A more holistic approach to autism using the International Classification of Functioning: The why, what, and how of functioning

A commitment to implementing a holistic approach to humans in research and practice appears implicitly or explicitly in the mission statements of most academic, clinical, social, and educational organizations. Even most professionals would likely agree that this is how they seek to approach service users and research participants they encounter. Claiming to work holistically is ambitious, and I doubt that I have ever seen it genuinely occur. Honestly, I do not know what precisely a truly holistic approach should and could look like, and I am confident that few know the answer to this question. That said, I suppose that a holistic approach should ideally be one that aims to picture the person’s body, mind, situation, and context, and derives service which conveys deep individual understanding and is consistent with the person’s own perspective, preferences, and needs. Unfortunately, the driving forces that dictate how things are done are not mission statements or good intentions but budgets, traditions, ideologies, bureaucracy, and paradigms that professionals prefer or feel obliged to use. Despite these obstacles, I am convinced that we could work far more holistically if we apply the appropriate frameworks. In this editorial, I will try to persuade you that the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF; WHO, 2001, 2007) is the logical and adequate choice for such a framework. It has holistic qualities, the necessary authority, and is more or less waiting to be implemented— with specific recent developments in relation to autism. Currently, the frameworks autism professionals most often relate to are the diagnostic systems Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) and International Classification of Diseases (11th Revision; ICD-11). In recent decades, these manuals have tremendously impacted how practitioners and researchers, think about autism. There are advantages to using these systems; for example, they define and operationalize the phenomena in question, improving communication and standardization of research. They also facilitate effective administrative processes and routine data collection. However, they surely do not provide a holistic understanding of unique individuals in their world. On the contrary, diagnosis seeks to condense individual information to a circumscribed entity, with the risk that an individual is perceived primarily within these confines. With long wait times and insufficient resources, limiting assessment to checking off diagnostic criteria outlined in these diagnostic systems is a top priority. This focus over-shadows evaluation of other dimensions of an individual and their context, which are necessary to more holistically understand the client and plan meaningful tailored support. Assessment cannot stop with assigning a signpost. Instead, diagnosis must be the starting point for collecting individual information on strengths and challenges and the facilitating and hindering factors in the individual’s everyday environment. This approach would at least approximate the notion of working holistically. In the best case, such assessments would not necessarily require a diagnosis and would take place outside clinical settings, that is, in education, social services, and working life. While the American Psychiatric Association only provides a classification system for mental conditions, an objective of the WHO is to provide nomenclatures for all conditions, factors associated with well-being, and interventions from an international and cross-disciplinary perspective. One of the WHO’s most important classifications is the ICF, which categorizes almost 1700 aspects of functioning, operationalizing human body functions and structures (a person’s somatic and psychological prerequisites and potential), activities (what a person is doing or not doing in their life), participation (social and societal involvement), and environmental factors (the micro, meso, and macro context). There are multiple ways in which this framework is ideal for application to holistic autism research and practice. It applies a biopsychosocial model of functioning, embracing the fact that these domains are interactive and all relevant to living a good life (Pellicano et al., 2022). It also uses accessible language, bridging disciplines and enabling communication with stakeholders. In the ICF, the primary perspective of people on their own functioning and ways to improve it is highly valued. It is an established system for goal-setting in somatic rehabilitation (e.g. cerebral palsy, encephalitis), but its value for A more holistic approach to autism using the International Classification of Functioning: The why, what, and how of functioning 1136444 AUT0010.1177/13623613221136444AutismEditorial editorial2022