Research Foundations for Using Clinical Judgment in Early Intervention

1. Research Foundations for Using Clinical Judgment in Early Intervention STEPHEN J. BAGNATO, Ed.D. Professor of Pediatrics & Psychology Director, Early Childhood Partnerships & PA TRACE Center Children’s Hospital of Pittsburgh The UCLID Center University of Pittsburgh School of Medicine steve.bagnato@chp.edu www.uclid.org

2. What is Clinical Judgment?

3. Rationale for and Status of Clinical Judgment in Early Intervention • State and federal Part C regulations allow “informed clinical opinion” under certain circumstances “to determine the existence of a condition that has a high probability of resulting in a developmental delay”. • Clinical judgment forms the basis for collaborative decision-making among parents and professionals. • All assessment involves some aspect of clinical judgment. • Despite the policy mandate, no clear definition of the phenomenon of clinical judgment exists. • No clear application procedures guide how to operationalize clinical judgment to fulfill early intervention purposes (e.g., early identification, eligibility determination). • Few well-designed studies have been conducted to support the evidence-base for informed clinical opinion in early intervention, specifically. • Clinical judgment is an indispensable tool in the early intervention assessment process.

4. Most Quoted Definition “Informed clinical opinion is used by early intervention professionals in the evaluation and assessment process in order to make a recommendation as to initial and continuing eligibility for services under Part C and as a basis for planning services to meet child and family needs. Informed clinical opinion makes use of qualitative and quantitative information to assist in forming a determination regarding difficult-to-measure aspects of current developmental status and the potential need for early intervention” (Shackelford, NECTAS, 1997; 2002).

5. Best Literature Definition Clinical judgment, defined as inference or evaluation derived from intuition and/or personal experience, is the basis of many daily routine assessments by parents and professionals(Hayes, 1990; Goodnow, 1988).

6. What is the Historical Context for Clinical Judgment Research?

7. Historical Context Summary for Clinical Judgment • Widely examined in psychology and medicine since 1950 regarding clinical vs. statistical predictions (Meehl, 1954; Grove, 2000; Dawes, 1989) • Appeal as a methodology in nursing, medicine, and communication disorders: nurse-midwifery, decisions about life-threatening conditions, presence/type of SPLD; physician judgments re: atypical development (Greener, 1988; Benner, 1987; Records, 1990; Glascoe, 1993). • Analysis in special education and school psychology: teacher judgments; functional classification, team decision-making about MR, LD (Gresham, 1987; Ysseldyke, 1983; Iscoe & Payne, 1972) • One notable resource for EI (Neisworth, TECSE, 1990)

8. What is the TRACE Research Process and Results on Clinical Judgment?

9. TRACE Literature Search Strategy and Results • Terms: clinical judgment, informed clinical opinion, team decision-making, judgment-based assessment, subjective judgment, qualitative assessment; • Focused on 0-5 in early intervention and related health and human service fields • Major databases (PsychInfo, SSCI, ERIC, Ovid, Medline, Cochrane) and university theses and dissertations • Reviewed 1164 sources • 19 studies emerged in EI and related fields that met research criteria

10. Emerged Categories of TRACE Relevant Research on Clinical Judgment in EI(19 Studies) • Early detection and classification (Kochanek, 1994; Glascoe, 1991) • Parent-professional and team congruence (Bagnato, 1984; 1985; Suen, 1993, 1995; Gradel, 1981) • Judgment-based scales and decision formats (SPECS, 1990; 1994; ABILITIES, 1995; TABS, 1999; ASQ, 2002; ABAS, 2004; APGAR, 1988-1992)

11. Sample EI Studies and Outcomes AUTHOR STUDY AND OUTCOME Suen (1993;1995) n= 467; typical/delay; D-Specs; 3 > judgments increased accuracy of correct classification: Generalizability analyses; parents added unique information on the team Bagnato (1994) n=715; typical/disability; SPECS 84.4% correct classification of disability category by rater group (n=200) parents and professionals using discriminant function analyses Simeonsson (1995) n=108;9 disability categories-ABILIITIES; supports tool accuracy for determining eligibility decisions

12. Working TRACE Definition of Clinical Judgment *CLINICAL JUDGMENT OR INFORMED CLINICAL OPINION refers to the knowledgeable perceptions of caregivers and professionals about the elusive capabilities and contexts of children which must be defined and quantified so that an individual and a team can reach an accurate decision about a child’s eligibility for early intervention. * TRACE supports the term INFORMED OPINION as the preferred and communicable terminology for this phenomenon in early intervention

13. What are the Practice Characteristics and Applied Implications of Clinical Judgment for Early Intervention?

14. Evidence-based Practice Characteristics and Implications for Clinical Judgment in Early Intervention: Range of Research Support Across Studies 1-3 • Create operational definitions for judged child/family attributes. (2) • Choose a format to structure and quantify informed opinions about attributes (2) • Gather informed opinions from > 3 people. (3) • Collect informed opinions across multiple settings. (3) • Reach consensus decisions from multiple data sources. (3) • Ensure training in methods to structure informed opinions. (1)

15. What Are Examples of Exemplary Clinical Judgment Formats and Measures?

24. Preschool and Kindergarten Behavior Scales (1994) SOCIAL SKILLSNever Rarely Sometimes Often Works or plays independently 0 1 2 3 Follows instructions from adults 0 1 2 3 Shows self-control 0 1 2 3 Participates in family or classroom discussions 0 1 2 3 Follows rules 0 1 2 3 Takes turns with toys and other objects 0 1 2 3