Abstract

The purpose of this article is to discuss 10 Clinical Judgment Standards and associated best practice indicators based on current literature and an understanding of the context of clinical judgment. Throughout the article, we stress the important role that clinical judgment plays in formulating valid and precise decisions and recommendations regarding diagnosis, classification, and planning supports.

Members of a variety of professions, such as psychologists, physicians, diagnosticians, expert educators, special education teachers, and social workers, are frequently involved in diagnosing, classifying, and planning supports for people with intellectual disability (ID). In this article and elsewhere (Schalock et al., 2010; Schalock & Luckasson, 2014) we suggest that these individuals can be considered clinicians in ID if they have relevant training in ID, have direct experience with people with ID, engage in clinical activities (diagnosis, classification, and planning supports), and use practices that are consistent with clinical judgment standards.

The roles played by clinicians in ID today are much different from their earlier roles. This change primarily results from three contextual factors. First, the high stakes involved in clinical functions related to diagnosis, classification, and planning supports necessitate that clinicians use best practices (Luckasson & Schalock, 2013b; Schalock & Luckasson, 2013). Second, the incorporation of the social-ecological model of disability into the ID field has underscored the role that influencing factors at the microsystem, mesosystem, and macrosystem levels play in human functioning and personal outcomes (Luckasson & Schalock, 2013a; Shogren, 2013; Shogren, Luckasson, & Schalock, 2014; Shogren, Luckasson, & Schalock, submitted for publication). Third, the transformational changes that are occurring across ecological systems require that clinicians align their thinking, decisions, and recommendations to major changes in public policy, organization policies and practices, and consumer involvement and expectations (Schalock & Verdugo, 2012, 2013).

Over the past decade, the term clinical judgment has come to be used in the field of ID to refer to the processes and strategies that clinicians can use to incorporate these contextual factors into high-quality, valid, and precise decisions and recommendations (Schalock et al., 2010; Schalock & Luckasson, 2014). The primary purpose of this article is to extend our understanding of clinical judgment and its use by discussing 10 clinical judgment standards and associated best practice indicators that can guide the formulation of the clinician’s decisions, recommendations, and actions. Throughout the article, clinical judgment is defined as “a special type of judgment that is built upon respect for the person [and] emerges from the clinician’s training and experience, specific knowledge of the person and his/her environments, extensive data, and use of critical thinking skills” (Schalock & Luckasson, 2014, p.1). Clinical judgment is considered a key component of professional responsibility, along with best practices in ID, professional standards, and professional ethics.

The article begins with an overview of the context of clinical judgment. This overview describes more fully the three contextual factors mentioned previously. Thereafter, we provide a listing of 10 clinical judgment standards that have been synthesized from the ID and related fields. In reference to each standard, we (a) provide a commentary that discusses the relevance of the standard, (b) discuss how in general the respective standard relates to the context of clinical judgment, and (c) suggest best practice indicators. The article concludes with a discussion of the importance of the proposed clinical judgment standards and indicators.

The Context of Clinical Judgment

The term context is used widely throughout a number of fields, including ID (Shogren, Luckasson, & Schalock, 2014). In this section of the article we use context as an integrative term that encompasses three phenomena that affect clinical judgment and its use. These three are the high stakes involved in diagnosis, classification, and planning supports; the factors that affect human functioning and personal outcomes; and the transformational changes that are occurring in human services at the microsystem, mesosystem, and macrosystem levels.

High-Stakes Decisions

In reference to diagnosis, high stakes involve fairness and accuracy, in that a diagnosis of ID not only establishes the presence of the disability in an individual, but also makes the person eligible (or ineligible) for services, benefits, and legal protections. Fairness and accuracy are enhanced when (a) the diagnosis of ID is based on the person meeting three criteria: significant limitations in intellectual functioning, significant limitations in adaptive behavior, and age of onset before age 18; (b) the individual’s functioning level is compared with age peers in typical (i.e., natural) community environments; (c) culturally and linguistically relevant individual assessments are made using psychometrically sound and individually administered instruments; and (d) the evaluator has expertise and training regarding the construct of ID, assessment strategies, and familiarity with the person (Luckasson & Schalock 2013b; Schalock & Luckasson, 2014).

There are also high stakes involved when a diagnosis of ID is made after the age of 18 when the individual with potential ID did not receive a formal diagnosis during the developmental period. A retrospective diagnosis may be required, for example, when clinicians are involved in determining eligibility for adult rehabilitation services, evaluating individuals for Social Security Disability assistance, or evaluating individuals involved in legal processes, such as guardianship petitions, competence determinations, or sentencing eligibility questions. In these situations, the clinician must use multiple sources of information to determine manifestations of possible ID before age 18 (Polloway, 2015; Schalock & Luckasson, 2014).

In reference to classification, high stakes include linking subgroup characteristics to important actions, fairness, and the equitable distribution of resources. Contextually, the classification process is affected by three current trends that involve (a) the acknowledgment of the multiple purposes for classification of individuals into subgroups that include describing functioning levels, operationalizing support need intensity levels, defining health status, and determining legal status (Schalock & Luckasson, submitted for publication); (b) the emergence of the multidimensional framework of human functioning (Buntinx, 2006; Luckasson & Schalock, 2013a; World Health Organization, 2001); and (c) the use of data-based approaches to classification (American Psychiatric Association, 2013; Tasse et al., 2012; Thompson, Schalock, Agosta, Teninty, & Fortune, 2014). These three trends lead logically to a systematic approach to subgroup classification that involves using a multi-dimensional classification framework, specifying the purpose for the classification subgrouping, selecting a classification schema, gathering information that meets the schema’s requirements, and designating the classification subgrouping (Schalock & Luckasson, submitted for publication).

In reference to planning supports, high stakes involve the deliberated alignment of needs, resources, and desired outcomes. At the microsystem level, this alignment involves the planning of individualized supports that are based on the individual’s personal goals and assessed support needs and focus on enhanced human functioning and personal goals. At the mesosystem level, the alignment involves building environments that enhance community integration through mediating access to community resources, providing opportunities for community participation and self-determination, and allowing individuals to build social capital (Christensen & Byrne, 2014; Eicher & Kawachi, 2011) .

Influencing Factors

Contextually, approaching individuals from a social-ecological perspective results in a better understanding of the personal and environmental factors that influence human functioning and personal outcomes. This approach reflects a common definition of context which is that “context is the totality of circumstances comprising the milieu for human life and human functioning” (Shogren et al., 2014, p. 110). As discussed more fully in Shogren et al. (submitted for publication), factors that influence human functioning and personal outcomes can be viewed from a systems perspective. Examples at the microsystem level include choices, opportunities, supported decision making, functioning level, self-advocacy, social networks, social support, information, and assistive technology devices. Examples at the mesosystem level include service delivery practices, education and employment programs, person-centered, holistic planning, stable and predictable environments, community experiences/awareness, and transportation availability. Examples at the macrosystem level include legal rights and protections, human rights, community-based alternatives, and disability policy goals.

In reference to clinical judgment, individualized supports and support strategies need to target those factors that influence human functioning and personal outcomes across ecological systems. This targeting can be operationalized through individual support plans, supports-focused organization policies and practices, and outcomes driven public policies (Schalock & Verdugo, 2012; Turnbull & Stowe, 2014).

Transformational Changes

From a contextual perspective, significant disability-related transformations are occurring across ecological systems. At the microsystem level, there is an increasing emphasis on inclusion, equity, self-determination, personal involvement, self-advocacy, personal well-being, and personal outcomes. These changes are occurring cross culturally, but in relative degrees and forms (Schalock & Keith, in press). At the mesosystem level, disability organizations are transforming their service delivery systems along the following lines (Schalock & Verdugo, 2013): (a) the person as central (e.g., person-centered planning, individualized supports, and personal outcomes); (b) streamlined organizations and the use of horizontally structured support teams composed of the individual, family member(s), direct support staff, a supports coordinator, and relevant professionals; and (c) continuous quality improvement that incorporates a learning culture and quality improvement strategies. At the macrosystem level, public policy is increasingly being influenced by constitutional and ethical principles and focusing on desired personal and societal outcomes (Shogren & Turnbull, 2010; Turnbull & Stowe, 2014).

These transformational changes require clinicians in ID to expand their thinking and practices. This expanded thinking is reflected in the use of the critical thinking skills discussed later in reference to Clinical Judgment Standard 5.

Clinical Judgment Standards

The 10 clinical judgment standards listed in Table 1 and discussed in this article reflect the context of clinical judgment, establish a foundation of respect for people whose functioning is being examined, provide guidance for evaluations of people with ID, shape the development of professional training and curricula, underscore the importance of critical thinking skills in clinical judgment, provide a framework for measuring the quality of clinical judgment, and assist with future developments and improvements in the clinical functions of diagnosis, classification, and planning supports. These standards have been synthesized from the published work in the field of ID and health-related areas (e.g., Christensen & Byrne, 2014; Faucher, 2011; Schalock & Luckasson, 2014; Scott & Havercamp, 2014; Tomlinson et al., 2014; Victor-Chmil, 2013).

Table 1

Clinical Judgment Standards in the Field of Intellectual Disability

Clinical Judgment Standards in the Field of Intellectual Disability
Clinical Judgment Standards in the Field of Intellectual Disability

Standard-Related Commentaries and Best Practice Indicators

The commentaries that follow were developed for three purposes. First, they reflect one or more of the contextual factors discussed in the previous section. Second, they integrate the four clinical judgment strategies published initially in Schalock and Luckasson (2005) and updated and expanded in Schalock and Luckasson (2014). The four clinical judgment action strategies are to clarify the question, assemble thorough history, conduct or access broad-based assessments, and synthesize the information. Third, they provide the rationale and basis for proposing best practice indicators regarding each standard. These indicators can be used for purposes such as self-evaluation, professional training, and subsequent work in the conceptualization and measurement of clinical judgment.

Standard 1: Respect

The foundation of clinical judgment is deep respect for the person and the individual’s family. Demonstrating respect involves “giving focused attention to the person, showing concern for the individual, respecting the person’s human and legal rights, and engaging in person-centered practices that facilitate the individual’s personal autonomy and personal well-being” (Schalock & Luckasson, 2014, p. 3–4).

A posture of respect is indicated by the clinician’s achieving precise, deep, broad, and far-reaching knowledge about the person and the person’s family. In interactions with the individual, respect includes clarifying the clinician’s identity and role; using the individual’s name properly and using person-first language; accessing and understanding the individual’s educational, social, medical and family history; asking the person’s opinion, goals, and aspirations; and developing clinical rapport and an honest evaluation relationship that honors the individual’s human dignity, and also leads to a more authentic interview and evaluation (see Appendix, “Best Practice Indicators for Standard 1”).

Standard 2: Best Practices

The clinician uses research-based best practices in conducting the three primary clinical functions of diagnosis, classification, and planning supports. Best practices in the field of ID relate to the definition of ID, the diagnosis of ID, the assessment of intellectual functioning and adaptive behavior, the selection of classification schema, the planning and implementation of individualized supports, the incorporation of a multidimensional model of etiology and human functioning, and the evaluation of personal outcomes (Schalock et al., 2010; Schalock & Luckasson, 2014).

In using research-based best practices, the clinician studies and thoroughly understands current literature regarding the diagnostic criteria for ID, multiple classification systems, systems of supports, the evaluation of support needs, individual support plans, and outcomes evaluation. A research-based, best practices approach to diagnosis, classification, and supports planning will result in a more valid and precise decision or recommendation regarding the individual’s diagnosis, relevant classification schema, and needed system of supports. Additionally, the approach will facilitate respectful interactions with individuals and their families, will increase effective multidisciplinary communication and efficient use of valuable time and other resources, and make it more likely that relevant questions and goals will be addressed (see Appendix, “Best Practice Indicators for Standard 2”).

Standard 3: Training and Experience

Relevant training for a clinician asserting clinical judgment includes academic coursework in ID and evaluation, as well as related practica, internships, or work-related experiences with individuals with ID. This theoretical and applied training is necessary to understand the condition of ID, causative risk factors, how best to assess the elements for a diagnosis of ID, the dynamics of everyday societal functioning of people with ID, and the strengths and limitations of individuals with this disability. In aggregate, this training assures higher levels of accuracy and avoids false positives and false negatives.

Relevant training includes developing the critical-thinking skills that form the basis of Clinical Judgment Standard 5 and are involved in forming valid and precise decisions and recommendations. These four critical thinking skills—analysis, alignment, synthesis, and systems thinking—should be developed through didactic coursework and practical experiences. Analysis, which involves examining and evaluating component parts of a phenomenon, is especially critical in diagnosis. Alignment, which involves placing or bringing clinical processes into a logical sequence, is especially critical in classification and planning supports. Synthesis, which involves integrating information from multiple sources, is essential in all three clinical functions. Systems thinking, which involves focusing on the multiple factors that affect human functioning at the microsystem, mesosystem, and macrosystem levels, is especially critical in classification and planning supports.

Relevant training also involves understanding basic statistical concepts and the research methods and guidelines used to interpret the evidence. Basic statistical concepts that are most relevant in interpreting the results of intellectual functioning and adaptive behavior assessments are norms, standard deviation, standard error of measurement, and confidence intervals. The most common research methods that are used to gather evidence about the effects of intervention, treatment, or supports include randomized controlled trials, multiple baseline studies, single-subject designs, qualitative approaches, and case studies (Schalock et al., 2011). Data-interpretation guidelines involve assessing the quality of evidence, the robustness of the evidence, and the relevance of the evidence. These three integrative guidelines provide the criteria for evidence-based practices (Claes, van Loon, Vandevelde, & Schalock, 2015; Schalock et al., 2011; see Appendix, “Best Practice Indicators for Standard 3”).

Standard 4: Data-Based Decisions

To achieve transparency and make data-based decisions, it is necessary to systematically collect extensive data prior to making decisions or recommendations. The goal is a holistic picture of the person, which will enhance understanding and help avoid both thinking errors and invalid decisions or recommendations.

A holistic understanding requires data. Data must be collected and analyzed according to a systematic plan for obtaining true understanding of the individual and the person’s human functioning. In reference to diagnosis, for example, the term extensive data refers not only to tests, scales, and measures, but also to social, medical, and educational records and history. Without considering extensive data that include relevant family and cultural factors, the clinician’s conclusion is more than likely not clinical judgment, and does not necessarily reflect the exercise of sound clinical judgment that avoids error.

The selection and relevance of the extensive data collected and analyzed are related to the question(s) being asked. For diagnosis, relevant data are the results of the standardized assessment of intellectual functioning and adaptive behavior and the interpretation of resulting scores along with social, medical, and educational history information. For classification, relevant data depends on the purpose of the classification and the specific classification schema used. Such schema include one or more of the following potential classification components: intellectual abilities, adaptive behavior, health status, level of participation, personal or environmental context, or intensity of support needs across major life activity areas and the individual’s exceptional medial and behavioral support needs.

By using extensive and systematically collected and analyzed data, the clinician not only makes a more valid and precise decision or recommendation, but he/she also avoids the misuse of clinical judgment. In that regard, “clinical judgment should not be thought of as a justification for abbreviated evaluation, a vehicle for stereotypes or prejudice, a substitute for insufficiently explored questions, an excuse for incomplete or missing data, or a way to solve political problems.” (Schalock et al. 2010, p. 87; see Appendix, “Best Practice Indicators for Standard 4”).

Standard 5: Critical Thinking Skills

Extensive literature in the health professions emphasizes the importance of using five critical- thinking skills to avoid thinking errors and generate better decisions and recommendations in terms of their accuracy, precision, and validity (Faucher, 2011; Schalock & Verdugo, 2012; Victor-Chmil, 2013). Each critical-thinking skill is directly related to decisions and recommendations regarding diagnosis, classification, and planning supports.

Analysis refers to the examination and evaluation of component parts of a phenomenon. As a critical-thinking skill, analysis helps the clinician dig deeply into each aspect of the question and is intractably involved in analyzing information required to make a diagnosis of ID.

Alignment refers to placing or bringing clinical processes into a logical sequence and adjusting them to their proper relationship to questions. As such, alignment helps the clinician assure that processes match inquiries, and is essential in classification and planning supports. Alignment, which is frequently depicted in a logic model with its input, throughput, and output components, underlies both classification and planning supports. In reference to classification, the input component includes the purpose of classification, a multidimensional classification framework, and the classification criteria. The throughput involves integrating the purpose to what is classified, components of the multidimensional classification framework to information sources, and synthesizing the information. The output is a relevant classification system (Schalock & Luckasson, 2014, p. 43). In reference to planning supports, alignment is reflected in a logical sequence whose input component involves the individual’s personal goals and assessed support needs, whose throughput component includes the provision of individualized supports, and whose output component includes assessed personal outcomes (see Clinical Standard 10).

Synthesis involves integrating information from multiple sources to create a more complete, accurate, and coherent form or pattern. Subskills involved in synthesis are analysis, evaluation, and interpretation. In addition to formulating a valid and precise decision or recommendation regarding diagnosis and classification, the use of synthesis, including those subskills listed previously, is critical in developing individual supports plans that reflect both best practices and evidence-based practices. Thus, synthesis helps the clinician develop opinions that take everything into consideration and assign appropriate weight to each factor and appropriate integration among all factors.

Systems thinking refers to focusing on the multiple factors that affect human functioning at the microsystem (i.e., individual and family), mesosystem (i.e., organization), and macrosystem (i.e., larger society and culture) system levels. In assuring that interrelated factors are synthesized across contexts, systems thinking sensitizes the clinician to the cultural and linguistic diversity of individuals, the culture of the organizations with which the clinician is working, the intent and content of public laws, and the elements of systems of support (Schalock & Verdugo, 2012; Thompson et al., 2014).

Transformational thinking refers to expanding one’s thinking to accommodate transformational changes occurring in organizations related to intellectual disability and public policies and practices. Transformational thinking, which is especially relevant to planning supports, assures that the clinician incorporates and accommodates to the transformational changes discussed earlier. Chief among these changes are the person as central, organization becoming streamlined and using horizontally structured support teams, quality improvement as a continuous process, and outcomes-focused public policy (see Appendix, “Best Practice Indicators for Standard 5”).

Standard 6: Professional Responsibility

Clinical judgment, together with professional standards and professional ethics, comprise professional responsibility. Clinical judgment plays a valuable role in supporting one’s professional responsibility, especially in situations that are complex or in which information is either incomplete or discrepant.

Clinical judgment is different from both professional standards and professional ethics. Professional standards provide the basis for developing professional training curricula, evaluating the everyday practices of members of the profession, and preparing personnel. They are used typically for accreditation, approval, quality control of practices, and as criteria to review professional behavior and enforce rules of conduct. Professional ethics represent critical human values and obligations, and generally involve themes of justice, beneficence, and autonomy (see Appendix, “Best Practice Indicators for Standard 6”).

Standard 7: Systems Focus

In using clinical judgment, one must understand the factors at the microsystem, mesosystem, and macrosystem levels that affect human functioning and personal outcomes, including the person’s educational, social, medical and family history; personal goals, desires and support needs; family and cultural background; and contacts with organizations and the larger society. In reference to making a diagnosis, for example, it is essential to realize that human functioning is influenced by both personal and environmental factors. Personal factors are characteristics of the person, such as gender, ethnicity, language, age, motivation, lifestyle, habits, upbringing, coping styles, social background, educational level, past and current life events, character style, and individual psychological assets. Any or all of these characteristics may play a role in the manifestation of a disability. They are composed of features of the person that are not part of a health condition or health state. In distinction, environmental factors make up the physical, social, and attitudinal environment in which people live and conduct their lives. Environmental factors interact with personal factors and thereby impact human functioning.

There are a number of potential purposes for recommending a particular classification schema. Chief among these are planning supports, obtaining health care, increasing meaningful communication, allocating resources, determining competency, and conducting research. Each of these purposes is impacted by factors operating at the microsystem, mesosystem, and macrosystem levels. In addition, when making decisions using a multidimensional framework, the clinician needs to be sensitive to the impact of systems-level factors impacting intellectual abilities, adaptive behavior, health status, participation, personal and environmental context, and supports provision.

An integrated approach to supports planning requires an understanding that supports are available across the three ecosystems. At the microsystem level, for example, supports can include natural sources (e.g., family, friends, colleagues), personal incentives, personal strengths/assets, and information technology (e.g., assistive technology, information technology, smart technology, prosthetics). At the mesosystem level, supports can include environmental accommodation, community resources, generic agencies, staff directed education/skill acquisition programs, and professional services. At the macosystem level, supports can include public polices, statutes, incentives, resource allocation patterns, public commitment, and legal mechanisms.

These factors and their relationships are not only among the individual factors at the micro-system level, but also incorporate the organizational and family factors at the mesosystem level, and the culture, language, politics, law, and government at the macrosystem. This thinking about the intertwined interfaces, influences, and levels is critical for a holistic (and accurate) approach to human functioning (see Appendix, “Best Practice Indicators for Standard 7”).

Standard 8: Aligning Clinical Functions

The proper exercise of clinical judgment requires alignment between the explicit question being asked, the procedures and instruments used to explore possible answers, and the decisions or recommendations that are made. The framework for assessment should first specify the assessment function. For example, is the question being asked a diagnosis question, a classification question, or a supports planning question? Second, the specific purpose for the assessment should be established. For example, is the purpose to establish the presence or absence of ID, classification for intensity of needed supports, or support to assure human rights? Third, do the procedures and strategies match the function and the purpose of the assessment (Schalock et al., 2010, p. 23)? (See Appendix, “Best Practice Indicators for Standard 8”).

Standard 9: Multidimensionality of Human Functioning

The multidimensional model of human functioning involves five components (Luckasson & Schalock, 2013a). These five are as follows: (a) intelligence, which is a general mental capacity that includes reasoning, planning, problem solving, abstract thinking, comprehending complex ideas, learning quickly, and learning from experience; (b) adaptive behavior that involves the collection of conceptual, social, and practical skills that have been learned and are performed by people in their everyday lives; (c) health, which is a state of complete physical, mental, and social well-being; (d) participation that involves roles and interactions in the areas of home living, work, education, leisure, spiritual, and cultural activities; and (e) context, which is the interrelated conditions (i.e., personal and environmental factors) within which people live their everyday lives.

The multidimensionality of human functioning must be reflected in diagnosis, classification, and supports planning. In diagnosis, clinical judgment requires analysis of extensive data and assessment in intellectual abilities, adaptive behavior, health, participation and context. In classification, a multidimensional classification system based upon multiple dimensions of human functioning can involve classification based on intellectual abilities, adaptive behavior, participation, environmental or personal context, or support intensity level. In supports planning, assistance for all areas of human functioning that involve intellectual functioning, adaptive behavior, health, participation, and the conditions within which people live their everyday lives. Thus, a multidimensional approach to individualized supports would include consideration of prosthetics, technology, learning supports, and environment accommodations (see Appendix, “Best Practice Indicators for Standard 9”).

Standard 10: Personal Outcomes

As the clinician exercises clinical judgment, the end goal is for the individual with ID to achieve their desired well-being and enhanced human functioning. This focus on personal outcomes is consistent with the intent of disability policy goals related to human dignity and autonomy, human endeavor, and human engagement. As discussed by Shogren, Luckasson, and Schalock (submitted for publication) personal outcome domains can be associated with each of these disability policy goals. Specifically, self-determination and full citizenship are associated with the policy goal of human dignity and autonomy; education/life-long learning, productivity, and well-being with human endeavor; and inclusion in society and community life and human relationships with human engagement.

A variety of frameworks might capture the measurement of these goals, including personal well-being frameworks, quality of life domains, holistic approaches to personhood, and other measurements related to human functioning (Luckasson & Schalock, 2013a; Schalock et al., 2010; Schalock & Verdugo, 2012). Ultimately, however, regardless of the framework chosen, the focus of clinical judgment is the enhancement of human functioning and personal outcomes (see Appendix, “Best Practice Indicators for Standard 10”).

The Importance of Clinical Judgment Standards and Best Practice Indicators

Today, clinicians in ID perform many functions that involve high stakes for individuals with ID and their families. Clinicians in ID diagnose, including making a retrospective diagnosis in some situations; they select among multiple classification systems one or more that best address classification needs; and they plan systems of supports that encompass the microsystem, mesosystem, and macrosystem levels and focus on the enhancement of human functioning and personal outcomes. The clinical judgment standards discussed in this article provide the basis for valid and precise decisions and recommendations related to these three clinical functions. Additionally, they establish a foundation of respect for people whose functioning is being examined, provide guidance for evaluations of individuals with ID, guide the development of professional training and curricula, prepare clinical personnel, show a basis for measuring the quality of evaluations, and assist with future developments and improvements in the use of clinical judgment in decision making. The best practice indicators associated with each of the standards provide guidelines for the implementation of the respective standard, content areas for curricula development, criteria for professional decisions, and the basis for subsequent developments in the area of clinical judgment.

The 10 clinical judgment standards and associated best practice indicators provide both a framework for determining quality or proficiency and a benchmark for the development and use of clinical judgment. As reflected throughout these 10 standards and their best practice indicators, clinical judgment is built on a foundation of demonstrating respect for individuals with ID, their human rights, and improving their opportunities for enhanced functioning and personal well-being. Clinical judgment, as used by clinicians in the field of ID, promotes sound professional decisions and recommendations, and promotes the good of society, fairness to individuals and their families, and the integrity of the profession.

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Appendix

Best Practice Indicators

Best Practice Indicators for Standard 1
  • Uses person-first language and current terminology

  • Is sensitive to the individual’s family and cultural background

  • Assures that the person understands the purpose of the evaluation and the role of the professional

  • Involves the person in decision making

  • Acquires knowledge about the person’s personal goals, strengths, and limitations

  • Supports the person’s growth and development, including opportunity development

  • Maintains a professional relationship

Best Practice Indicators for Standard 2
  • Develops a diagnostic evaluation rooted in best practices in the assessment of intellectual functioning and adaptive behavior

  • Selects a classification system with a clearly defined relevant purpose based on important information, and used to better understand the individual and what the person needs

  • Plans supports that are based on the individual’s personal goals and interests, assessed support needs, and support strategies that are individual-referenced and outcome oriented

Best Practice Indicators for Standard 3
  • Uses standardized assessments to determine intellectual functioning and adaptive behavior levels, and the profile and intensity of needed supports across major life activity areas

  • Incorporates a multifactorial approach to etiology

  • Integrates evidence into decision or recommendations, weighted according to its quality, robustness, and relevance to the person

  • Interprets information using critical-thinking skills related to analysis, alignment, synthesis, and systems thinking

Best Practice Indicators for Standard 4
  • Collects and analyzes all data in order to answer the question(s) asked

  • Bases the individual’s diagnosis on psychometrically sound individual assessment instruments, considering their statistical properties, standard error of measurement, and age peer comparison norms, as well as social, medical, and educational histories

  • Bases classification on measurable components of the selected classification schema

  • Plans supports based on the individual’s personal goals and assessed support needs as assessed on a standardized support needs assessment instrument

  • Articulates how the data were collected, analyzed, and used to formulate the decision or recommendation

Best Practice Indicators for Standard 5
  • Uses critical thinking skills of analysis, alignment, synthesis, systems thinking, and transformational thinking

  • Analyzes information from a thorough history and broad-based assessment instruments in formulating a potential diagnosis of ID

  • Aligns the input, throughput, and output components involved in using a classification system and developing an individualized supports plan (ISP)

  • Synthesizes information from multiple sources to formulate a diagnosis, classify on the basis of criteria that relevant to a specific purpose, and develop an individualized supports plan that is relevant and outcomes focused

  • Integrates microsystem, mesosystem, and macrosystem thinking and influencing factors into classification (in terms of purpose) and planning supports (in terms of support strategies)

  • Incorporates transformational thinking reflecting a focus on the community, the supports paradigm, horizontally structured support teams, user-friendly support plans, and evidence-based practices

Best Practice Indicators for Standard 6
  • Demonstrates professional standards and ethics

  • Augments professional standards and ethics by using clinical judgment strategies in all situations, including those that are complex or in which information is either incomplete or discrepant

  • Exercises professional responsibility by integrating clinical judgment with professional standards and ethics

Best Practice Indicators for Standard 7
  • Integrates personal characteristics that affect intellectual functioning and adaptive behavior and environmental factors that affect human functioning into the formulation of a diagnosis of ID

  • Incorporates information regarding microsystem, mesosystem, and macrosystem level factors into decisions and recommendations regarding selecting a classification schema

  • Incorporates information regarding microsystem, mesosystem, and macrosystem level factors into decisions and recommendations regarding implementing a multidimensional classification system

  • Integrates mult-system support strategies into individualized supports plans and supports coordination

Best Practice Indicators for Standard 8
  • Specifies the precise question to be answered

  • States clearly the purpose for the assessment

  • Aligns assessment activities and instruments to assessment function

  • Formulates a diagnosis of ID based on the three operational criteria: significant limitations in intellectual functioning, significant limitations in adaptive behavior, and age of onset prior to age 18

  • Aligns classification criteria (e.g., adaptive behavior levels, IQ ranges, health status, or participation) to commonly used measures and classification systems

  • Develops support plans based on personal goals, assessed support needs, and elements of a system of supports

Best Practice Indicators for Standard 9
  • Incorporates the multidimensionality of human functioning in formulating a diagnosis of ID

  • Incorporates the multidimensionality of human functioning in selecting and implementing a classification system

  • Incorporates the multidimensionality of human functioning in planning a comprehensive approach to individualized supports

Best Practice Indicators for Standard 10
  • Selects a personal outcomes framework (e.g., quality of life or human functioning dimensions)

  • Establishes measurement techniques to assess the respective outcomes

  • Aligns personal goals and assessed support needs to individualized support strategies using a personal outcomes framework

  • Assesses personal outcomes

  • Uses assessment information for multiple purposes such as counseling, quality improvement, ISP development, and supports coordination

Author notes

Ruth Luckasson, Distinguished Professor of Special Education, Chair of Department of Educational Specialties, University of New Mexico, College of Education, Albuquerque, New Mexico; Robert L. Schalock, Professor and Chair Emeritus, Hastings College, Hastings, Nebraska.