriction such that the ability to get 
                    around is not interfered with but getting 
                    around may take longer, e.g., because seeing 
                    disability makes the individual uncertain in 
                    getting around, or because of other 
                    uncertainty, or, in an urbanized society, 
                    because the individual has difficulty but 
                    nevertheless is able to cope with public 
                    transport under all circumstances

3    Reduced mobility (not in categories 4-9)
     Includes:      reduction such that the ability to get around 
                    is curtailed, e.g., because seeing disability 
                    interferes with the ability to get around; or 
                    curtailment because of uncertainty, frailty, 
                    or debility; or disability on severe exertion 
                    due to cardiac or respiratory impairment; or, 
                    in an urbanized society, inability to cope 
                    with public transport under all 
                    circumstances; or
                    interference with following occupation by 
                    virtue of difficulty in getting to and from 
                    occupation when this is followed away from 
                    the individual's dwelling 

4    Neighbourhood restriction (not in categories 5-9)
     Includes:      restriction to immediate neighbourhood of 
                    dwelling, such as by disability on moderate 
                    exertion owing to cardiac or respiratory 
                    impairment

5    Dwelling restriction (not in categories 6-9)
     Includes:      confinement to dwelling such as by severe 
                    seeing disability or disability on mild 
                    exertion owing to cardiac or respiratory 
                    impairment

6    Room restriction (not in categories 7-9)
     Includes:      confinement to room, such as by disability at 
                    rest owing to cardiac or respiratory 
                    impairment

7    Chair restriction (not in categories 8 or 9)
     Includes:      confinement to chair, such as by disability 
                    when recumbent owing to cardiac or 
                    respiratory impairment, or by dependence on 
                    hoists or similar appliances for getting in 
                    and out of bed

8    Total restriction of mobility
     Includes:      bedfast or confined to bed

9    Unspecified

Rules for assignment

i    categorize an individual according to his independent 
     abilities, taking account of aids and appliances and 
     modification or adaptation of his immediate environment, bus 
     disregarding his accomplishments with the aid of other 
     persons (thus uncertainty leading to classification to 
     category 3 or 4 may be reduced in the company of other 
     persons; this consequential reduction should nevertheless 
     not be taken into account, but the dependence on other 
     persons should be identified under category 3 or 5, as 
     appropriate, of physical independence handicap, 2);

ii   occasional reduction or restriction of mobility should not 
     preclude assignment to a less disadvantaged category (i.e., 
     that with a lower number);

iii  aids or adaptations that it is intended to provide or 
     prescribe should not be taken into account;

iv   if doubt is experienced about the category to which an 
     individual should be assigned, rate him to the less 
     favourable category (i.e., that with a higher number);

v    an individual should be categorized according to his actual 
     degree of mobility, rather than to what the assessor thinks 
     he may be capable of
Notesa)   Problems may be encountered in selecting categories, 
          such as the choice between categories 2 and 3 in areas 
          where a public transport system is not available. In 
          instances like these the individual should be assigned 
          to the less favourable category, in accordance with 
          Rule iv, because it is only by providing a special 
          vehicle that category 2 mobility can be accomplished.
               This convention should be applied even if the 
               individual's occupation or way of life does not 
               call for overall mobility; it is only the effort 
               that would be deployed in trying to modify his 
               category that would be influenced by these facts
          b)   The depencence of disadvantage on cultural norms 
               is well illustrated by a problem in urbanized 
               societies. The behaviour of bus drivers in one 
               area might preclude use of public transport by 
               disabled persons in that area, whereas more 
               sympathetic behaviour by bus drivers in another 
               area might allow someone with the same disability 
               to use public transport.
               This leads to a conflict between reproducibility 
               (a category meaning the same thing in all places) 
               and the ability of the classification to reflect 
               an individual's needs. The handicap classification 
               is intended predominantly for the latter purpose, 
               and only secondarily for transcultural comparisons
          4    OCCUPATION HANDICAP

Definition 

Occupation is the individual's ability to occupy his time in the 
manner customary to his sex, age, and culture

Characteristics
Scale construct:the ability to sustain appropriate occupation of 
               time for the working day
Includes:           play or recreation, employment, and the 
                    elderly pursuing occupations customary to 
                    their age group, which in many cultures 
                    includes their assuming a more domestic role 
                    and fulfilling this after the upper age for 
                    normal employment 
Excludes:           restriction or loss of the ability to follow 
                    an occupation that is not due to an 
                    individual's impairment, such as might arise 
                    because of changes in employment 
                    possibilities

Scale categories
0    Customarily occupied (not in categories 1-9)
     Includes:      where educational opportunities exist, the 
                    ability of a child to attend a normal school; 
                    independent of educational opportunities, the 
                    ability of a child to participate in the 
                    activities customary for his age grouo; the 
                    ability to run a household in the accepted 
                    manner; and the ability to discharge the 
                    responsibilities customarily expected of a 
                    parent bringingup young children 

1    Intermittently unoccupied (not in categories 2-9)
     Includes:      intermittend inability to follow customary 
                    occupation or leisure-time activities, e.g., 
                    because of interference by conditions such as 
                    epilepsy, migraine, or allergy, or because of 
                    occasional falls (with or without injury) in 
                    the elderly

2    Curtailed occupation (not in categories 3-9)
     Includes:      reduces ability to follow customary 
                    occupation, such as in children able to 
                    attend normal scholl but who suffer from 
                    disabilities that restrict participation in 
                    all the activities of the school; individuals 
                    who are unable to participate in all the 
                    activities associated with their customary 
                    occupation or recreation (e.g., "light 
                    work"); and individuals experiencing 
                    difficulty in running a household or in 
                    discharging the responsibilies customarily 
                    expected of a parent bringing up young 
                    childten, although they are able to manage 
                    these activities                             
3    Adjusted occupation (not in categories 4-9)
     Includes:      inability to follow customary occupation, but 
                    the individual is able to follow modified or 
                    alternative full-time occupation (including 
                    modifications to customary occupation because 
                    of disability, e.g., alterations at work 
                    place or provision of special assistance or 
                    aids); alteration of recreations and other 
                    leisure activities (e.g., hobbies); need for 
                    special help at ordinary school (e.g., 
                    because the individual is partially sighted 
                    or partially deaf, or because he needs toilet 
                    assistance or help with feeding); restriction 
                    of career choice because of impairment or 
                    disability; necessity to change employment or 
                    occupation (including premature retirement - 
                    after attaining the customary age of 
                    retirement the individual should be 
                    reassigned to one of the categories 0-2, as 
                    appropriate); and having to make special 
                    arrangements to allow continued running of 
                    household or looking after children (e.g., by 
                    compensatory role adaptation by spouse, by 
                    some extra support from social network, by 
                    special pyrchase of labour-saving devices, or 
                    by employment of some paid assistance with 
                    general duties such as cleaning)

4    Reduced occupation (not in categories 5-9)
     Includes:      limitations on the amount of time the 
                    individual is able to devote to his 
                    occupation, such as curtailment of recreation 
                    and other leisure activities (e.g., because 
                    of conditions such as rheumatic heart 
                    disease); able to attend school only 
                    part-time, or other reduction in amount of 
                    regular educational instruction; able to 
                    sustain only part-time employment or 
                    occupation because of impairment or 
                    disability; impaired concentration in the 
                    elderly (domestic and parental 
                    responsibilities can usually be discharged on 
                    a more fluid time scale than other 
                    occupations, and this may allow compensation 
                    for limitations in the time that can be 
                    devoted to them - interference with these 
                    activities therefore does not feature in this 
                    category)
5    Restricted occupation (not in categories 6-9)
     Includes:      limitations on the type of occupation the 
                    individual follows, such as severe 
                    restriction of participation in activities 
                    customary for the individual's age group; 
                    disabilities that preclude a child from 
                    attending a normal school (e.g., the need to 
                    attend a special establishment for disabled 
                    children, where such exists); moderate mental 
                    retardation; able to gain employment only 
                    under special circumstances (e.g., in a 
                    sheltered workshop); has to delegate most of 
                    responsibilities for running a household or 
                    bringing up children (e.g., by appreciable 
                    support from social network or by employment 
                    of assistance); and frequent falls in the 
                    elderly

6    Confined occupation (not in categories 7-9)
     Includes:      limitations on both the type of occupation 
                    the individual follows and the amount of time 
                    he devotes to it, such as inability to 
                    participate in activities customary for the 
                    individual's age group; disabilities that 
                    require a child to be resident in an 
                    institution for purposes of education (where 
                    such exists), or to be educated at home 
                    (where this is not customary); severe mental 
                    retardation; able to carry out only very 
                    limited domestic activities (e.g., those 
                    connected with running a household or 
                    bringing up children); an impairment of 
                    concentration leading to difficulty in 
                    sustaining an occupation
     Excludes:      residence in an institution by virtue of 
                    behavioural maladjustment or the need for 
                    restraint (categories 5-8 of physical 
                    indepence handicap, 2)

7    No occupation (not in categories 8 or 9)
     Includes:      inability to follow occupation because of 
                    impairment or disability, such as severe 
                    limitation in ability to benefit from 
                    educational endeavours (e.g., profound mental 
                    retardation); unable to sustain any form of 
                    employment; unable to run a household or 
                    bring
                    up children; and severe impairment of 
                    concentration leading to inability to sustain 
                    an occupation
8    Unoccupiable
     Includes:      inability to occupy self in a meaningful 
                    manner

9    Unspecified

Rules for assignment

i    occasional less favourable experience should not preclude 
     assignment to a less disadvantaged category (i.e., that with 
     a lower number);

ii   if doubt is experienced about the category to which an 
     individual should be assigned, rate him to the less 
     favourable category ( i.e., that with as higher number)

iii  an individual should be categorized according to his actual 
     occupation status, rather than to what the assessor thinks 
     he may be capable of
          5    SOCIAL INTEGRATION HANDICAP

Definition

Social integration is the individual's ability to participate in 
and maintain customary social relationships

Characteristics
Scale construct:individual's level of contact with a widening 
               circle, from the reference point of self

Scale categories

0    Socially integrated (not in categories 1-9)
     Includes:      full participation in all customary social 
                    relationships

1    Inhibited participation (not in categories 2-9)
     Includes:      individuals in whom the presence of an 
                    impairment or disability gives rise to 
                    nonspecific disadvantage that may inhibit but 
                    not prevent participation in the full range 
                    of customary social activities (includes 
                    embarrassment, shyness, and other defects of 
                    self-image due to disfigurement or other 
                    impairments and disabilities); and certain 
                    mild personality impairments or behaviour 
                    disabilities

2    Restricted participation (not in categories 3-9)
     Includes:      individuals who do not participate in the 
                    full range of customary social activities, 
                    such as those with impairments or 
                    disabilities that interfere with 
                    opportunities for marriage; curtailment of 
                    sexual activity because of impairment or 
                    disability; and certain personality 
                    impairments or behaviour disabilities
     Excludes:      impairments and disabilities that do not 
                    interfere with social relationships, such as 
                    prolapse of the womb controlled by a ring 
                    pessary that does not give rise to 
                    appreciable curtailment of sexual activity

3    Dimisnished participation (not in categories 4-9)
     Includes:      individuals who are unable to relate to 
                    casual acquaintances, so that social 
                    relationships are confined to primary and 
                    secondary contacts such as family, friends, 
                    neighbours, and colleagues: and individuals 
                    who are retarded in physical, or social 
                    development but in whom development 
                    improvement is continuing                    
4    Impoverished relationships (not in categories 5-9)
     Includes:      individuals who have difficulty in sustaining 
                    relations with secondary contacts such as 
                    friends, neighbours, and colleagues: and 
                    individuals who are retarded in physical, 
                    psychological, or social development and in 
                    whom there is no evidence that development 
                    improvement is occuring

5    Reduced relationships (not in categories 6-9)
     Includes:      individuals who are able to relate only to 
                    significant others, such as parent or spouse; 
                    general withdrawal or disengagement by an 
                    elderly person; and moderately severe 
                    behaviour disorders

6    Disturbed relationships (not in categories 7-9)
     Includes:      individuals who have difficulty in relating 
                    to significant others; and severe behaviour 
                    disorders

7    Alienated (not in categories 8 or 9)
     Includes:      individuals who are unable to relate to other 
                    people; impairment or disability preventing 
                    the development of normal social 
                    relationships; and individuals in whom  
                    behavioural maladjustment prevents 
                    coexistence and integration in the customary 
                    home and family; and elderly persons 
                    following the loss of family and friends and 
                    with reduced capacity to enter into new 
                    relationships

8    Socially isolated
     Includes:      individuals whose capacity for social 
                    relationships is indeterminable because if 
                    their isolated situation, such as those 
                    admitted to institutional care because of 
                    lack of social support in the home or 
                    community (e.g., children in an orphanage or 
                    otherwise abandoned, and residents in an old 
                    people's home)

9    Unspecified

Rules for assignment

i    occasional reduction in social integration should not 
     preclude assignment to a less disadvantaged category (i.e., 
     that with a lower number)

ii   if doubt is experienced about the category to which the 
     individual should be assigned, rate him to the less 
     favourable category (i.e., a higher number)                      
iii  an individual should be categorized according to his actual 
     degree of social integration, rather than to what the 
     assessor thinks he may be capable of
          6    ECONOMIC SELF-SUFFICIENCY HANDICAP

Definition
Economic self-sufficiency is the individual's ability to sustain 
customary socioecomic activity and independence

Characteristics
Scale construct:fundamentally related to economic 
               self-sufficiency, from the reference point of zero 
               economic resources, but, unlike with the other 
               handicap scales, the construct has been extended 
               so as to include possession or command of an 
               unusual abundance of resources; the justification 
               for this extension is the potential that abundant 
               resources provide for relieving or ameliorating 
               disadvantage in other dimensions

Includes:           the individual's self-sufficiency in regard 
                    to obligations to sustain others, such as 
                    members of the family; economic 
                    self-sufficiency sustained by virtue of any 
                    compensation or standard disability, 
                    invalidity, or retirement pension that the 
                    individual receives or to which he may be 
                    entitled, but excluding any supplementary 
                    allowances or benefits to which the 
                    individual's poverty may entitle him; 
                    economic self-sufficiency by virtue of income 
                    (earned or otherwise) or material possessions 
                    such as natural resources, livestock, or 
                    crops; and poverty resulting from or 
                    exacerbated by impairment or disability
Excludes:           economic deprivation due to factors other 
                    than impairment or disability

Scale categories
0    Wealthy (not in catogories 1-9)
     Includes:      individuals in possession of resources 
                    considerably in excess of those available to 
                    the majority of the population of which the 
                    individual forms a part

1    Comfortably off (not in categories 2-9)
     Includes:      individuals in possession of resources 
                    sufficiently in excess of their requirements 
                    for sustaining their accustomed style of 
                    living that the additional resource 
                    expenditure incurred in attempts to 
                    ameliorate handicap and disability can be 
                    accommodated without appreciable sacrifice
2    Fully self-sufficient (not in categories 3-9)
     Includes:      economic self-sufficiency without support 
                    from or dependence on financial or material 
                    aid from other individuals or the community 
                    (including the state, but compensation or 
                    standard disability, invalidity, or 
                    retirement pensions shall be regarded as 
                    income entitlement rather than aid in this 
                    context) and such that the burden of attempts 
                    to ameliorate handicap and disability can be 
                    accommodated without appreciable deprivation

3    Adjusted self-sufficiency (not in categories 4-9)
     Includes:      individuals who, although economically 
                    self-sufficient, have suffered a reduction in 
                    economic wellbeing when compared with status 
                    before impairment or disability developed or 
                    that expected if the individual were not 
                    impaired or disabled, such as those who have 
                    experienced lower economic reward as a 
                    consequence of having had to change their 
                    occupation, or those who have incurred extra 
                    expenses because of their disability and to 
                    such a degree as to lead to appreciable 
                    deprivation

4    Precariously self-sufficient (not in categories (5-9)
     Includes:      individuals who, following a reduction in 
                    economic well-being, remain self-sufficient 
                    only by virtue of appreciable support from or 
                    dependence on financial or material aid from 
                    other individuals or the community (including 
                    the state, such as an allowance or benefit 
                    supplementary to the customary provisions for 
                    disability or retirement pensions to which 
                    they are entitled), and who in the process 
                    may jeopardize their family's 
                    self-sufficiency or cause other family 
                    members to be deprived

5    Economically deprived (not in categories 6-9)
     Includes:      individuals who economically are only 
                    partially self-sufficient because their 
                    income or possessions or financial or 
                    material aid from other individuals or the 
                    community meets only part of their needs, and 
                    who in the process may reduce their family to 
                    a subsistence level of existence
6    Impoverished (not in categories 7-9)
     Includes:      Individuals who economically are not 
                    self-sufficient by virtue of being totally 
                    dependent for financial or material aid on 
                    the goodwill of other individuals or the 
                    community, because of ineligibility for or 
                    non-availability of disablement or retirement 
                    pensions or supplementary benefits, and who 
                    in the process may reduce their family to 
                    existence below subsistence level; or 
                    individuals residing in institutions for the 
                    indigent

7    Destitute (not in categories 8 or 9)
     Includes:      individuals who economically are not 
                    self-sufficient and to whom support from 
                    others is not available, so that their 
                    disability status is further aggravated

8    Economically inactive
     Includes:      individuals without family support who are 
                    unable to undertake economic activity by 
                    virtue of limited competence (such as that 
                    resulting from mental retardation) or tender 
                    years (such as a child that has not passed 
                    the customary age at which he normally 
                    becomes independent of the family for 
                    complete economic or material support)
     Excludes:      those with family support and those often 
                    regarded as being economically inactive by 
                    virtue of their "dependent" status, such as a 
                    spouse or other cohabitant (assign to one of 
                    the categories 0-7, as appropriate, according 
                    to economic self-sufficiency of family or 
                    head of family)

9    Unspecified

Rules for assignment

i    categorize an individual according to the economic 
     self-sufficiency of his family, so that dependent status is 
     not taken into account;
ii   occasional reduction in economic self-sufficiency should not 
     preclude assignment to a less disadvantaged category (i.e., 
     that with a lower number);

iii  pensions or supplementary benefits that it is intended to 
     provide or prescribe should not be taken into account;

iv   if doubt is experienced about the category to which an 
     individual should be assigned, rate him to the less 
     favourable category (i.e., that with a higher number)
          7    OTHER HANDICAPS

Definition
Other circumstances that may give rise to disadvantage

Characteristics
Excludes: disadvantages identified elsewhere in the handicap 
          classification

Categories

0    Not subject to disadvantage
     Includes: impairments or disabilities not giving rise to 
               appreciable disadvantage, such as some chronic 
               diseases that do not appreciably interfer with 
               everyday life

1    Minor disadvantage
     Includes: the need to use minor aids that do not appreciably 
               interfere with everyday life, such as dentures, 
               reading glasses, or a ring pessary to control 
               uterine prolapse; intermittent use of aids or 
               medication to control disability

2    Nonspecific disadvantage
     Includes: impairments or disabilities that give rise to 
               general or nonspecific disadvantage, such as 
               coeliac disease or the state of being delicate

3    Specific disadvantage
     Includes: reduction of the quality of life as a result of 
               specific disadvantages not elsewhere identified in 
               the handicap classification

9    Unspecified disadvantage
          GUIDANCE ON ASSESSMENT

The structure of the H code is radically different from that of 
all other ICD-related classifications. Thus the codes are not 
hierarchical in the customarily accepted sense, and abbreviation 
is not really acceptable. What is called for is that every 
individual should be categorized according to each dimension of 
the H code, the latter relating to various circumstances in which 
disabled people are likely to find themselves. As a result of 
these considerations, the difficulties in applying the H code 
relate not to assignment, but to assessment of the individual's 
status in regard to each dimension of handicap. However, the 
basis for such assessments has been indicated under each of the 
dimensions.

For retrospective application to existing records, the major 
difficulty is likely to be incomplete information, Nevertheless, 
as noted in the Introduction, the orientation of whatever 
information may be available to the dimensions of the H code can 
still be very instructive.

From now on, it is hoped that information will be gathered so as 
to permit assessment in each dimension of the code. The main 
aspect likely to command attention in the future relates to the 
development of assessment schedules. These are likely to be based 
on a questionnaire approach, so that problems with language will 
loom large, and so it will not be easy to developn instruments 
capable of transcultural application.


1

1. Badley, E.M., Lee J & Wood, P.H.N. (1979) Rheumatology and        
Rehabilitation, 18, 105-109