Research Foundations for Using Clinical Judgment in Early Intervention

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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
• Childrens Hospital of Pittsburgh
• The UCLID Center
• University of Pittsburgh School of Medicine
• steve.bagnato_at_chp.edu
• www.uclid.org

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What is Clinical Judgment?
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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.

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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).

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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).

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What is the Historical Context for Clinical
Judgment Research?
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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)

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

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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)

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Sample EI Studies and Outcomes

• AUTHOR STUDY AND
  OUTCOME
• Suen (19931995) n 467 typical/delay
  D-Specs 3 gt judgments increased accuracy of
  correct classification Generalizability
  analyses parents added unique information on the
  team
• Bagnato (1994) n715 typical/disability SPECS
  84.4 correct classification of disability
  category by rater group (n200) parents and
  professionals using discriminant function
  analyses
• Simeonsson (1995) n1089 disability
  categories-ABILIITIES supports tool accuracy for
  determining eligibility decisions

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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
  childs eligibility for early intervention.
• TRACE supports the term INFORMED OPINION as the
  preferred and communicable terminology for this
  phenomenon in early intervention

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What are the Practice Characteristics and Applied
Implications of Clinical Judgment for Early
Intervention?
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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 gt 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)

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What Are Examples of Exemplary Clinical Judgment
Formats and Measures?
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Preschool and Kindergarten Behavior Scales (1994)

• SOCIAL SKILLS Never 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