Application of the International Classification of Functioning, Disability and Health for Children and Adolescents (ICF-CY) in the Context of Inclusive Education Policies

Kaloyan Damyanov

Sofia University “ St. Kliment Ohridski ”

https://doi.org/10.53656/str2025-5-2-app

Abstract. The purpose of this study is to analyse the effectiveness of the International Classification of Functioning, Disability, and Health for Children and Adolescents (ICF-CY) in the context of inclusive education by evaluating its impacts on the functional assessment and integration of students with special educational needs (SEN). A mixed methodology including quantitative and qualitative approaches such as surveys, interviews, and classroom observations was used. Key findings show that ICF-CY significantly facilitates the functional assessment process and development of individualised support plans, leading to improved academic achievement and social integration of students. Despite these positive effects, limitations related to the need for additional teacher training and provision of adequate resources were also identified.

Keywords: ICF-CY, inclusive education, functional assessment, special educational needs (SEN)

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1.Introduction

In the context of contemporary social transformations and efforts to democratise education, inclusive education is emerging as a key priority at the global and national levels. Countries worldwide, including Bulgaria, are committed to developing and implementing policies that ensure equal access to education for all children, regardless of their individual needs and challenges. In this context, the International Classification of Functioning, Disability, and Health for Children and Adolescents (ICF-CY) offers a holistic approach to assessing children's functional abilities and limitations, providing a structured framework for analysing specific needs in the school setting (WHO 2007).

The main aim of this study is to analyse the effectiveness of ICF-CY in inclusive education practice by formulating and testing the following working hypothesis: the application of ICF-CY leads to a more accurate and objective assessment of the functional abilities and needs of children with special educational needs (SEN) in the context of inclusive education. Functional assessment based on the ICF-CY contributes to more effective planning and provision of individualised support, leading to improved learning achievement and social integration of children with SEN. Teachers and professionals using the ICF-CY as a functional assessment tool demonstrated higher levels of satisfaction and confidence in implementing inclusive educational practices. According to the legislative framework, the assessment of individual needs for additional support for the personal development of children and students with SEN is based on the functional approach, considering disability not as an isolated characteristic but as a result of the complex interaction between the individual's state of health and the social and physical environment, in accordance with the concepts of the International Classification of Human Functioning, Disability, and Health (ICF) of the World Health Organization (ZPUO).

In 2023, the Ministry of Education and Science officially published a manual for implementing the functional assessment card, marking the beginning of its implementation in Bulgaria's preschool and school education systems (Damyanov, Zamfirov et al. 2023). This innovation necessitates an in-depth analysis and discussion of the effectiveness of this assessment model, not only for children and students with special educational needs (SEN) but also for other groups of students who can be identified as potential users of additional support for personal development. In the context of inclusive education, the assessment of students' functionality is critical to provide adequate support and develop personalised interventions. The application of the International Classification of Functioning, Disability, and Health for Children and Adolescents (ICF-CY) provides a comprehensive approach that integrates not only medical aspects but also social and educational conditions that affect children's development. Ren et al. (2022) and Karem et al. (2022, pp. 4 – 23) show that ICF-CY allows for the integration of diverse perspectives by including environmental factors, personal skills, and social integration. This is vital for understanding the functionality of children with diverse needs. ICF-CY's systematic approach provides tools to identify students' needs and adapt teaching methods to reduce barriers and improve learning outcomes. This is particularly important for promoting inclusion in education and reducing the social exclusion of vulnerable groups.

The formulation of research questions plays a crucial role in guiding the entire research process, defining its scope, and determining its expected outcomes. In the context of inclusive education, an ICF-CY-based functional assessment is necessary to address the impact of various factors related to the learning and social integration of children with diverse needs. The questions focused on identifying students' specific needs and evaluating the effectiveness of individualised approaches, as noted by Groma et al. (2019, pp. 26 – 56). Analysis of in-school documents, such as the functional assessment map and support plans related to the implementation of ICF-CY, can provide additional data on the mechanisms for integration into the school system (Dainese et al. 2018, pp. 111 – 124). By framing these questions, this research provides not only a theoretical but also a practical contribution to improving inclusive education practices.

Systematic review of existing studies The application of ICF-CY in education provides an innovative and powerful theoretical toolkit for a deeper understanding of children's functionality in inclusive environments. Through the lens of a biopsychosocial approach, learning motor skills and integrating students with diverse needs create opportunities for personalised intervention and targeted support. As highlighted by Minghelli et al. (2023), the use of nonlinear pedagogy can significantly enhance individual student participation, which is critical to achieving social and educational autonomy. Furthermore, the ICF-CY enables a detailed assessment of students' needs, aligning with educational inclusion policies and the principles of individualised support (Ren et al. 2022, pp. 34 – 38). The implementation of adapted learning strategies that address social and emotional aspects is essential to optimise the learning environment and achieve the successful integration of all students.

Research in the field of inclusive education highlights the importance of integrating functional assessment to improve the learning process for children with diverse needs, which ensures a fundamental right to education that is realised with a focus on the well-being, dignity, independence, and community belonging of all participants (Balkanska & Tsvetkova-Arasova 2023).

According to Damyanov (2020), the ICF-CY approach offers a holistic perspective that encompasses the physical, cognitive, and social-emotional aspects of development (Damyanov 2020). These findings align with current literature trends, with Hikmat (2024) emphasising the importance of pedagogical innovation in fostering social and cultural bonds across generations within communities. The application of ICF-CY in the context of inclusive education offers a new perspective on assessing and supporting children with diverse needs. It is essential to analyse existing policies and approaches that define the framework of inclusive practice. According to Kumari et al. (2024), inclusive education aims to provide equal access to education by focusing on individualising classroom methods and strategies. This is also supported by Trosheva (2023), who points out that inclusion implies, on the one hand, a school that offers equitable education for all children and, on the other hand, individualization of education, i.e. it can also meet the specific needs of each child individually (Trosheva 2023). Despite the progress made in Bulgaria, significant challenges remain, including the need for more targeted professional development of teachers and limited resources to support inclusive education, as well as the importance of differentiating additional support for personal development, which is also the subject of discussion at professional and policy levels for future normative changes in this area.

Damyanov's (2020) analysis revealed that a significant proportion of students require an intermediate level of support, and the implementation of functional assessment and individualised interventions can significantly improve their academic outcomes. Coordinated efforts between educational institutions, families, and professionals are essential for the successful implementation of inclusive practices. In the literature related to the application of ICF-CY in education, there have been significant advances in the area of functional assessment and individualised interventions. This tool provides a systematic and multidimensional approach to assessing the needs of children with diverse needs, while providing an integrated understanding of their opportunities for additional personal development support in kindergartens and schools. This is particularly important in small settlements in Bulgaria, where resources are limited (O'Ajani et al. 2024).

Research has shown that integrating ICF-CY into teachers' practices leads to improved academic outcomes and increased student socialisation (Ruiz-Navas et al. 2024). The key role of ICF-CY in the educational process is contingent on the ability to dynamically adapt approaches that match the specific demands of students, as well as the need for active family and community involvement in the educational process. The result is the creation of an inclusive educational environment that ensures equal access to education for all children.

Functional assessment plays a central role in the inclusion process, providing the necessary basis for individualised learning and support. Through the application of the ICF-CY framework, professionals can identify students' specific needs and adapt learning materials and methodologies, significantly increasing the effectiveness of inclusive practices (Damyanov et al. 2023). It is important to emphasise that assessment is not just a formal process, but a dynamic tool that needs to be linked to constant feedback and adjustments. Effective interaction among teachers, parents, and specialists is particularly important to ensure consistent and holistic student development to meet students' unique challenges (Zamfirov 2019).

The conclusion that creating an inclusive educational environment that provides equal access to education for all children is the ultimate goal of ICF-CY implementation is based on the integrative nature of this approach. ICF-CY not only identifies individual needs but also encourages collaboration between all stakeholders and teachers, parents, and professionals-to ensure that every child receives the support needed.

Research methodology For the purpose of inclusive education analysis, combining quantitative and qualitative methods provides a more prospective view of the impact of ICF-CY. The quantitative aspect allows for statistical evaluation of data related to the effectiveness of specific interventions and supports, while qualitative approaches consider the experiences of participants and their families as well as perceptions of inclusion in education (Kamionka et al. 2021, pp. 105 – 119).

Through the integration of quantitative and qualitative methods, this study provides a multifaceted analysis of the application of functional assessment and ICF-CY in educational practice. This approach allows the consideration of both objective measurable outcomes and the subjective perceptions and experiences of participants, leading to a more holistic understanding of the complexities of inclusive education and the role of functional assessment in this process.

Thus, the integrated methodological approach not only offers a balanced analysis of the quantitative and qualitative aspects of the research but also contributes to making recommendations based on real data and a contextual understanding of inclusive practices.

The sample included 260 functional assessment cards for children and students with special educational needs (SEN), as well as other groups of students in need of additional support within the system of pre-school and school education in Bulgaria. Participants were selected based on criteria that included educational institutions (kindergartens and schools) from all 28 districts of the country, from different age groups, and types of needs. Interviews with teachers, parents, and specialists working in the Regional Centres for Support of the Inclusive Education Process were also included.

In this study, data were collected through a combination of different methods that provide a rich and multilayered analysis of the application of ICF-CY in educational practice. Each method was carefully selected to complement the others and provide a holistic view of the impact of functional assessment on students with special educational needs (SEN) and their inclusion process in the education system.

The surveys were conducted with a wide range of teachers and professionals directly involved in the inclusive education process. The surveys were designed to assess the impact of functional assessment on educational practices and students' learning outcomes. The questionnaires included a variety of question types, both closed and open-ended, allowing for both quantitative and qualitative information to be gathered. The main focus is on identifying the effectiveness of different ICF-CY-based interventions and uncovering the challenges faced by educators in implementing these methods.

Semi-structured interviews were conducted with teachers, parents, and institutional representatives to gather in-depth data on their personal perceptions and experiences with the implementation of ICF-CY. This method allowed for a more detailed exploration of the subjective aspects of the implementation of functional assessment, allowing participants to express their thoughts, feelings, and impressions in a more free format. The interviews were conducted using pre-prepared questions that remained flexible, however, to allow for the consideration of important themes that emerged during the interview. Through this method, the key factors that influence the successful implementation of ICF-CY and the interaction between different stakeholders in the educational process are identified.

Classroom observations were conducted in environments where individualised support programs for students with special educational needs (SEN) were implemented. The objective of these observations was to investigate the impact of functional assessment and associated interventions on the daily learning process and interactions among students, educators, and other professionals. The observations focused on the practical application of personalised plans, identifying both efficacious outcomes and potential challenges. Comprehensive records of the observations were maintained to establish a thorough dataset for subsequent analysis.

Document analysis includes a review and analysis of various internal school documents that are directly related to the implementation of ICF-CY. Among the documents analysed were functional assessment maps, individualised support plans developed, and other relevant documents. This method provides valuable information about the structures and procedures used in schools to support students with SEN. By analysing these documents, the best practice is identified, as well as areas where improvements are needed.

In the context of this study, qualitative methods include content analysis, ABC analysis, and “Questions About Behavioral Function” (QABF).

Content analysis is a key method for examining qualitative data collected from interviews and support plans. This method allows the identification of key themes, ideas, and patterns in the textual data, focusing on the significant concepts that are relevant to the research. Through content analysis, not only are key themes related to the implementation of ICF-CY and challenges in inclusive education revealed, but also the specific ways in which different stakeholders perceive and implement these methods. The analysis involved a systematic coding of the textual data, leading to the identification of recurring themes and sub-categories associated with the successful inclusion of students with special educational needs (SEN).

ABC (Antecedent-Behaviour-Consequence) analysis is a qualitative research method that focuses on understanding student behaviour by analysing the antecedents (Antecedents), behaviour itself (Behaviour), and subsequent reactions (Consequences). This approach is particularly useful in the context of inclusive education, as it allows practitioners to identify the specific conditions that lead to certain behaviours and how these behaviours are reinforced or changed. Through ABC analysis, targeted interventions have been developed that address specific behavioural problems while promoting positive behaviours and minimising negative reactions. This method provides valuable data for individualising support and interventions tailored to each student's unique needs.

The Questions About Behavioural Function (QABF) is an instrument that assesses the behavioural functions of students by examining why a student exhibits a particular behaviour. This tool is used to identify the motives behind certain behaviours, such as task avoidance, attention seeking, sensory needs, and others. By implementing the QABF, researchers and practitioners can better understand the reasons behind certain behaviours and develop interventions to address specific needs. This method is particularly useful when working with students with learning disabilities, as it allows for the customisation of support approaches based on students' specific behavioural motivations.

Study results The results of the study showed that the application of the International Classification of Functioning, Disability, and Health for Children and Adolescents (ICF-CY) significantly facilitates the process of functional assessment and the development of individualised learning plans for students with special educational needs (SEN). Early intervention based on ICF-CY results and collaboration between multidisciplinary teams, including teachers, parents, and professionals, are essential for the successful integration of these children into the mainstream education system. The results of the ICF-CY implementation in the context of inclusive education are detailed in Table 1. The table illustrates the distribution of students with special educational needs by levels of support (low, medium, and high), while also showing their average academic and social integration outcomes.

Table 1. Results of the application of the functional assessment according to the intensity of support Level of Support Number of Students Average Academic Score (on a six-point scale) Average Social Integration Score (0-100 points) Low Support 78 5.3 85 Moderate Support 104 4.5 70 High Support 78 3.8 55

The results of the implementation of the ICF-CY in the context of inclusive education are detailed in Table 1. The table illustrates the distribution of students with special educational needs by level of support (low, medium, and high), while also showing their average academic and social integration scores. The social integration scores presented in the table are formed on the basis of systematic observation and assessment of the behaviour and interactions of students with SEN in the learning and social environment. These include criteria such as participation in group activities, interactions with classmates and teachers, the degree of involvement in extracurricular activities, and students' ability to build and maintain social relationships. The assessment was expressed in points on a scale of 0 to 100, with a higher score indicating better social integration. These indicators were collected through a combination of classroom observations, interviews with classmates and teachers, and analysis of documents and reports from various school activities.

Table 1 reveals that students who receive low support achieve the highest mean score (5.3 on a six-point system) and the highest score on social integration (85 points). These results suggest that students with milder functional difficulties that require minimal support perform better both academically and socially.

In contrast, students in need of average support showed moderate achievement (4.5) and social integration (70). These students often face serious challenges that require greater individualisation of the learning process, yet their scores remain relatively high.

Students with high support had the lowest average grade point (3.8) and the lowest social integration score (55 points). These scores can be explained by the fact that these students have more severe functional difficulties that significantly complicate their academic and social adaptation, despite the support provided.

These data highlight the importance of early intervention and adequate functional assessment to enable professionals to determine the optimal level of support for each student. Although the implementation of the ICF-CY significantly supports the integration process for students with SEN, the results indicate that additional resources and support are needed for high-needs students to achieve more successful social and academic integration.

Figure 1. Levels of support and average learning outcomes

The graph clearly illustrates the trend that as the intensity of support increases, students' average learning outcomes decrease. Students with low support showed the highest academic achievement, while those who received medium and high support achieved lower results. This trend is related to the more complex needs of students who require more intensive support.

This visualisation highlights the need for a differentiated and individualised approach to the implementation of ICF-CY while also showing that students with greater functional difficulties face greater challenges in the learning process, regardless of the intensity of the support provided. This further supports the conclusion that more specialised interventions and resources are needed for these students to successfully integrate and maximise their learning opportunities.

The study confirms two of the three formulated hypotheses, while the third is partially confirmed.

Hypothesis 1. The application of the ICF-CY leads to a more accurate and objective assessment of the functional abilities and needs of children with special educational needs (SEN) in the context of inclusive education has been confirmed.

Analysis of the data collected indicates that the ICF-CY offers a framework that provides an accurate and objective assessment of students' functional abilities. Teachers and professionals using the ICF-CY have achieved a better assessment of students' needs and have developed more adequate support plans.

Arguments and data in support of Hypothesis 1 suggest that the application of the ICF-CY leads to a more accurate and objective assessment of the functional abilities and needs of children with special educational needs (SEN). Comparative analysis of functional ability assessment revealed that teachers and professionals who use the ICF-CY can identify a greater number of functional difficulties and needs than those who do not use this approach. For those who did not use the ICF-CY, gaps in the identification of specific needs were often observed, resulting in less effective interventions.

In addition, teachers and professionals who used the ICF-CY demonstrated higher levels of satisfaction and confidence in developing individualised support plans. This is due to the structured and systematic approach that the ICF-CY provides for assessing student needs. It can also be highlighted that ICF-CY greatly facilitates coordination and collaboration between different professionals, such as psychologists, speech therapists, special educators, and others. By providing a common framework and language to describe students' functional difficulties and needs, the ICF-CY facilitates better-coordinated and targeted interventions that lead to more effective support and improved learning outcomes.

Table 2. Comparison of assessment performance with and without the use of ICF-CY Indicator With ICF-CY (n=50) Without ICF-CY (n=50) Number of Accurately Identified Needs 45 30 Percentage of Adequately Developed Plans 90% 65% Teacher Satisfaction Level 4.8/5 3.7/5 Student Academic Achievement (Average Score) 5.0 4.2

Table 2 presents a comparative analysis of assessment effectiveness with and without the use of ICF-CY based on data from 50 teachers and specialists in the two categories. The results showed that using ICF-CY significantly increased the number of accurately identified student needs (45 vs. 30), resulting in better-tailored interventions. The percentage of adequately developed support plans was also significantly higher for those using ICF-CYs (90% vs. 65%). In addition, the satisfaction rate of teachers using the ICF-CY was significantly higher (4.8/5 vs. 3.7/5), indicating that they felt more confident and effective at their work. It is important to note that the average student achievement was also higher for those who were assessed and supported using ICF-CY (5.0 vs. 4.2), highlighting the importance of accurate and objective assessment in achieving better learning outcomes.

Hypothesis 2. Functional assessment based on ICF-CY contributes to more effective planning and provision of individualised support, leading to improved academic achievement, and the social integration of children with SEN has been partially validated. While higher intensity of support and individualised plans do lead to better academic performance and social integration, in some cases, the quality of school-family interaction and the availability of resources were also observed to play a significant role. This means that while functional assessment is an important factor, it is not the only determinant of student success.

Data analysis shows that the intensity of support and individualised plans developed based on ICF-CY lead to significantly better academic outcomes and more successful social integration of students. These plans are more adaptable to the specific needs of each student, allowing them to meet their educational and social needs better.

However, the analysis shows that the quality of the interaction between the school and the family, as well as the availability of resources, also plays a significant role in student success, as shown in Figure 2. In cases where school-family interaction is weak or where sufficient resources are lacking (e.g. additional teachers, specialised materials, and therapeutic support), the effectiveness of ICF-CY-based individualised plans is reduced. This suggests that while functional assessment is a key element, it must be supported by a broader set of factors to achieve optimal outcomes.

Figure 2. Influence of resources and family involvement on students' academic achievement and social integration

Figure 2 shows a clear correlation between the availability of resources, active family involvement, and student success in both academic and social integration. Under conditions of high resources and active family involvement, students achieve the highest academic performance and social integration. With declining resources and low family involvement, both students' academic achievement and social integration have declined significantly. Interestingly, even with lower family participation, this factor can be influenced by motivating them to actively participate in the ICF-CY-based functional assessment process. This highlights the importance of a holistic approach to student support that includes both school resources and active interactions with parents to achieve better outcomes.

Hypothesis 3. Teachers and professionals using the ICF-CY as a functional assessment tool demonstrated higher levels of satisfaction and confidence in implementing inclusive educational practices has been confirmed.

Survey data showed significant differences in satisfaction and confidence between those who used ICF-CYs and those who did not.

Teachers and professionals who use the ICF-CY report that the framework provides clarity and structure in the assessment of students, leading to a better understanding of their needs and more effective interventions. This gives them a sense of professional satisfaction, as they see real results from their work. In addition, they feel more relaxed and confident when they have a systematised tool, such as ICF-CY, available to guide their actions.

The ICF-CY provides teachers and professionals with a more objective and reliable basis for decision-making related to the learning process and interventions for students with SEN. This leads to greater confidence in their ability to effectively implement inclusive educational practices. They can better justify their decisions to colleagues, parents, and other stakeholders, which also contributes to their professional confidence.

Teachers and practitioners using ICF-CY report that the framework is in line with inclusive policies and good practices being promoted nationally and internationally. This further boosts their confidence as they feel that they are working in line with recognised standards and guidelines.

The table below (see Table 3) shows comparative data on the satisfaction and confidence of teachers and professionals who use ICF-CY versus those who do not:

Table 3. Comparative analysis of teachers' and professionals' satisfaction and confidence in implementing inclusive practices with and without the use of ICF-CY Indicator With ICF-CY (n=50) Without ICF-CY (n=50) Job Satisfaction (on a scale of 1-5) 4.7 3.9 Confidence in Implementing Inclusive Practices (on a scale of 1-5) 4.8 4.1 Percentage of Teachers Who Feel Supported in Their Work 92% 75% Percentage of Teachers Reporting Positive Outcomes for Students 88% 65%

The table shows that teachers and professionals using the ICF-CY reported higher levels of satisfaction and confidence in implementing inclusive practices. The mean job satisfaction score for those using ICF-CY was 4.7, compared to 3.9 for those not using it. Confidence in implementing inclusive practices was also higher (4.8 vs. 4.1). Additionally, the percentage of teachers who felt supported in their work and reported positive student outcomes was significantly higher for those who used the ICF-CY. These data clearly demonstrate that the ICF-CY contributes to higher professional satisfaction and confidence among teachers and professionals, ultimately leading to more effective inclusive educational practices.

Discussion and conclusions This study clearly demonstrates that the integration of ICF-CY into the education process can significantly improve the effectiveness of inclusive education policies. The data show that teachers and professionals who use ICF-CY are more confident and satisfied with their work, leading to better outcomes both academically and in the social integration of students with special educational needs (SEN). The ICF-CY framework provides a holistic view of a child's needs by integrating information about the physical, cognitive, and social aspects of their development. This makes the ICF-CY a valuable tool not only for teachers but also for policymakers and parents who are involved in the inclusive education process. By improving the accuracy and objectivity of the functional assessment, the ICF-CY helps to plan better individualised support that is critical for the successful inclusion of students in the education system.

Although research has shown numerous benefits of implementing ICF-CY, certain limitations must be considered. One of the primary challenges is the need for additional training of teachers and professionals to implement ICF-CY effectively. A lack of sufficient training may lead to inadequate use of the framework, and consequently, less effective assessment and interventions. Additionally, the implementation of ICF-CY may face challenges related to the consistency and sustainability of processes across various educational settings. Different schools and regions may have different levels of resources and support, making it challenging to implement ICF-CY in a uniform and consistent manner.

Another limiting factor is the influence of contextual conditions, such as school-family interactions and the availability of resources, which also play a significant role in student success. This study demonstrates that, while ICF-CY-based functional assessment is a crucial factor in enhancing inclusive educational practices, it must be complemented by other supportive measures to achieve optimal outcomes.

The results of this study highlight the importance of integrating the International Classification of Functioning, Disability, and Health for Children and Adolescents (ICF-CY) into inclusive education. This study demonstrates that the ICF-CY is an effective tool for facilitating the accurate and objective assessment of the functional abilities and needs of students with special educational needs (SEN). Teachers and professionals who use the ICF-CY demonstrate higher levels of confidence and satisfaction in implementing inclusive education practices, leading to improved academic outcomes and social integration of students.

At the same time, the research shows that the success of inclusive practices depends not only on functional assessment but also on the quality of interaction between the school and the family, as well as on the availability of sufficient resources. Although the ICF-CY provides a structured framework for assessment and intervention, further training of teachers and the creation of conditions for consistent and sustained implementation of the framework in different educational settings are needed.

This study aimed to evaluate the effectiveness of the International Classification of Functioning, Disability, and Health for Children and Adolescents (ICF-CY) in the context of inclusive education. Analysis of the collected data confirmed that the ICF-CY is a powerful tool that significantly facilitates the functional assessment process and development of individualised learning plans for students with special educational needs.

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ZPUO Preschool and School Education Act. Published in the State Gazette, issue 79 of October 13, 2015, amended and supplemented in issue 98 of December 9, 2016.

Dr. Kaloyan Damyanov, Chief. Assist. Prof.

WoS Researcher ID:AGB-8272-2022 ORCID iD:0000-0002-7005-5811

Faculty of Educational Sciences and Arts

Sofia University “St. Kliment Ohridski”

Email: kdamjanov@uni-sofia.bg

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Application of the International Classification of Functioning, Disability and Health for Children and Adolescents (ICF-CY) in the Context of Inclusive Education Policies

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